Should I choose an HMO or PPO health plan? And what do those terms mean?

Whether you’re looking at individual or group health insurance, you can choose from several different types of health plans—including HMOs, PPOs and EPOs. If that sounds confusing, don’t worry. We’ll explain each type below.

Generally speaking, some of these plan types provide you with as many choices as possible when it comes to doctors and hospitals. Others keep costs in check by limiting you to a network of doctors and hospitals.

Which type is the best for you? That depends on how much convenience and protection you want, and how much you are willing to spend.

Here’s a brief overview of three popular types of health insurance plans:

PPO

PPO stands for Preferred Provider Organization. Like the name implies, persons covered under a PPO plan generally need to get their medical care from doctors or hospitals on the insurance company’s list of preferred providers in order for claims to be paid at the highest level. It’s your responsibility to make sure that the health care providers you visit participate in the PPO. Services rendered by out-of-network providers may not be covered or may be paid at a lower level.

A PPO plan may be right for you if:

  • Your favorite doctor already participates in the network
  • You want some freedom to direct your own health care but don’t mind working within a list of preferred providers

HMO

HMO stands for Health Maintenance Organization. HMO plans offer a wide range of health care services through a network of providers that contract with the HMO, or who agree to provide services to members. Members of HMO plans will typically need to select a primary care physician to provide most of their health care and refer them to HMO specialists as needed. Health care services obtained outside of the HMO are typically not covered, except in an emergency.

An HMO plan may be right for you if:

  • You’re willing to play by the rules and coordinate your care through a primary care physician
  • You want to save every dollar possible; many HMO plans typically have lower monthly premiums than comparable PPO plans

EPO

EPO stands for Exclusive Provider Organization. EPO plans are similar to PPO plans but may be somewhat more restrictive when it comes to your network of doctors and hospitals. EPO plans typically do not provide you with coverage outside your network, except in emergencies. EPO plans are becoming more popular with health insurance shoppers, and health insurance companies are offering more of them as well. You’re generally not required to select a single primary care doctor with an EPO plan.

An EPO plan may be right for you if:

  • You don’t mind getting your care through a specific network of doctors and medical providers
  • You prefer not to coordinate your medical care through a primary care doctor

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.