PPO vs EPO: Comparing Types of Medicare Advantage Plans


When you qualify for Medicare, you must decide how you want to receive your coverage. You have several options to choose from, such as Original Medicare, Medicare Advantage plans, Medicare Supplement plans, and others. Even within those options you have additional choices. For example, there are different types of Medicare Advantage plans, each with different costs, networks, and requirements for care.

When comparing options, you'll see acronyms such as PPO, EPO, and HMO, as well as terms like co-pay, co-insurance, deductible, provider network, and more.

All this information can make it challenging to choose how to receive coverage. Here, learn about the different types of Medicare Advantage plans available and get a better understanding of how to decide which type of plan is right for you.

Are there different types of Medicare Advantage plans?

Original Medicare is made up of Part A, which is your hospital coverage, and Part B, which helps pay for medical services and supplies.

An alternative way you can get your Part A and B coverage is through a Medicare Advantage (Part C) plan. MA plans are sold by private insurance companies and cover everything Original Medicare does and more, often including routine hearing, vision, and dental coverage, and other benefits. In addition, around 90% of MA plans also include prescription drug coverage.

There are primarily five types of Medicare Advantage plans:

  • Health Maintenance Organization (HMO) plans
  • Preferred Provider Organization (PPO) plans
  • Exclusive Provider Organization (EPO) plans
  • Private Fee-for-Service (PFFS) plans
  • Special Needs Plans (SNPs)

In most cases, you may only see doctors or providers who are in the plan's network and you must live within the service area the plan covers. However, provider networks, costs, and coverage can vary depending on the plan.

What are provider networks?

Before learning the difference between the different types of MA plans, it's important to understand provider networks.

A provider network is a list of the doctors, healthcare providers, facilities, and hospitals a plan's members can see or go to for care. In-network providers are those that are contracted with a plan, and out-of-network providers are not contracted with the plan.

Depending on the type of MA plan you purchase, care may only be covered when you see an in-network provider. Or, though you can see an out-of-network provider, you may have to pay more or get a referral.

  • HMO: With these plans, you're typically limited to receive care from doctors who are in-network, and out-of-network care is not covered except for emergencies. You also usually need a referral from your primary care provider (PCP) in order to see a specialist.
  • PPO: While you pay less if you see in-network providers, PPO plans allow you to get care from out-of-network providers without a referral. This may cost more but provides more flexibility to see any doctor.
  • EPO: Somewhere in the middle of an HMO and PPO plan, you do not need a referral to see a specialist if you have an EPO plan. However, you typically do have to stay in-network and there are no out-of-network benefits.

When choosing a plan, it's important to understand the provider network to make sure you get the care you need at the lowest cost. You can find the plan's provider directory on their website, or you can contact the plan and request one.

What is an HMO plan?

An HMO plan generally has the lowest premiums and deductibles of all the MA plans, as well as fixed co-pays and co-insurance for medical services. This type of health plan offers a network of providers to choose from for care, and you typically must only see providers in that network (except for emergency care, out-of-area urgent care, and out-of-area dialysis).

If you see an out-of-network provider, you may have to pay the full cost out-of-pocket.

When you have an HMO plan, you must choose a primary care provider to help coordinate your care and provide any referrals for visits to a specialist. They will also handle any pre-approvals you need for certain medical services.

In most cases, prescription drugs are also covered if you join a plan that offers Part D coverage.

If you want MA coverage with a lower cost and you don't have outstanding medical issues or concerns, an HMO plan may be right for you.

Key takeaways for HMO plans

  • Is a PCP required? Yes.
  • Is there coverage for out-of-network care? In emergencies only.
  • Are referrals needed? Yes.

What is a PPO plan?

PPO plans give you flexibility to see both in- and out-of-network providers, though you'll pay less to see in-network "preferred" providers and more for out-of-network services. But, you can get healthcare from any doctor, healthcare provider, or hospital.

In addition to higher costs to see out-of-network providers, PPO plans typically have higher monthly premiums.

Another difference is that you're not required to have a PCP, and you are less likely to need a referral to see a specialist. However, you may still need pre-approvals for certain medical services so you should check with the plan to learn more.

In most cases, prescription drugs are also covered, though you must join a plan that offers Part D coverage.

If having the ability to see any provider for care is important to you, and you don't mind paying a higher premium or costs for care, a PPO plan could be a good option.

Key takeaways for PPO plans

  • Is a PCP required? No.
  • Is there coverage for out-of-network care? Yes, although at a higher cost.
  • Are referrals needed? No.

What is an EPO plan?

Only in-network care is covered by an EPO plan, though these provider networks are typically larger than HMO plans. If you choose to get care from an out-of-network provider, the costs will likely not be covered (except for an emergency).

Though similar, there are a few differences between an HMO and EPO plan. First, you are less likely to need a PCP, and you can see a specialist without a referral. You can usually get care from any provider if you stay in-network.

Because you aren't required to have a PCP, you're more likely to need pre-approvals before receiving certain medical services.

As for cost, premiums are typically higher than HMO plans but lower than PPO plans. However, you may have a higher deductible.

Key takeaways for EPO plans

  • Is a PCP required? Not always.
  • Is there coverage for out-of-network care? In emergencies only.
  • Are referrals needed? No.

So, which is better: PPO or EPO?

Deciding which type of MA plan is right for you depends on your unique situation. A few things to ask yourself or keep in mind include:

  • List any doctors, hospitals, or other providers you want access to, especially your existing doctors. When comparing plans, check to see if those providers are in- or out-of-network.
  • Ask yourself how important it is to be able to see out-of-network providers. If it's important to have more flexibility, a PPO plan may work better, because with an EPO plan, you're restricted to see in-network providers only.
  • If you want to pay a lower premium and co-pays, an EPO plan may cost less. On the other hand, PPO plans sometimes have a lower deductible.

Are you ready to join a Medicare Advantage plan? Just call us toll-free at 1-855-537-2378 to talk to one of our licensed Medicare agents. They'll explain your plan options and answer your questions in language you can understand.

Additional resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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