What is the Difference Between an HMO, EPO, and PPO?

What are HMO, PPO, and EPO plans?

It can be difficult knowing how to choose the right health insurance plan. Before we compare HMOs, EPOs, and PPOs, let’s review what each type of health plan offers.

What is an HMO?

An HMO is a type of health plan that offers a local, limited network of doctors and hospitals for you to choose from. Because of this, an HMO plan usually has lower monthly premiums than a PPO or an EPO health plan. HMO plans often require a primary care physician (PCP) and referrals to see a specialist, leading to more integrated care.

What is a PPO?

A PPO is a type of health plan that offers a larger network. This gives you more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan.

What is an EPO?

An EPO is a type of health plan that offers a local network of doctors and hospitals for you to choose from but networks are generally larger than HMO networks. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it may not be covered (except in an emergency).

What are the main differences between HMO, PPO, and EPO plans?

HMO, PPO, and EPO plans all have their pros and cons. Learn more about these plans’ costs and coverage.

Which health plan is right for me?

Is an HMO plan right for me?

An HMO may be right for you if you’re comfortable choosing a PCP to coordinate your health care. It may also be right for you if you’re willing to pay a higher deductible to get a lower monthly health insurance premium.

This plan may also be a good choice for those who:

• Are comfortable with getting referrals from your PCP to see a specialist.
• Are comfortable with a more limited network of providers.

Is a PPO plan right for me?

A PPO health plan may be right for you if you're willing to pay a higher monthly premium to get more choice and flexibility when it comes to your physician and health care options.

This plan may also be a good choice for those who:

• Don’t want to have to go through a PCP to coordinate care.
• Don’t want referrals to be required to see a specialist.
• Are looking for a wider network of providers.

Is an EPO plan right for me?

An EPO health plan may be right for you if you want to pay lower monthly premiums. It may also be right for you if you are willing to pay a higher deductible when you need health care.

This plan may also be a good choice for those who:

• Are looking for a more budget-friendly plan.
• Are comfortable with a more limited network of providers.

What are the differences between HMO and PPO dental plans?

You can also get dental HMO and dental PPO plans. Learn more about the differences between DHMO and DPPO plans.

Does Medicare have HMO and PPO options?

Yes, there are many options for Medicare plans. Some Medicare Advantage (Part C) plans are HMO or PPO. Learn more about the types of Medicare Advantage plans.

HMO, EPO, and PPO Frequently Asked Questions

What’s the difference between in-network coverage and out-of-network coverage?

Each time you seek medical care, you can choose your doctor. You have the choice between an in-network and out-of-network provider. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs. That’s because participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges.

If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher. Otherwise, your visit may not be covered.

What if I need to be admitted to the hospital?

In an emergency¹, your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance (also called prior authorization or pre-certification). This allows Cigna Healthcare^SM to determine if the services are covered by your plan.

Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections. Depending on your plan, you may be eligible for additional coverage.

Who is responsible for getting prior authorization?

Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor is in the Cigna Healthcare network, they will arrange for prior authorization.

If you use an out-of-network doctor, you are responsible for making the arrangements. Your plan materials will identify which procedures require prior authorization.

How do I find out if my doctor is in the Cigna Healthcare plan’s network before I enroll?

It’s quick and easy to search for participating providers, specialists, pharmacies, hospitals, and facilities to match your needs.

1. Visit the Find a Doctor page.
2. Choose a provider directory:
   1. If you're a Cigna Healthcare customer, log in to myCigna to quickly see in-network providers.
   2. If you're not a Cigna Healthcare customer yet, select the type of plan you're enrolling in.
3. Once on the provider directory, enter your search location, select the plan type, and enter the search terms in the search box related to type of provider or facility you're looking for.
4. Your search results will show the in-network providers based on your search criteria, along with other details that can help you when enrolling.

View Cigna Healthcare Company Names

¹ Emergency Services as defined by your specific plan. Some plans may also provide out-of-network coverage for certain Urgent Care Services. See your plan documents for the details of your specific medical plan.

Plans contain exclusions and limitations and may not be available in all areas. For costs and details of coverage, review your plan materials.

Individual and Family Medical products and services are provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. In Utah, all products and services are provided by Cigna Health and Life Insurance Company (Bloomfield, CT).

Individual and Family Dental products and services are provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company and Cigna Dental Health, Inc. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan and this plan utilizes the national Cigna Dental PPO Network. In Utah, all products and services are provided by Cigna Health and Life Insurance Company (Bloomfield, CT).

Group Medical and Dental products and services are provided exclusively by or through operating subsidiaries of The Cigna Group including Cigna Health and Life Insurance Company (Bloomfield, CT.) (CHLIC), Evernorth Behavioral Health, Inc., Evernorth Care Solutions, Inc., Express Scripts, Inc., or their affiliates. In Utah, all products and services are provided by Cigna Health and Life Insurance Company (Bloomfield, CT).

© 2024 Cigna Healthcare