PPO vs EPO vs HMO

May 6, 2016

Most people have heard of HMOs and PPOs... but what is an EPO?  Now that we're talking about it... what is the difference between an HMO and a PPO?

 

HMOs main difference is the role of a "Primary Care Physician"

 

The PCP is a doctor that acts like a gatekeeper to the specialist doctors within the same network.  A patient would visit a PCP first, explaining their ailment.  The PCP would then refer that patient to a specialist of their choosing that can help.  With a PPO plan, you can go straight to a specialist without seeing a PCP.  In fact, you can even choose which specialist you'd like to visit.

 

The other main difference is that of the "Network"

 

Doctors and insurance carriers partner up and decide on networks they will participate in.  For example, a doctor may decide they wish to participate in the Blue Shield Full PPO network, the UnitedHealthcare Full PPO and Limited PPO network, but not the Blue Shield Limited PPO network.  It can get very confusing and often times patients struggle to understand whether a doctor is within their network of doctors.  This confusion can lead to expensive medical bills.  Sometimes it is best to call the doctor's office and ask specifically if they accept your insurance as "in-network".

 

Now finally, what is the difference between PPO, EPO and HMO?

 

HMO 

Patients must have a primary care physician.  If you have an ailment, you will visit this PCP who will send you to a specialist.  

 

You also must stay in the HMO network or you’ll pay 100% of the costs.  There are no out of network benefits with an HMO plan.

 

EPO 

With an EPO, there is no need to have a primary care physician.  You can see any specialist you choose. 

 

However, like an HMO there are no out of network benefits.  if you choose a doctor outside the network, you pay 100% of the costs.

 

PPO

With a PPO, there is no need to have a primary care physician.  You can choose which doctors you wish to see.  

 

Also, if you select to visit a doctor outside your network, your insurance carrier will usually pay a portion of the costs.  The benefits are not as good as if you went in network, but you still have a portion of you costs covered by your insurance plan.

 

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