EPO vs. HMO: How to choose

Two popular types of health insurance plans are Health Maintenance Organizations (HMOs) and Exclusive Provider Organization (EPOs). And while neither plan is better than the other, each has its advantages and disadvantages. When deciding which type of plan is best for you, it’s important to know your needs and situation. This article will help you determine the best option for you.

Exclusive Provider Organization (EPO)

What is Exclusive Provider Organization health insurance?

An EPO (or Exclusive Provider Organization) plan offers in-network coverage only and does not require referrals for specialty care. EPO members may be required to select a PCP and should refer to their summary of benefit and coverage. Also, EPO plans don’t cover out-of-network care unless it’s an emergency.

Health Maintenance Organization (HMO)

What is Health Maintenance Organization health insurance?

An HMO (or Health Maintenance Organization) is a health plan that requires members to select a PCP. Members need a referral from their PCP to see a specialist in the HMO network, such as a cardiologist (heart doctor). Typically, only emergency services are covered if you go outside the HMO’s network of participating providers.

Advantages & Disadvantages: HMO vs. EPO comparison

In-network coverage
Out-of-network coverage For urgent and emergency care only
Required to select a PCP May be required
Referrals needed for specialists  
Option to open a tax advantaged health savings account (HSA) on qualified plans  

How do I find out if my doctor is in the AmeriHealth New Jersey network before I enroll?

Use our Find a Doctor tool to see if a provider or hospital is in the AmeriHealth New Jersey network.

So which plan is right for you?

When it comes to health coverage, everyone has different needs. Understanding your situation can help you pick the plan that’s right for you — one that strikes a balance between what you’re willing to pay and the level of coverage you are comfortable with.

  • If you’re trying to save money, an EPO plan with a health savings account (HSA) can help you save tax-free dollars for qualified medical expenses.*
  • If you see the doctor often or have an ongoing medical condition, depending upon the plan, an HMO may have a higher monthly premium than an EPO plan, but you’ll pay less out-of-pocket each time you receive care.
  • If you only see doctors once in a while, an EPO plan might be right for you. With an EPO plan, you’ll have a lower monthly premium, and you’ll pay out-of-pocket costs when you actually need care.
  • If you want to manage your own care without referrals, then an EPO plan might be right for you. EPO members can receive care from any in-network provider without a referral.

Choosing a health insurance plan on your own can be challenging, but don’t feel like you have to make this decision on your own.

  • If you are are purchasing a plan for yourself or your family and need help choosing or enrolling in a health plan, call AmeriHealth New Jersey at 877-744-5422.
  • To see if you are eligible for financial assistance, please visit the Health Insurance Marketplace.
  • To find out if a provider or hospital is considered in-network, use our Find a Doctor tool.
  • Ready to enroll in a plan? Apply now.

If you are a New Jersey employer managing your groups’s health care benefits, please speak to your broker about AmeriHealth New Jersey group health plans.

*Tax rules vary at the state and federal level. Please consult your tax advisor for guidance.