HMO vs PPO
The plan type decides two things that shape where you can get care: whether you need a referral to see a specialist, and whether care outside the plan’s network is covered.
Last reviewed against MedlinePlus, HealthCare.gov, and CMS pages linked on this page on .
The four common plan types
| Plan type | Out-of-network care | Referral to see a specialist |
|---|---|---|
| HMO (Health Maintenance Organization) | Generally not covered, except in an emergency. May require you to live or work in its service area. | Often required |
| PPO (Preferred Provider Organization) | Covered, at an additional cost | Not required |
| EPO (Exclusive Provider Organization) | Covered only in the network, except in an emergency | Depends on the plan |
| POS (Point of Service) | You pay less in the network | Required from your primary care doctor |
From HealthCare.gov’s plan-type definitions and glossary. Check your own plan’s summary of benefits — details vary.
Choosing between them
- Want a specific doctor or hospital? Check whether they are in each plan’s network before you choose.
- See specialists often? Referral rules matter; a PPO avoids them, at a cost.
- Travel or live part-time elsewhere? An HMO or EPO may not cover routine care outside its area.
- Compare total cost, not just premiums: deductibles, copays, and out-of-network coinsurance.
Referrals
HealthCare.gov defines a referral as a written order from your primary care doctor to see a specialist or get certain services, and notes that in many HMOs, if you do not get a referral first, the plan may not pay.
Common questions
- Is a PPO better than an HMO?
- Neither is better in general. PPOs offer more flexibility to see out-of-network providers without referrals; HMOs usually cost less but limit you to the network.
- Does an HMO cover emergencies out of network?
- HealthCare.gov says HMOs generally will not cover out-of-network care except in an emergency.
Sources
- Health insurance plan & network types (opens in a new tab) — HealthCare.gov (CMS)
- Referral (glossary) (opens in a new tab) — HealthCare.gov (CMS)
- Network (glossary) (opens in a new tab) — HealthCare.gov (CMS)
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Last reviewed against MedlinePlus, HealthCare.gov, and CMS pages linked on this page on .
Definitions and rules on this page come from the sources listed. If one has changed, tell us and we will correct it.