When shopping for a health plan, it is important to understand the differences between the types of health plans to select the one that best fits your needs.
There are 3 types of health plans offered on the Covered California health exchange:
HMO
EPO
PPO
The difference between these plans primarily comes down to the flexibility to choose providers when you need medical care.
HMO PLANS
HMO (health maintenance organization) plans offer the least amount of flexibility. With an HMO plan, you pre-select one doctor to be your primary care physician (PCP). Your PCP acts as a 'gatekeeper' for your medical care. If you need to see a specialist, you must get a referral from your PCP first. With an HMO, you are not allowed to 'self-refer' to a specialist in the health plan's network without a referral from your PCP. HMOS also generally have more limited networks and choice of providers available to you. However, HMOS are typically the most affordable of the health plan choices.
EPO PLANS
An EPO (exclusive provider organization) is a hybrid between an HMO and a PPO and offers moderate flexibility. Unlike an HMO, you are not required to select a primary care physician and generally will have access to a larger network of providers. An EPO allows you to 'self-refer' to any provider in the plan's network without the need to obtain a referral first. Unlike PPO plans, EPO plans do not allow you to see a provider that is not in the health plan's network. EPOs typically provide greater choice and more flexibility than an HMO.
PPO PLANS
PPO (preferred provider organization) plans offer the most flexibility. Like an EPO, you can self-refer to any provider in the network, without the need to obtain a referral. The main benefit of a PPO, however, is that the plan provides some benefits for out-of-network providers. Some doctors may not accept any health insurance and require cash payment for services. With a PPO, you can see an out-of-network doctor that does not accept your insurance and the health plan will reimburse a portion of the costs. PPO plans typically have the largest network of providers to choose from. If choice and flexibility is important to you, a PPO plan may be the plan for you.
PLAN FEATURE
HMO
EPO
PPO
Need to designate a primary care physician?
Yes
No
No
Need a referral to see a specialist?
Yes
No
No
Is there an out of network benefit?
No
No
Yes
Level of flexibility
Low
Medium
High
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