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HMO vs PPO vs EPO: California Health Insurance Networks

Understanding the differences between HMO, PPO, and EPO health plans is crucial when choosing Covered California insurance. The network type affects which doctors you can see, how much you'll pay, and whether you need referrals for specialists.

Quick Answer: HMOs are the most affordable but require referrals and restrict you to network providers. PPOs offer maximum flexibility to see any doctor but cost more. EPOs are a middle ground with lower costs than PPOs but no out-of-network coverage except emergencies.

What Are Health Insurance Network Types?

When you enroll in a Covered California health plan, you're not just choosing a metal tier (Bronze, Silver, Gold, or Platinum) — you're also selecting a network type that determines how you access healthcare.

A health insurance network is a group of doctors, hospitals, and other healthcare providers that have contracted with your insurance carrier to provide services at negotiated rates. The network type defines:

  • Which doctors and hospitals you can visit
  • Whether you need referrals to see specialists
  • How much you'll pay for care
  • What happens if you go out-of-network

The three most common network types in California are HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), and EPO (Exclusive Provider Organization).

Important: All Covered California plans — regardless of network type — cover the 10 essential health benefits including doctor visits, emergency care, hospitalization, prescription drugs, maternity care, and mental health services.

HMO vs PPO vs EPO: Side-by-Side Comparison

Feature HMO PPO EPO
Monthly Premium Lowest Highest Medium
Primary Care Doctor (PCP) Required Yes No No
Specialist Referrals Required Yes No No
Out-of-Network Coverage No (except emergencies) Yes (higher cost) No (except emergencies)
Network Size Medium Largest Medium
Flexibility to Choose Doctors Limited Maximum Moderate
Best For Budget-conscious, local care Frequent travelers, specific doctors Balance of cost and flexibility

HMO Plans (Health Maintenance Organization)

HMO plans are the most common network type in California and typically offer the lowest monthly premiums. They emphasize coordinated care through a primary care physician (PCP) who manages your overall healthcare.

How HMO Plans Work

Choose a Primary Care Doctor

When you enroll, you select a PCP from the plan's network. This doctor becomes your main point of contact for all non-emergency care and coordinates your treatment.

Get Referrals for Specialists

To see a specialist (like a cardiologist or dermatologist), you must first get a referral from your PCP. Without a referral, the visit typically won't be covered.

Stay In-Network

You must use doctors, hospitals, and providers within the HMO network. Out-of-network care is not covered except for emergency situations.

Lower Out-of-Pocket Costs

HMO plans typically have lower copays and deductibles compared to PPO plans, making them ideal for budget-conscious individuals and families.

Pros and Cons

Advantages

  • Lowest monthly premiums
  • Lower copays and deductibles
  • Coordinated care through PCP
  • No claim forms to file
  • Preventive care emphasized

Disadvantages

  • Must choose a primary care doctor
  • Referrals required for specialists
  • Limited to network providers
  • Less flexibility when traveling
  • Can't see specialists directly
California HMO Carriers: Kaiser Permanente, Blue Shield HMO, Health Net HMO, LA Care, Molina Healthcare, and others offer HMO plans through Covered California.

PPO Plans (Preferred Provider Organization)

PPO plans offer the greatest flexibility to see any doctor or specialist without needing referrals. You can even get coverage for out-of-network care, though you'll pay more.

How PPO Plans Work

No Primary Care Doctor Required

You don't have to choose a PCP or go through them for care. You can see any doctor in the PPO network directly.

Direct Access to Specialists

Need a dermatologist or cardiologist? Just schedule an appointment — no referral needed. This speeds up access to specialized care.

Out-of-Network Coverage

PPO plans cover out-of-network providers, though you'll pay higher copays and deductibles. This is ideal for frequent travelers or those with specific doctors.

Higher Costs

The flexibility comes at a price: PPO plans have higher monthly premiums and out-of-pocket costs compared to HMO plans.

Pros and Cons

Advantages

  • No PCP or referrals required
  • See any doctor or specialist
  • Out-of-network coverage available
  • Great for frequent travelers
  • Maximum flexibility and choice

Disadvantages

  • Highest monthly premiums
  • Higher copays and deductibles
  • Out-of-network costs can be very high
  • May need to file claim forms
  • Less coordinated care
Limited Availability: PPO plans are less common in Covered California compared to HMO plans and are typically only available in certain regions and metal tiers.

EPO Plans (Exclusive Provider Organization)

EPO plans are a hybrid between HMO and PPO, offering more flexibility than HMOs at a lower cost than PPOs. They're becoming increasingly popular in California.

How EPO Plans Work

No Referrals Needed

Like PPOs, EPO plans don't require you to choose a primary care doctor or get referrals to see specialists. You have direct access to all in-network providers.

Network-Only Coverage

Like HMOs, EPO plans do NOT cover out-of-network care (except emergencies). You must use providers within the EPO network.

Moderate Pricing

EPO premiums fall between HMO (lowest) and PPO (highest), offering a good balance of cost and flexibility.

Broad Networks

EPO networks are often comparable in size to PPO networks, giving you access to many doctors and hospitals without the PPO price tag.

Pros and Cons

Advantages

  • No referrals required
  • Lower premiums than PPO
  • Direct access to specialists
  • Broad provider networks
  • Balance of cost and flexibility

Disadvantages

  • No out-of-network coverage (except emergencies)
  • Higher cost than HMO
  • Less availability than HMO plans
  • Must verify network before appointments
  • Not ideal for frequent travelers
Who Offers EPO Plans? Several Covered California carriers offer EPO options including Blue Shield EPO, Anthem EPO, and Health Net EPO in select regions.

Cost Comparison: What You'll Pay

The network type significantly impacts your monthly premium and out-of-pocket costs. Here's what you can expect to pay in California:

Monthly Premium Comparison

Example: 40-year-old individual, Silver 70 plan, Los Angeles County (before subsidies)

HMO

$450

Lowest monthly cost

EPO

$520

Moderate monthly cost

PPO

$625

Highest monthly cost

Annual Cost Comparison

Estimated total yearly cost including premiums and typical medical use (primary care, specialist visits, prescriptions)

Network Type Annual Premium Typical Medical Costs Total Annual Cost
HMO $5,400 $1,200 $6,600
EPO $6,240 $1,200 $7,440
PPO $7,500 $1,500 $9,000
Good News for California Residents: Covered California subsidies can significantly reduce these premiums based on your income. Many Californians pay $10 or less per month after subsidies! Learn more about subsidies

Which Network Type is Right for You?

Choosing the right network type depends on your healthcare needs, budget, and personal preferences. Use this decision guide:

Choose an HMO if:

  • You want the lowest monthly premium — HMOs save you $100-200/month vs PPOs
  • You don't mind choosing a primary care doctor — Coordinated care can be beneficial
  • You primarily need local care — Don't travel frequently or need care outside California
  • You're comfortable with referrals — Don't mind getting PCP approval for specialists
  • You're budget-conscious — Lower copays and deductibles reduce out-of-pocket costs
  • You have a preferred network provider — Check if your doctors are in the HMO network

Choose a PPO if:

  • You value maximum flexibility — Want to see any doctor without restrictions
  • You travel frequently — Need coverage across state lines or in rural areas
  • You have specific doctors — Current providers aren't in HMO/EPO networks
  • You see specialists regularly — Don't want referral delays
  • You can afford higher premiums — Willing to pay extra for flexibility
  • You live part-time in different states — Need nationwide coverage

Choose an EPO if:

  • You want a balance of cost and flexibility — Don't need out-of-network but want no referrals
  • You like direct specialist access — Don't want to go through PCP for referrals
  • You primarily stay in California — Comfortable with network-only coverage
  • You want to save vs PPO — Get similar flexibility for $100-150/month less
  • Your doctors are in the EPO network — Verify providers before enrolling
  • You're organized — Willing to check network status before appointments

Pro Tip: Check Your Doctors First

Before choosing a network type, verify that your preferred doctors and hospitals accept the plan. Use our provider search tool or call our agents for help.

Find Your Doctor Speak with an Agent

California Carrier Network Types

Not all Covered California carriers offer all network types. Here's what each major carrier provides:

Network Type: HMO Only

Kaiser operates its own integrated healthcare system with employed doctors and owned hospitals. All Kaiser plans are HMO-style, requiring you to use Kaiser facilities and providers (except emergencies).

Best For: Coordinated care, all-in-one medical system, budget-conscious families. Learn more about Kaiser

Network Types: HMO, EPO, PPO (limited)

Blue Shield offers multiple network types depending on your region. HMO and EPO plans are widely available, while PPO options exist in select areas and metal tiers.

Best For: Flexibility to choose network type, broad provider access, statewide coverage. Learn more about Blue Shield

Network Types: HMO, EPO

Anthem primarily offers HMO and EPO plans in California through Covered California. Their EPO plans provide good network access without referrals at a reasonable price.

Best For: Large provider network, regional and statewide plans, EPO flexibility. Learn more about Anthem

Network Types: HMO, EPO

Health Net provides HMO and EPO options throughout California with competitive pricing and broad networks, especially in Southern California.

Best For: Affordable premiums, Southern California coverage, HMO and EPO choices. Learn more about Health Net

LA Care, Molina, Sharp Health Plan, Valley Health, and others:

Regional carriers typically offer HMO plans with very competitive pricing in their service areas. These plans are often the most affordable option in specific counties.

Best For: Lowest cost, county-specific coverage, deep regional networks. See all carriers

Network Availability Varies: The network types available to you depend on your county, metal tier choice, and the carriers operating in your area. Use our plan comparison tool to see your specific options.

Ready to Compare Plans?

Now that you understand HMO, PPO, and EPO networks, explore your Covered California plan options. Our licensed agents can help you choose the right network type for your needs.

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