HMO, PPO, EPO or POS: Which Health Plan Network Type Fits You
How HMO, PPO, EPO and POS plans differ on referrals, out-of-network coverage and cost, with a decision table and the federal rules that protect you in an emergency.
The four network types differ on two questions: whether the plan pays anything for care outside its network, and whether you need a referral from a primary care doctor before seeing a specialist. HMOs and EPOs generally cover only in-network care except in an emergency, PPOs let you go out of network without a referral at a higher cost, and POS plans charge less in network and require a referral to see a specialist.
Which one fits depends less on the label than on how you use care: whether your doctors are all in one network, how often you see specialists, and how much you would pay to keep the option of going elsewhere. This guide covers each type, what changes on a bill outside the network, the emergency protections that apply everywhere, and a decision table.
Marketplace open enrollment for 2027 coverage on HealthCare.gov runs from November 1, 2026 to January 15, 2027, so this is when you choose the network type for next year. Open enrollment for 2027 health plans covers the deadlines.
Key takeaways
- An HMO usually covers only care from its own network, except in an emergency, and many HMOs require a referral to see anyone but your primary care doctor.
- An EPO covers services only from its network, except in an emergency.
- A PPO pays for care from providers outside its network, with no referral needed, but that care costs you more.
- A POS plan costs less when you use its network and requires a referral from your primary care doctor to see a specialist.
- Out-of-network spending does not count toward your out-of-pocket maximum, and an out-of-network provider can bill you for the gap between its charge and the plan's allowed amount.
- Emergency care is the exception to every network rule: a plan that covers it must do so without prior authorization and at no more than in-network cost sharing, whatever the network type.
How each network type works
A network is the group of doctors, hospitals and other providers that have a contract with the plan. The plan's allowed amount is the most it will pay for a covered service, and providers in the network may not bill you for more than that for covered services. The four types set different rules for staying inside that group.
HMO (health maintenance organization)
An HMO generally pays only for care from doctors who are employed by it or have a contract with it, and it usually leaves out-of-network care uncovered unless there is an emergency. You may have to live or work inside the HMO's service area to qualify. Many HMOs also want a referral, meaning a written order from your primary care doctor, before they will pay for care from any other provider. Skip that step and the plan may refuse to pay.
EPO (exclusive provider organization)
An EPO is a managed care plan that pays for services only when the doctor, specialist or hospital belongs to its network, emergencies aside. HealthCare.gov's description of EPOs says nothing about referrals, so check the plan's own rules if you see specialists often.
POS (point of service)
A POS plan charges you less when you stay with doctors, hospitals and other providers in its network, and you need a referral from your primary care doctor before you see a specialist. HealthCare.gov's description does not say how POS plans pay for care outside the network, so read the plan's documents for that.
PPO (preferred provider organization)
A PPO has a network of contracted doctors and hospitals and charges you less when you use them. You can also go to providers outside the network without a referral, but you pay more for that care. In KFF's 2025 survey of employer health plans, the average annual premium for single coverage was $9,818 for workers in PPOs, higher than the $9,325 average across all plan types.
| Feature | HMO | EPO | POS | PPO |
|---|---|---|---|---|
| Out-of-network care covered? | Generally no, except emergencies | No, except emergencies | Check the plan; network care costs less | Yes, at an additional cost |
| Referral to see a specialist? | Required in many HMOs | Check the plan | Required | Not needed, even out of network |
| Other rules to know | May require you to live or work in its service area | Network rule is strict outside emergencies | Primary care doctor refers you to specialists | Out-of-network costs do not count toward the out-of-pocket maximum |
Among covered workers in job-based plans, PPOs remain the most common type. KFF's 2025 Employer Health Benefits Survey found 46% of covered workers in a PPO, 33% in a high-deductible plan with a savings option, 12% in an HMO, 9% in a POS plan and less than 1% in a conventional plan. On the Marketplace, HealthCare.gov says the types you find at each metal level depend on how many plans are offered in your area.
In network vs out of network: what changes on the bill
Going out of network changes three things at once. The plan may pay less or nothing. The provider has not agreed to the allowed amount, so it can send you a balance bill for the difference between its charge and what the plan allows. And HealthCare.gov's definition of the out-of-pocket maximum leaves out out-of-network care, so that spending does not move you any closer to the cap.
Example: An enrollee who has already met any deductible that applies needs a specialist visit. The plan's allowed amount is $200, and the out-of-network provider charges $350. These prices and percentages are illustrative.
In network, with 20% coinsurance, the enrollee pays $40 (20% of $200), and that $40 counts toward the out-of-pocket maximum.
Out of network in a PPO with 40% out-of-network coinsurance, the enrollee pays $80 (40% of $200) plus a balance bill of $150 ($350 minus $200), for $230 in total, none of which counts toward the in-network maximum.
Out of network in an HMO or EPO, outside an emergency, the plan pays nothing, so the enrollee can owe the full $350.
The coinsurance percentage, then, tells only part of the out-of-network story. The provider's charge and the plan's allowed amount are the two figures that decide the rest. The guide to comparing health plans by total yearly cost shows how to fold out-of-network care into a full-year estimate.
Emergencies and surprise bills: the rules that apply to every type
Federal No Surprises Act rules, in effect since January 1, 2022, override the network rules above in the situations below.
Emergency care
Under the federal regulation on emergency services (45 CFR 149.110), a plan that covers emergency services must cover them without requiring prior authorization, even if they are given out of network, and whether or not the provider is in the network. Your cost sharing cannot be higher than it would be in network, and what you pay counts toward your in-network deductible and in-network out-of-pocket maximum. CMS adds that when your plan covers emergency care, an air ambulance provider cannot charge you more than your in-network cost-sharing amount either.
Out-of-network providers at in-network facilities
The law also shields you from out-of-network charges for non-emergency care connected to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center. The shield does not extend to other places, such as a doctor's office that is not part of a hospital outpatient department.
In some situations an out-of-network provider asks you to sign a notice-and-consent form. Signing it means you accept out-of-network care, give up these protections and will likely pay more. CMS names providers who are not allowed to ask for that signature: emergency medicine providers, anesthesiologists, pathologists, radiologists, neonatologists, assistant surgeons, hospitalists, intensivists and providers of diagnostic services such as lab work. The form also may not be used when no in-network provider at the facility can give the care you need.
What is not covered
Ground ambulance services are generally outside the No Surprises Act billing protections and can still charge out-of-network rates, unless a state law says otherwise. If you think a bill breaks these rules, the No Surprises Help Desk is 1-800-985-3059. What the No Surprises Act protects you from covers disputes and reporting in more detail.
Which network type fits how you use care
Each row is a starting point; the plan's own network, premium and cost sharing decide the final answer.
| If this describes you | Types that usually fit | What to check before enrolling |
|---|---|---|
| Your doctors and hospital all belong to one plan's network | HMO or EPO | Every doctor you use is in the provider directory; the HMO's service area covers where you live or work; the premium compared with other plan types |
| You see one or more specialists regularly and would rather not ask for referrals | PPO, or an EPO that does not require referrals | The referral rules in the plan documents; the specialists are in network |
| Your doctors are spread across systems, or one you rely on is out of network | PPO | The out-of-network deductible and coinsurance, and whether that provider balance bills |
| You want a primary care doctor coordinating your care, with lower costs in network | HMO or POS | Your primary care doctor is accepting new patients; how out-of-network care is handled |
| You live part of the year in another area, or cover a family member who does | PPO, or a network that covers both places | Coverage for non-emergency care away from home |
| You mainly need preventive care and protection against a large bill | Any type | The network for routine care and the out-of-pocket maximum |
The table comes down to one trade-off. If every provider you use is inside one network, a restricted network costs you nothing in access, so compare its premium and cost sharing with a PPO's. If keeping a particular out-of-network doctor matters, the extra you would pay for a PPO is the price of that option. A permanent move can matter too, because an HMO may require you to live or work in its service area; what happens to your health insurance when you move states explains the special enrollment rules.
Frequently asked questions
Does an HMO require a referral to see a specialist?
In many HMOs, yes. A referral is your primary care doctor's written order for the specialist visit; go without one and the plan may decline to pay. POS plans also require a referral to see a specialist.
What is the difference between an HMO and an EPO?
Both generally cover only in-network care except in an emergency. HMOs can limit eligibility to people who live or work in their service area, and many require referrals. HealthCare.gov's description of EPOs does not address referrals, so read the plan's documents.
Does a PPO cover out-of-network care at the same cost as in-network care?
No. You can see out-of-network providers without a referral, but at an additional cost. That spending does not count toward your out-of-pocket maximum, and the provider can balance bill you for charges above the plan's allowed amount.
Does an HMO or EPO cover an emergency at an out-of-network hospital?
Yes. HMOs and EPOs make an exception for emergencies, and federal rules require a plan that covers emergency services to cover them without prior authorization, regardless of whether the hospital is in network, and to charge no more than in-network cost sharing. Those payments count toward your in-network deductible and out-of-pocket maximum.
Can a surprise bill still arrive after care at an in-network hospital?
For most care connected to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, the No Surprises Act protects you from out-of-network charges. Two gaps to know about are signing a valid notice-and-consent form and ground ambulance rides, which are generally outside the federal protections.
Sources
- Health insurance plan & network types: HMOs, PPOs, and more (HealthCare.gov)
- Referral (HealthCare.gov)
- Allowed amount (HealthCare.gov)
- Out-of-pocket maximum/limit (HealthCare.gov)
- When can you get health insurance? (HealthCare.gov)
- 45 CFR 149.110: Preventing surprise medical bills for emergency services (Electronic Code of Federal Regulations)
- Know your medical bill rights when using insurance (Centers for Medicare & Medicaid Services)
- Employer Health Benefits 2025 Annual Survey: Summary of Findings (KFF)