What is the Difference Between an HMO, EPO, and PPO?

What are the main differences between HMO, PPO, and EPO plans?

Which plan is right for me?

What is an HMO?

A Health Maintenance Organization (HMO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. It usually has lower monthly premiums than a PPO or an EPO health plan. An HMO may be right for you if you’re comfortable choosing a Primary Care Provider (PCP) to coordinate your health care and are willing to pay a higher deductible to get a lower monthly health insurance premium.

What is a PPO?

A Preferred Provider Organization (PPO), is a type of health plan that offers a larger network so you have more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. If you're willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and health care options, you may want to choose a PPO health plan.

What is an EPO?

An Exclusive Provider Organization (EPO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan.

HMO, EPO, and PPO Frequently Asked Questions

What’s the difference between in-network coverage and out-of-network coverage?

Each time you seek medical care, you can choose your doctor. You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs. That’s because participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher or your visit may not be covered.

What if I need to be admitted to the hospital?

In an emergency¹, your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance or pre-certified. This allows Cigna to determine if the services are covered by your plan. Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections. Depending on your plan, you may be eligible for additional coverage.

Who is responsible for getting pre-certification?

Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor is in the Cigna network, they will arrange for pre-certification. If you use an out-of-network doctor, you are responsible for making the arrangements. Your plan materials will identify which procedures require pre-certification.

How do I find out if my doctor is in the Cigna plan’s network before I enroll?

It’s quick and easy to search for participating doctors, specialists, pharmacies, hospitals, and facilities to match your needs.

1. Visit the Find a Doctor page.
2. Choose a directory:
   1. If you're a Cigna customer, log in to myCigna to quickly see in-network providers.
   2. If you're not a Cigna customer yet, select the type of plan you're enrolling in.
3. Once on the provider directory, enter your search location, select the plan type, and enter the search terms in the search box related to type of provider or facility you're looking for.
4. Your search results will show the in-network providers based on your search criteria, along with other details that can help you when enrolling.