A plain-language breakdown of HMOs, PPOs, EPOs, Medicare, and Marketplace coverage — plus the cost-sharing terms that show up on nearly every plan.
HMO plans generally require choosing a primary care provider and getting referrals to see specialists. Care is typically covered only within the plan's network, except in emergencies. In exchange for these restrictions, HMOs often carry lower monthly premiums than plans with broader network access.
PPO plans allow visits to specialists without a referral and provide some coverage for out-of-network care, usually at a higher cost. This flexibility comes with a trade-off: PPO premiums are typically higher than HMO premiums for comparable coverage.
EPO plans sit between HMOs and PPOs. Like an HMO, care is generally limited to the plan's network, but like a PPO, referrals typically aren't required to see specialists. This structure can offer a mid-range premium with defined network boundaries.
Medicare is a federal health insurance program primarily for people age 65 and older, and for some younger people with qualifying disabilities. It's organized into distinct parts that cover different types of care.
Covers inpatient hospital stays, skilled nursing facility care, and some home health care.
Covers outpatient care, doctor visits, preventive services, and durable medical equipment.
Private plans that bundle Parts A and B, often with added benefits like vision or dental.
Helps cover the cost of prescription medications through private, Medicare-approved plans.
Health Insurance Marketplace plans are available to individuals and families who don't have access to employer coverage. Plans are grouped into metal tiers — Bronze, Silver, Gold, and Platinum — which reflect the balance between premium cost and how much the plan pays toward care.
These three terms describe how costs are split between you and your plan once care is received.
The amount paid for covered care before the plan begins sharing costs.
A fixed dollar amount paid for a specific service, like a doctor visit or prescription.
A percentage of the cost of care you pay after the deductible has been met.
There's no universally "best" plan — the right fit depends on how much care you expect to use. Lower premiums with higher deductibles can work well for occasional care, while higher premiums with lower cost-sharing may suit ongoing or predictable medical needs.
Try the Plan Analyzers