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HMO vs EPO vs PPO Obamacare Networks Explained

With the Affordable Care Act plans you might be seeing this term “EPO” as an option. You’ve probably heard of HMOs and PPOs, but EPO is not as widely used until now. The new Bronze, Silver, Gold, and Platinum plans in many states will offer EPOs. To make it easier, we decided to explain the difference between all three so you know which type of plan is best for you.


What is an HMO?

HMO is short for Health Maintenance Organization. Here’s the basics of an HMO: you MUST use network providers. This means your doctors, hospitals, and other health care providers must be in your network or you will pay out of pocket for all costs. There is one exception: emergency care. If you have an emergency your HMO plan must cover you at the same cost whether that hospital is in-network or out of your network.

You will also have to choose a Primary Care Physician (PCP), typically all referrals to see a specialist come from your PCP.

What is an EPO?

EPO is short for Exclusive Provider Organization.  EPOs are similar to HMOs, in that you must stay within your network (emergency care is an exception), however with an EPO you generally do not need to select a Primary Care Physician nor receive a referral to see a specialist. This type of plan gives you a little more freedom than an HMO plan.

What is a PPO?

PPO is short for Preferred Provider Organization. PPOs do not require you to choose a PCP nor stay within network, however if you choose to go outside of your network your cost-sharing will be higher and not as many benefits will be covered (emergency services exempted). Due to PPOs having a larger network, they usually have a higher monthly premium. These plans have the most freedom.

Should You Choose an EPO, HMO or a PPO?

That’s up to you. You have to weigh your budget and if you have specific doctors and/or hospitals that you prefer to use, as well as if you want the freedom to use a specialist without a referral. Best advice before choosing any plan is to learn what your network is (even if it is a PPO plan). You don’t want to be surprised by a bill because you didn’t know your doctor or hospital wasn’t in your network.

All new qualified health plans will include the essential health benefits, such as maternity, $0 preventive care, and emergency services.

ACA Deadline

The ACA deadline for the federal exchange is December 23, 2013, other states may have earlier deadlines. However, don’t wait to the last minute to apply because your paperwork still needs to be processed. To get an Affordable Care Act application go to HealthApplication.com.

For further help deciding which plan is right for you call 800-930-7956 or contact Medicoverage.

Comments and Questions

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Comment from Ryan on July 10, 2016

OK I have two questions. First one is. Which is better Medicare or Medicaid. And the other question is as follows. Is my job provide insurance better than any of latter. I’m on an union and the insurance kicks in after 90 days. That’s in about two weeks. I currently have Medicaid. Even though I haven’t used it. Should I keep it or take the union insurance plan. I don’t know anything about either insurance plans and could use the advise. Thank you.

We know how confusing this can be. So, first I’ll explain the difference between Medicare and Medicaid. Medicare is for those over 65, and those under 65 with certain disabilities. Medicaid is for those who qualify based off financial needs. And, you can have both at the same time.

When your union insurance kicks in, you may have to take it. You will have to contact your union and Medicaid to confirm this. If you need private health insurance (Medigap or an Obamacare plan) please call one of our licensed independent insurance agents at 800-930-7956.

-Amy from http://www.medicoverage.com/

Comment from Carol Griffin on June 09, 2016

I just switched from an MA plan starting in July I was explained that with my Medicare and Medicaid I wouldn’t have to pay a co pay or a yearly fee like l did before so hoping it will be better for me financially but I am still wondering why I need it if I have Medicare and Medicaid since 2005 not sure if he answered this for me ty


Most times if you have Medicare and Medicaid, you will be enrolled in a Medicare Advantage Special Needs Plan. What this means for you is: while Original Medicare covers your hospice care (if needed), all other services are “replaced” into a small, local Medicare Advantage network. It’s not so much that you need it, but it makes the plan more affordable for the government if you’re enrolled in a plan with a small network and a managed care system that requires a primary care physician who is the gatekeeper for your care. Hope this helps!

-Amy from http://www.medicoverage.com/</div>

Comment from Quickpaydayz on January 06, 2014

Oh it is great that you agree with this. I know that its hard to belive on this but u did and wrote a good post.

Comment from John on December 03, 2013

Thanks so much for this! I had never heard of an EPO before. Does a PPO pay more toward your care? 


Thanks for your question. If you were to choose an EPO, HMO, or PPO at the same metal level, each should cover you at the same overall percentage of cost. Each plan or provider, however, may choose to break down their costs differently by network. For instance, if you are hospitalized, an HMO may have a set per day cost, whereas a PPO may charge a percentage of your total cost. To learn specific plan cost breakdowns give us a call.
-Jacima at www.medicoverage.com

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