It's the part most people skip when comparing plans, and the one that causes the most grief in January. You can see the premium; you don't see the network until you need it.
The difference, in short
| Type | How it works |
|---|---|
| HMO | Only covers doctors in its network. You normally need a primary care doctor to refer you to a specialist. Outside the network it covers nothing, except emergencies. |
| EPO | Only covers its network, like an HMO, but with no referral needed to see a specialist. |
| PPO | Covers both in and out of network, though out of network you pay considerably more. No referrals. It's the most flexible and the most expensive. |
On the Marketplace most plans you'll see are HMO and EPO. PPOs exist but there are fewer of them and they cost more.
Which one suits your case
If you have doctors you don't want to lose — a specialist managing something chronic, your children's pediatrician, your longtime OB-GYN — the first thing is to check which network they're in. If they're all in the same one, an HMO costs you less without giving anything up.
If you travel a lot or live between two states, an HMO is going to give you trouble. A PPO covers outside its area; an HMO, practically not at all.
If you're healthy and hardly ever see a doctor, an HMO or EPO with a good local network is usually the best value. You'd be paying for PPO flexibility you probably won't use.
If you have something in active treatment, the network outranks the price. Switching plans mid-treatment because the hospital fell out of network is the worst possible situation.
Look at the network first, the price second. The other way round is like buying shoes for the color without checking the size.
Why this matters so much where you live
In the areas where I work there are two or three large hospital systems that divide up almost everything, and not every plan includes all of them.
In Orlando it's AdventHealth and Orlando Health. In Tampa, BayCare and HCA. In Miami, Baptist Health and Jackson. In Jacksonville, UF Health, Baptist and Ascension. In Atlanta there's more competition and more networks to choose from.
The question I ask everyone before looking at prices is simple: which hospital would you go to if something happened tonight? With that answer the plans filter themselves.
Check for yourself before you sign
You don't have to take anyone's word for it. You can verify whether your doctor or hospital is in a given plan's network, and I have a free provider search tool using official data.
A warning: carrier directories aren't always up to date. If a doctor really matters to you, besides checking the directory, call their office and ask whether they accept that specific plan for next year. Two minutes on the phone beats any search tool.
Want to know which plans cover your doctors?
Send me the list of doctors and the hospital you want to keep. I'll filter the plans by that and tell you which ones work.
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General information, not legal, tax or immigration advice. The rules can change. For your specific case, message me. Omar Mendoza, licensed agent — NPN 21726482.