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Health insurance
HMO vs. POS vs. PPO vs. EPO: health plan comparison
Health plans differ mainly in whether you need a primary care doctor, whether specialists need a referral, and what happens if you go outside the plan’s network. This chart lines up the four common plan types so you can see the trade-offs at a glance.
| Feature | HMO | POS | PPO | EPO |
|---|---|---|---|---|
| Primary care doctor (PCP) required | Yes | Yes | No | Usually no |
| Referral needed to see a specialist | Yes | Yes, for in-network care at the lowest cost | No | Usually no |
| Out-of-network coverage | None, except emergencies | Yes, at higher cost | Yes, at higher cost | None, except emergencies |
| Premium | Lowest | Middle | Highest | Low to middle |
| Paperwork | Little | Some, such as claim forms for out-of-network care | Some, for out-of-network care | Little |
| Best for | Cost-focused members who are fine staying in one network | Members who want HMO pricing with an escape hatch | Members who want freedom to see any doctor without referrals | Members who want no referrals but can stay in network |
| How it works | You pick a PCP who coordinates all your care. Specialists need a referral, and you stay in network or pay full cost. Kaiser is the classic example. | You have a PCP and referrals for in-network care, which keeps costs low. You can go out of network without a referral, usually with a deductible, then coinsurance (often 30–50%), and you may file the claim yourself. | No PCP and no referrals. You can see any provider, and in-network care costs less. You pay for that flexibility in higher premiums. | Like a PPO without referrals, but with no out-of-network coverage. |
California small group notePOS plans are less common in California small group than HMOs, PPOs and EPOs. With CalChoice, employees can each pick the plan type that suits them, so an HMO and a PPO can sit side by side in the same group.
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