What is the difference between an HMO and a PPO?
Plan type shapes which doctors the plan covers and whether you need a referral before a specialist. HMO and PPO are two Marketplace labels for those network rules.
Arun Verma, co-founder of Triangle · 2026-10-19
This is not clinical evidence and not medical advice. It does not replace your care team. Discuss anything here with your clinician before you act on it.
What is the difference between an HMO and a PPO?
An HMO usually limits coverage to care from doctors who work for or contract with the HMO, and it generally will not cover out-of-network care except in an emergency. A PPO costs less when you use providers in the plan's network, and you can use doctors, hospitals and providers outside the network for an additional cost, without a referral. The difference is what happens outside the network: an HMO generally does not cover it except in an emergency, and a PPO covers it for an additional cost. HealthCare.gov describes the same split more broadly: some Marketplace plans restrict your provider choices or encourage care inside the plan's network of doctors, hospitals, pharmacies and other providers; others pay a greater share of costs for providers outside that network. Depending on what is offered in your area, you may see HMO or PPO plans at each metal level: Bronze, Silver, Gold and Platinum.
What is an HMO?
HealthCare.gov defines an HMO as a health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally will not cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. CMS's networks guide says the same: you are usually limited to those contracted doctors and are not covered for out-of-network care except in an emergency. HealthCare.gov adds that HMOs often provide integrated care and focus on prevention and wellness.
What is a PPO?
HealthCare.gov's glossary defines a PPO as a plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network, and you can use doctors, hospitals and providers outside the network for an additional cost. On the Marketplace plan-types page, that additional-cost out-of-network care does not need a referral. CMS's networks guide repeats the same PPO pattern: pay less in network, and for an additional cost you can use out-of-network doctors without a referral.
What are EPO and POS plans?
An EPO is a managed care plan where services are covered only if you use doctors, specialists or hospitals in the plan's network, except in an emergency. A POS plan costs less when you use doctors, hospitals and other providers in the plan's network, and it requires a referral from your primary care doctor to see a specialist. HealthCare.gov lists EPO and POS next to HMO and PPO as Marketplace plan types you may find, depending on how many plans are offered in your area. CMS's networks guide matches those EPO and POS lines.
What is a referral, and which plan types usually need one?
A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services. In many HMOs you need one before you can get care from anyone except your primary care doctor, and if you do not get a referral first, the plan may not pay for the services. PPOs generally do not require a referral: HealthCare.gov and CMS say you can use doctors, hospitals and providers outside the network without a referral, for an additional cost, and Medicare.gov's compare table says a Medicare Advantage PPO does not need a referral to use a specialist. POS plans also require a referral from your primary care doctor to see a specialist.
How do I check whether my doctors are in a plan's network?
A network is the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. CMS's networks guide says insurance companies may have different networks for different plans, so the check is against each specific plan you compare, not against the insurer's name alone. That guide says you can search each plan's provider network and call the insurer's customer service. On HealthCare.gov, the plan type initials PPO, POS, HMO or EPO appear under the plan name, and the type is also listed on each plan's Summary of Benefits and Coverage. CMS notes that providers can include doctors and pharmacies, among other facilities, and that people who travel a lot can check whether the network has providers where they might need care. A fair starting point the same guide names is a list of the providers you use, then a search for those doctors and facilities in each plan you are comparing.
How do Medicare Advantage HMOs and PPOs differ?
On Medicare.gov's compare table, Medicare Advantage HMOs usually require you to choose a primary care doctor and to get a referral to use a specialist, and you generally must get covered care from providers in the plan's network except for emergencies and other exceptions Medicare lists. Medicare Advantage PPOs do not require a primary care doctor or a specialist referral, and you can generally go to out-of-network providers for covered services while usually paying more. That table is about Medicare Advantage plan types, not Marketplace plans, so the labels match while the rules come from Medicare.gov.
What could I ask when comparing an HMO and a PPO?
You could ask whether each of your doctors and pharmacies sits in that plan's specific network, whether the plan is labeled HMO, PPO, EPO or POS, and whether a specialist visit needs a referral from a primary care doctor. A fair question for an HMO is whether you must live or work in its service area to be eligible. CMS says Marketplace plans cannot make you pay more for emergency care at an out-of-network hospital than they charge for in-network emergency care. No source says which plan type suits a given household.
Sources
- HealthCare.gov: Health insurance plan & network types: HMOs, PPOs, and more: HealthCare.gov says an HMO usually limits coverage to care from doctors who work for or contract with the HMO, and generally will not cover out-of-network care except in an emergency.
- HealthCare.gov: Health insurance plan & network types: HMOs, PPOs, and more: HealthCare.gov says a PPO is a type of health plan where you pay less if you use providers in the plan's network, and you can use doctors, hospitals and providers outside of the network without a referral for an additional cost.
- HealthCare.gov: Health insurance plan & network types: HMOs, PPOs, and more: HealthCare.gov says that depending on how many plans are offered in your area, you may find plans of all or any of these types (EPO, HMO, POS, PPO) at each metal level: Bronze, Silver, Gold and Platinum.
- HealthCare.gov: Health insurance plan & network types: HMOs, PPOs, and more: HealthCare.gov says some types of Marketplace plans restrict your provider choices or encourage you to get care from the plan's network of doctors, hospitals, pharmacies and other medical service providers, while others pay a greater share of costs for providers outside the plan's network.
- HealthCare.gov Glossary: Health Maintenance Organization (HMO): HealthCare.gov's glossary defines an HMO as a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO, generally will not cover out-of-network care except in an emergency, and may require you to live or work in its service area to be eligible for coverage.
- HealthCare.gov Glossary: Health Maintenance Organization (HMO): HealthCare.gov's glossary says HMOs often provide integrated care and focus on prevention and wellness.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says that with an HMO you are usually limited to care from doctors who work for or contract with the HMO and are not covered for out-of-network care except in an emergency, and that you may be required to live or work in the HMO's service area to qualify for coverage.
- HealthCare.gov Glossary: Preferred Provider Organization (PPO): HealthCare.gov's glossary defines a PPO as a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers; you pay less if you use providers that belong to the plan's network, and you can use doctors, hospitals and providers outside of the network for an additional cost.
- HealthCare.gov Glossary: Exclusive Provider Organization (EPO) Plan: HealthCare.gov's glossary defines an EPO as a managed care plan where services are covered only if you go to doctors, specialists or hospitals in the plan's network (except in an emergency).
- HealthCare.gov Glossary: Point of Service (POS) Plans: HealthCare.gov's glossary defines a POS plan as a type of plan in which you pay less if you use doctors, hospitals and other health care providers that belong to the plan's network, and says POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
- HealthCare.gov: Health insurance plan & network types: HMOs, PPOs, and more: HealthCare.gov lists Exclusive Provider Organization (EPO), Health Maintenance Organization (HMO), Point of Service (POS) and Preferred Provider Organization (PPO) as examples of plan types you will find in the Marketplace.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says Exclusive Provider Organizations (EPOs) cover you only if you use doctors, specialists or hospitals in the plan's network (except in an emergency), and that Point-of-Service (POS) plans require referrals from your primary care doctor to go to specialists while you pay less if you use providers in the plan's network.
- HealthCare.gov Glossary: Referral: HealthCare.gov's glossary defines a referral as a written order from your primary care doctor for you to see a specialist or get certain medical services.
- HealthCare.gov Glossary: Referral: HealthCare.gov's glossary says that in many HMOs you need to get a referral before you can get medical care from anyone except your primary care doctor, and that if you do not get a referral first the plan may not pay for the services.
- HealthCare.gov Glossary: Network: HealthCare.gov's glossary defines a network as the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says insurance companies may have different networks for different plans, and that the provider network of each specific plan you compare is the one to search.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says you can also call the insurance company's customer service phone number to find out if your providers are in the plan's network.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says that when comparing plans on HealthCare.gov the plan type is listed immediately below its name (look for the initials PPO, POS, HMO or EPO), and that the type of plan is also listed on each plan's Summary of Benefits and Coverage.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says providers can include doctors, psychologists or physical therapists, and health care facilities like hospitals, urgent care clinics or pharmacies.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says that if you travel a lot, check if the plan's network has providers where you might need care.
- Medicare.gov: Compare types of Medicare Advantage Plans: Medicare.gov's compare table says that for a Medicare Advantage HMO you usually need to choose a primary care doctor and need a referral from your doctor to use a specialist, and that you generally must get care and services from providers and facilities in the plan's network (except emergency or urgent care and other exceptions Medicare lists).
- Medicare.gov: Compare types of Medicare Advantage Plans: Medicare.gov's compare table says that for a Medicare Advantage PPO you do not need to choose a primary care doctor and do not need a referral to use a specialist, and that you may also go out of the plan's provider network but may pay more.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says insurance plans cannot make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says to make a list of all the providers you use, and when you compare plans, search for your doctors and health care facilities.
- CMS: What You Should Know About Provider Networks (CMS Product No. 11766, February 2026): CMS's networks guide says that with Preferred Provider Organizations (PPOs) you pay less if you use providers in the plan's network, and for an additional cost you can use doctors, hospitals and health care providers outside of the network without a referral.
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