Is a PPO's extra flexibility worth the cost?

That depends on how much you value seeing doctors outside the network. The Texas Department of Insurance says PPO costs are generally the highest of the four plan types. In exchange, you can go out of network, though you pay more when you do. If all your doctors and hospitals are in a plan's network, compare total costs on HealthCare.gov before you pay extra for out-of-network flexibility you may not use.

Should I get an EPO or an HMO?

Both plan types generally cover only network care, except for emergencies and, in Texas, care that isn't available in network. The main difference is access to specialists. In a Texas HMO you choose a primary care physician and usually need a referral, while an EPO usually requires neither. TDI says HMO costs are generally the lowest of all plans and EPO costs are usually lower than PPO.

What happens if my doctor leaves my plan's network mid-year?

In Texas, plans must let you keep seeing that doctor for a period of time if you have a terminal illness, disability, or life-threatening condition, or are pregnant, and the doctor agrees to keep treating you at the plan's contract rate. CMS says Marketplace enrollees may also qualify as a continuing care patient if the plan ends a provider's contract mid-treatment. In a Medicare Advantage HMO, the plan will notify you, and you may choose another provider in the plan.

Does Original Medicare have a network?

No. With Original Medicare you can use any doctor or hospital that takes Medicare anywhere in the U.S., and in most cases you don't need a referral to see a specialist. Keep in mind that Original Medicare has no yearly out-of-pocket limit unless you have supplemental coverage. Medicare Advantage plans do have a yearly limit, which may differ for in-network and out-of-network services.

Am I protected from surprise bills if an out-of-network doctor treats me at an in-network hospital?

If you have health insurance other than Medicare, TDI says state and federal surprise-billing laws ban surprise bills for care at an in-network hospital. You can still be billed your normal copay, coinsurance, or deductible. These protections don't change how your plan covers out-of-network care you choose on your own.

HMO vs PPO vs EPO: How Health Plan Networks Differ

The main differences between HMO, PPO, and EPO plans are whether the plan pays for care outside its network and whether you need a primary care doctor and referrals. HMO and EPO plans generally cover only network care, while PPO plans let you go out of network if you pay more. A fourth type, the point-of-service (POS) plan, mixes features of both. This guide compares all four for Marketplace plans and Medicare Advantage, with Texas rules and questions to ask before you choose.

Key takeaways

The Texas Department of Insurance (TDI) lists four types of major medical plans: HMO, EPO, PPO, and point-of-service. All four use a network of providers who agree to discounted rates.
HMO and EPO members must use network providers, except for emergencies and care that isn't available in network. PPO and POS members can go out of network but pay more.
HMOs and POS plans usually require a primary care physician and referrals. EPOs and PPOs usually don't.
Network type and metal level are separate choices, and the plan types you can buy depend on your area.
In Medicare Advantage, the common types include HMO, HMO Point-of-Service, and PPO. EPO is not one of the Medicare Advantage types Medicare.gov lists.

What is the difference between an HMO, PPO, EPO, and POS plan?

TDI says all four plan types are managed care plans. Each one contracts with doctors, hospitals, and other providers at discounted rates to form a network. They differ in how strictly you must stay in that network and how you reach specialists.

Feature	HMO	EPO	PPO	POS
Out-of-network care	Not covered, except emergencies and care not available in network	Not covered, except emergencies and care not available in network. You might pay the full cost	Covered, but you pay more	Covered, but you pay more
Primary care physician	Must choose one	Usually not required	Not required	Usually required
Specialist referrals	Usually needed	Not required	Not required	Usually needed (check plan documents)
General cost tendency (TDI)	Generally lowest of all plans	Usually lower than PPO	Generally highest of all plans	Usually lower than PPO

The cost row shows general tendencies from TDI, not promises. Prices for any plan depend on where you live and the year. Check current premiums on HealthCare.gov.

HMO (health maintenance organization)

In a Texas HMO, you choose a primary care physician and usually need a referral to see a specialist. HealthCare.gov adds that an HMO may require you to live or work in its service area to be eligible.

EPO (exclusive provider organization)

An EPO usually doesn't require a primary care physician or referrals. The tradeoff is that if you use providers outside the network, you might have to pay the full cost of your care.

PPO (preferred provider organization)

PPO members don't need a primary care physician or specialist referrals. You can see out-of-network providers, but you pay more than you would in network.

POS (point-of-service)

POS members usually must have a primary care physician and get referrals, and they can go out of network for a higher cost. TDI says women don't need a referral to see an OB/GYN in a point-of-service plan. HealthCare.gov's definition says POS plans require a referral, so read the specific plan's documents to see its rules.

What happens if you go out of network on an HMO or EPO?

In general, the plan doesn't pay. TDI names two exceptions: emergencies, and care you need that isn't available in the network. In an EPO, TDI warns you might pay the full cost of care from an out-of-network provider.

Federal Marketplace rules add emergency protections. CMS says Marketplace plans can't charge higher copayments or coinsurance for emergency care at an out-of-network hospital. You may still owe costs like your deductible at in-network rates. They also can't require prior approval for out-of-network emergency services.

If you think you need an out-of-network provider, CMS says you can ask your plan for an exception to cover that care like in-network care. If the plan won't cover your doctor, you can appeal and get an independent review.

Most plans require prior approval for some services

TDI says most plans require approval before some covered services, such as surgery or a hospital stay. If you don't get approval, the plan might not pay. Free preventive services also require using an in-network doctor.

Do you need a referral to see a specialist?

It depends on the plan type. HMOs and POS plans usually require referrals. EPOs and PPOs don't.

Texas HMOs have two exceptions worth knowing:

Women don't need a referral to see an in-network OB/GYN.
Someone with an ongoing, disabling, or life-threatening condition may be able to use a specialist as their primary care physician.

Families with children who see specialists

If your kids see specialists, list every provider each family member uses. CMS suggests including your dependents' providers when you search a plan's network. Then weigh whether a referral step fits your routine, or whether a plan without referrals matters more to you. A licensed agent can walk you through the plans available where you live.

Does an HMO cover you if you travel or live part of the year in another state?

Usually only for emergencies. HealthCare.gov says an HMO generally won't cover out-of-network care except in an emergency, and it may require you to live or work in its service area.

There are a few other exceptions. Texas HMOs must also pay for care that isn't available in the network. A Medicare Advantage HMO also covers out-of-area urgent care and temporary out-of-area dialysis.

This matters if you have a second home, spend winters away, or help a parent who travels. CMS suggests checking whether a plan has network providers where you travel.

COBRA has its own wrinkle. TDI notes that if you continue HMO coverage under COBRA and move out of the service area, the HMO will pay only for emergency care. Our guide to health insurance after losing a job covers COBRA and other options.

Is network type the same as metal level or deductible?

No. HealthCare.gov says that, depending on how many plans are offered in your area, you may find HMO, EPO, POS, and PPO plans at each metal level: Bronze, Silver, Gold, and Platinum.

So you make two separate choices:

Network type decides which providers you can use and whether you need referrals.
Metal level decides how you and the plan split costs.

Because you may find each network type at each metal level, how a plan splits costs is a separate choice from its network type. Our guide to Bronze vs Silver vs Gold health plans explains the metal levels.

Why can't I find PPO plans in my area?

HealthCare.gov says the plan types you can buy depend on how many plans are offered in your area. Some areas may not have every type. Don't rely on old articles or claims about which types exist in Texas. Look at HealthCare.gov each year, since offerings can change.

CMS says the plan type (PPO, POS, HMO, or EPO) appears right below the plan name when you compare plans on HealthCare.gov. It's also on each plan's Summary of Benefits and Coverage.

What protections do Texas plans have to follow?

TDI says Texas law requires HMOs, PPOs, and EPOs to:

Make covered services available within a certain distance of your home or office
Have enough providers to meet members' needs
Pay for care to stabilize you after an emergency
Pay for out-of-network care if the care you need isn't available in network

What if your doctor leaves the network?

Texas plans must let you keep seeing a doctor for a period of time after the doctor leaves the network if you have a terminal illness, disability, or life-threatening condition, or are pregnant. The doctor must agree to keep treating you at the plan's contract rate.

CMS adds that Marketplace enrollees may qualify as a continuing care patient if the plan ends a provider's contract mid-treatment.

Surprise billing protections and their limits

TDI says state and federal surprise-billing laws apply to anyone with any type of health insurance except Medicare. They ban surprise bills:

In emergencies
For air ambulance
For care at an in-network hospital
For labs and imaging ordered by an in-network doctor

Texas law also bans surprise bills from ground ambulances if your insurance card has "DOI" or "TDI" printed on it. The ban also covers certain state employee and teacher plans and some plans that opted in. TDI's surprise billing page lists them.

You can still be billed your normal copay, coinsurance, or deductible. The law also doesn't change your plan's coverage for out-of-network care you choose. If you pick an out-of-network doctor in a PPO, for example, you still pay the higher out-of-network share.

How do HMO and PPO plans work in Medicare Advantage?

If you're turning 65, the network question looks different. Medicare.gov lists these Medicare Advantage plan types: HMO, HMO Point-of-Service, PPO, Private Fee-for-Service (PFFS), Special Needs Plans (SNP), and Medical Savings Account (MSA). EPO is not on that list.

Feature	Original Medicare	Medicare Advantage HMO	HMO Point-of-Service	Medicare Advantage PPO
Network	None. Any doctor or hospital that takes Medicare, anywhere in the U.S. You may pay more if the doctor doesn't accept assignment.	Network required, except emergency care, out-of-area urgent care, and temporary out-of-area dialysis	Network, but some services may be covered out of network for a higher copayment or coinsurance	Can use out-of-network providers that participate in Medicare or accept assignment, usually for more
Primary care doctor	No network, so you can see any doctor that takes Medicare	Most plans require one	Check plan documents	Not required
Specialist referrals	Not needed in most cases	Needed in most cases	Check plan documents	Not required

A few more details from Medicare.gov:

In a Medicare Advantage HMO, certain services, like yearly mammogram screenings, don't need a referral. Care outside the network may cost you the full amount.
In a Medicare Advantage PPO, you're always covered for emergency and urgent care. Medicare.gov advises contacting the PPO before out-of-network care to confirm it's covered and medically necessary.
Medicare Advantage may require network providers within the plan's service area for non-emergency care.
Original Medicare has no yearly out-of-pocket limit unless you have supplemental coverage. Medicare Advantage plans have a yearly limit, which may differ for in-network and out-of-network services. Check current amounts in Medicare Plan Finder on Medicare.gov.

The drug coverage rule

If you join a Medicare Advantage HMO or PPO that doesn't include drug coverage, you can't join a separate Medicare drug plan (Part D). Check this before you enroll.

Plan choices vary by county. See Medicare Advantage in Texas by county and Medicare Advantage vs Medigap for more.

How do you check whether your doctor is in network before you enroll?

CMS says insurers may have different networks for different plans. A doctor in one plan from an insurer may not be in another plan from the same insurer. Follow these steps:

List every provider. Include doctors, specialists, and hospitals for you and each dependent.
Note the plan type. On HealthCare.gov it's below the plan name and on the Summary of Benefits and Coverage.
Open that plan's provider directory. Each Marketplace plan description links to it. Search the specific plan, not just the insurer.
Call the insurer to confirm. CMS says you can call the insurer's customer service number to check.
Ask each doctor's office whether it's in network for that exact plan.
Check where you travel. Look for network providers in places you spend time.
For a Medicare Advantage PPO, contact the plan before out-of-network care to confirm coverage.

When can you switch plan types if you picked the wrong one?

CMS says Marketplace Open Enrollment runs November 1 to January 15. After coverage starts, you can't change plans until the next Open Enrollment unless you qualify for a Special Enrollment Period. Dates are set at HealthCare.gov, so check there. Our list of qualifying life events explains Special Enrollment Periods.

Medicare has its own enrollment windows. See our open enrollment dates guide and how to switch Medicare Advantage plans.

Common mistakes to avoid

Assuming the insurer's whole network applies. Each plan can have its own network.
Checking only doctors. Confirm hospitals and every family member's providers too.
Ignoring the service area. An HMO may require you to live or work there.
Confusing metal level with network type. HealthCare.gov says you may find HMO, EPO, POS, and PPO plans at each metal level, so how a plan splits costs is a separate choice from its network type.
Skipping prior approval. Without approval for services like surgery, the plan might not pay.
Picking a Medicare Advantage HMO or PPO without drug coverage by accident. With those plan types, you can't add a separate Part D plan.

Questions to ask before choosing a plan

Is this plan an HMO, EPO, PPO, or POS?
Are all my doctors, specialists, and hospitals in this specific plan's network?
Do I need a primary care physician and referrals?
What does the plan pay, if anything, for out-of-network care?
Do I need to live or work in the service area?
Are there network providers where I travel or spend part of the year?
Which services need prior approval?
For Medicare Advantage: does the plan include drug coverage, and what is its yearly out-of-pocket limit in and out of network?

Where to get help and what to do next

Marketplace plans: Compare plan types and directories on HealthCare.gov. Our Texas Health Insurance Marketplace guide explains how it works.
Medicare: The Texas Health Information, Counseling and Advocacy Program (HICAP) offers Medicare counseling through the Texas Medicare Help Line at 800-252-9240. It explains and compares Medicare Advantage and Medigap and helps with enrollment.
A licensed agent: An agent can compare the plans sold in your area against your provider list.

MeetBrokers is free to use. Every listed agent holds a state license that anyone can verify by National Producer Number. Profiles marked "unclaimed" come from public licensing records. Browse licensed health insurance agents in Texas or Medicare agents in Texas.

When you're ready, you can request help from a licensed agent you choose. Your request goes only to that agent. MeetBrokers is not connected with or endorsed by the U.S. government or the federal Medicare program.