Which health insurance plan is right for you?

Selecting the right health plan for you and your family is a big decision, especially since there are so many different types of plans.

Having a clear understanding of the fundamental differences between Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO) plans can help guide you to the right decision. So what should you consider before making a decision?

Overview and comparison

Health Maintenance Organization (HMO)

  • Offers a limited network of doctors and hospitals.
  • Typically has a lower monthly premium than a PPO, but less flexibility on choice of specialists.
  • Requires a primary care provider (PCP) to coordinate your health care.
  • Does not cover the cost of your treatment when you visit a doctor outside the network (except in the case of an emergency).

Preferred Provider Organization (PPO)

  • Offers a more extensive network of doctors, hospitals, and specialists.
  • Typically has a higher monthly premium and out-of-pocket costs than a HMO or EPO, in exchange for greater flexibility in choice of doctors/specialists.
  • Covers the cost of your treatment when you visit a doctor both in and out of the network.

Exclusive Provider Organization (EPO)

  • Offers a more limited network of doctors, hospitals, and specialists (like an HMO), but does not require a referral from a PCP (flexibility in choice of doctor/specialist like a PPO).
  • Typically has a lower monthly premium than a PPO health plan (for in-network only).
  • Does not cover the cost of your treatment when you visit a doctor outside the network (except in the case of an emergency).

PPO Tiered Plans (PPO Choice/ PPO Choice Select/Performance PPO)

  • Similar to an EPO where it offers a limited network of doctors and hospitals for the first tier of benefits.
  • Has the added benefit of a more extensive network of doctors and hospitals with a higher out of pocket costs for the second tier of benefits.
  • Typically has a lower monthly premium than a PPO health plan.
  • Covers the cost of your treatment when you visit a doctor both in and out of the network.
  HMO EPO PPO Choice
PPO Choice Select Performance PPO		 PPO

In-network coverage



Out-of-network coverage

 For these plans, out-of-network services are generally not covered unless otherwise provided in the contract (e.g., emergency services)

National Access with BlueCard network

 


Uses a tiered network to help save you money

  
  

Uses a specific hospital network

 
 

PCP required
 
  
  

Referrals required to see a specialist
 
  
  

Finding the plan that fits best: Price vs flexibility

Choosing the right plan ultimately depends on what will work best for you and your family.

A PPO may be better if you already have a doctor or medical team that you want to keep. An HMO might make sense if you don’t mind having a PCP manage your care. An EPO and PPO Tiered plan is a nice compromise…. between both a PPO and an HMO plan, but the decision still comes down to the amount of flexibility you and your family will need.

If you have a doctor or specialist you like, you can determine if they are in-network by using the MyCare Finder tool.

Plan options

We're here to help

Have questions or need more information about our individual and family plans? Call 800.451.1181 for assistance.

You can also walk-in or schedule an appointment at one our Capital Blue Cross Connect health and wellness centers.