Quick Comparison
| Feature | First option | Second option |
|---|---|---|
| Network care | Generally required except emergencies | Generally required except emergencies |
| Primary care provider | Often required | May not be required |
| Specialist referral | Often required | Often not required |
| Out-of-network benefits | Generally no routine coverage | Generally no routine coverage |
How an HMO Generally Works
An HMO usually requires members to use network providers for non-emergency services. Many HMOs use a primary care provider to coordinate care and require referrals for specialists, although exact rules vary.
How an EPO Generally Works
An EPO also generally limits non-emergency coverage to its network, but often allows direct access to in-network specialists without a primary-care referral. Preauthorization can still apply.
Choosing Between Them
Check your doctors, hospitals, labs, behavioral-health providers, and prescriptions. Then compare referral convenience, premium, deductible, cost sharing, network size, and access while traveling.
Questions to Ask Before Choosing
- Which option am I eligible to enroll in now?
- What is the net annual premium after applicable contributions or savings?
- Are my providers, facilities, and prescriptions covered?
- What would I pay under low, expected, and high use of care?
- Which deadlines, effective dates, and documents control?
Read how health insurance works or browse health insurance information by state.
Frequently Asked Questions
Is an EPO a PPO?
No. An EPO generally does not cover routine out-of-network care, while a PPO may provide out-of-network benefits at higher cost.
Do all HMOs require referrals?
No. Referral rules depend on the specific plan.
Does either plan cover emergencies away from home?
Emergency services have special protections, but follow-up and non-emergency care rules should be checked.
Official Sources
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HealthInsuranceMatch.com is an independent informational and matching resource. It is not affiliated with or endorsed by any insurer, HealthCare.gov, Medicare, Medicaid, or the federal government. Availability, eligibility, benefits, costs, networks, and enrollment rules vary by location and plan year.