Last reviewed: 3 October 2026
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HMO, PPO, EPO and POS: how the plan types differ, as two regulators describe them
The short answer: all four are plan types built around a network of doctors and hospitals. They differ in how much they cover outside the network, whether you need a primary care doctor, and whether you need a referral to see a specialist.[1] This page reports what two regulators say: HealthCare.gov (federal) and the Texas Department of Insurance, whose guide describes Texas. Rules in your state may differ. It does not say which type to choose.
The short version
- A network is the group of doctors, hospitals, pharmacies and other providers a plan contracts with.[2]
- HealthCare.gov says some plan types restrict your provider choices or encourage you to use the network. Others pay a greater share of costs for providers outside it.[2]
- The Texas Department of Insurance (TDI) says managed care plans limit your choice of doctors or encourage you to use their networks, and that in return you pay less out of pocket.[1]
What each source says about each plan type
| Plan type | HealthCare.gov | Texas Department of Insurance |
|---|---|---|
| HMO (Health Maintenance Organization) | 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. May require you to live or work in its service area.[2] | You must use network providers, with exceptions for emergencies and care not available in the network. You must choose a primary care physician and usually need a referral to a specialist.[1] |
| EPO (Exclusive Provider Organization) | Services are covered only if you use doctors, specialists or hospitals in the plan's network, except in an emergency.[2] | You must use network providers, with the same two exceptions. EPO plans usually do not require a primary care physician, and you do not need a referral to a specialist.[1] |
| PPO (Preferred Provider Organization) | You pay less if you use network providers. You can use providers outside the network without a referral for an additional cost.[2] | You can go to any doctor, but out-of-pocket costs are lower in the network. You do not have to choose a primary care physician or get a referral to a specialist.[1] |
| POS (Point of Service) | You pay less if you use network providers. HealthCare.gov says POS plans require a referral from your primary care doctor to see a specialist.[2] | You can go to any doctor, but out-of-pocket costs are lower in the network. You usually must have a primary care physician and get referrals to specialists.[1] |
The two sources word the POS referral rule differently: HealthCare.gov says POS plans require a referral, and TDI says "usually." Your plan's own documents control what applies to you.
TDI's side-by-side answers
| Question TDI asks | HMO | EPO | PPO | POS |
|---|---|---|---|---|
| Do I have to use providers in the network?[1] | Yes, with exceptions | Yes, with exceptions | No, but you pay more out of network | No, but you pay more out of network |
| Do I have to choose a primary care physician?[1] | Yes | No | No | Usually |
| Do I need a referral to a specialist?[1] | Yes | No | No | Usually |
TDI's table also has a "What's the cost?" row: HMO "Generally lowest of all plans," EPO "Usually lower than PPO," PPO "Generally highest of all plans," and POS "Usually lower than PPO."[1] TDI does not say whether that row means premiums or total spending. Prices depend on the specific plan, so compare each plan's own costs.
Details on the network and primary care rules
- TDI says HMO and EPO enrollees might have to pay the full cost of care outside the network, with exceptions for emergencies and for care not available in the network.[1]
- TDI says women do not need a referral to go to an OB/GYN in an HMO if the doctor is in the HMO's network.[1]
- TDI says that under some circumstances an HMO member can use a specialist as a primary care physician, with an ongoing, disabling or life-threatening condition.[1]
- TDI says you usually do not have to pay coinsurance in an HMO.[1]
HealthCare.gov adds that, depending on how many plans are offered in your area, you may find plans of any of these types at each metal level (Bronze, Silver, Gold and Platinum).[2]
How to verify this yourself
Read the two pages listed below. Then ask any plan you are considering for its Summary of Benefits and Coverage and its provider directory, and check whether your doctors and hospitals are in the network. TDI notes that if you ask, your plan must give you a Summary of Benefits and Coverage.[1]
What this page does not cover
TDI's guide describes Texas; HealthCare.gov describes Marketplace plans. We did not read other states' guidance, so rules, exceptions and wording may differ where you live and for employer plans. We do not cover other plan categories, costs of any specific plan, or whether your own doctors participate. We do not recommend a plan type. This is general information, not insurance, medical or legal advice. For your own case, ask the plan, your employer's benefits office, your state insurance regulator or HealthCare.gov.
Your next step
List the doctors, hospitals and prescriptions you use. Check each against a plan's network before you compare plan types. If you are picking a plan during an enrollment window, our guide to ACA enrollment periods explains the dates.
Related checks
Our standard explains how we check an agent's license and disciplinary history. Check an agent reports our findings at category level, as a method and not a verdict. Neither reviews any insurer, plan or product. To confirm the person selling you coverage is licensed, see how to check an agent's license. More plain-language guides are in the agent guides.
When we will update this page
We re-read the sources when they change. If something here is out of date, tell us. Corrections are dated on the page.
References
- [1] Texas Department of Insurance, "Health care coverage guide" (consumer bulletin), read 3 October 2026 — tdi.texas.gov/pubs/consumer/cb005.html
- [2] HealthCare.gov (U.S. Centers for Medicare & Medicaid Services), "Health insurance plan & network types: HMOs, PPOs, and more", read 3 October 2026 — healthcare.gov/choose-a-plan/plan-types/
What you can do next
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