What is the difference between an HMO, EPO, and PPO?
What are the main differences between HMO, PPO, and EPO plans?
|PCP required||And it is||nope||often not always|
|Out-of-network coverage||For medical emergencies only 1||Yes, at a higher cost||For medical emergencies only 1|
|referrals needed||And it is||nope||nope|
What is an HMO?
An HMO, or Health Maintenance Organization, is a type of health plan that offers a local network of doctors and hospitals that you can choose from. It generally offers lower monthly premiums than a PPO or EPO health plan. An HMO may be right for you if you are comfortable with choosing a primary care provider (PCP) to coordinate your health care and are willing to pay a higher deductible to receive a lower monthly health insurance premium.
What is a PPO?
A PPO, or Preferred Provider Organization, 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 generally higher with a PPO plan than with an HMO or EPO. If you are willing to pay a higher monthly premium for more choice and flexibility in selecting your doctor and health care options, we recommend that you choose a PPO health plan.
What is an EPO?
An EPO, or Exclusive Provider Organization, is a type of health plan that offers a local network of doctors and hospitals to choose from. An EPO is generally cheaper than a PPO plan. However, if you choose to get care outside of the plan’s network, it generally won’t 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, we recommend you consider an EPO plan.
HMO, EPO, and PPO FAQs
What is the difference between in-network and out-of-network coverage?
Whenever you seek medical care, you can choose your doctor. You have the option to choose between an in-network doctor and an out-of-network doctor. When you visit an in-network doctor, you’ll receive in-network coverage and have lower out-of-pocket costs. This is because participating health care providers have agreed to charge lower rates, and plans typically cover a larger portion of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will be higher or your visit will not be covered.
What happens if I need to be hospitalized?
In an emergency 1, 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. Precertification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for cesarean deliveries. Depending on your plan, you may be eligible for additional coverage.
Who is responsible for obtaining precertification?
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, he or she will be responsible for obtaining precertification. If you see a doctor outside the network, you will be responsible for making arrangements. The plan documents will identify the procedures that require prior certification.
How can I find out if my doctor is in Cigna’s network before I sign up?
Finding participating doctors, specialists, pharmacies, hospitals, and facilities that are right for you is quick and easy.
- Visit the Find a Doctor page
- Choose a directory:
- If you’re a Cigna customer, sign in to myCigna SM to quickly view in-network providers
- If you are not yet a Cigna customer, select the type of plan you will enroll in
- Once in the provider directory, type in your search location, select the plan type and enter your search terms in the search box linked to the type of provider or facility you’re looking for.
- Search results will display in-network providers based on your search criteria, along with other details that may help you enroll
Affordable health insurance plans
The Open Enrollment Period for coverage in 2022 has ended, but you can still get your health coverage if you have a qualifying life event. To shop for a new plan during the Special Enrollment Period, which runs through October 31, 2022, visit HealthCare.gov.
Looking for health insurance in 2022?
If you had a recent qualifying life event such as marriage, moving, birth or adoption of a child, or the loss of your current health insurance coverage, you may be eligible to enroll during the Special Enrollment Period, which runs through October 31 of 2022.
Your Special Enrollment Period lasts 60 days after your qualifying event and allows you to enroll in or change a plan outside of the annual Open Enrollment Period.
You may also qualify for government subsidies, such as a premium tax credit, which can help pay your monthly premiums, or a cost-sharing reduction, which lowers the amount you pay for deductibles, copays, and coinsurance.