Today’s health insurance marketplace can be confusing. That applies not only to consumers but to those who work in the health insurance industry as well as related fields.
To help you, your colleagues, staff, and clients, we’re happy to provide this health plan “cheat sheet.”
4 Major Health Plan Types Compared: HMO, PPO, EPO, and POS
There are four primary health plan types available in the commercial health marketplace:
What Is an HMO? (Health Maintenance Organization)
- Network: In-network care only, except in case of emergency
- Required Primary Care Physician (PCP) to manage care: Yes
- Referrals: Required from PCP to see a specialist
- Cost: Budget-friendly; often offers the lowest premiums and out-of-pocket costs
- Best For: Budget-conscious individuals who need minimal care (routine check-ups and wellness visits, but not out-of-area or specialized care)
What Is a PPO? (Preferred Provider Organization)
- Network: Plan offers access to both in-network and out-of-network providers
- Required Primary Care Physician (PCP) to manage care: No
- Referrals: Not required to see a specialist; self-referrals available
- Cost: Higher premiums, but PPOs offer greater flexibility; lower costs when using in-network care
- Best For: Individuals who prioritize flexibility, frequent travelers, and those who need regular access to specialized care without gatekeeper referrals
What Is an EPO? (Exclusive Provider Organization)
- Network: In-network care only, similar to an HMO; EPO networks are often larger than HMO networks, which could offer more convenience
- Required Primary Care Physician (PCP) to manage care: a PCP is not generally required by an EPO
- Referrals: Generally, not required to see a specialist
- Cost: Moderate premiums – higher than HMOs but lower than PPOs; some view an EPO as an HMO alternative but with greater freedom (like with a PPO)
- Best For: Those seeking reduced cost (as compared to a PPO) and the freedom to see a specialist without referrals
What Is a POS Plan? (Point of Service)
- Network: Both in-network and out-of-network care are available; out-of-network costs are higher than in-network care
- Required Primary Care Physician (PCP) to manage care: Yes
- Referrals: Often required to see a specialist
- Cost: Moderate premiums; zero and lower-cost deductibles and copays for in-network care
- Best For: Individuals who want a budget-friendly premium like an HMO with the flexibility to see out-of-network specialists on occasion; a good fit if you are okay with a required PCP referral to specialists
Don’t overlook the “Health Care Quick Flicks” posted on YouTube that highlight different plan types and address other questions being ask by clients. This online series includes nine videos.
What Is an HDHP? The High-Deductible Health Plan Alternative
A High-Deductible Health Plan (HDHP) can be an HMO, PPO, or EPO plan. An HDHP features lower monthly premiums, but a higher initial deductible before insurance begins to pay toward members’ medical costs.
Preventive care services are usually covered in-network without having to meet the HDHP deductible for:
- annual physicals and well-women visits
- routine vaccinations (flu shots, COVID-19, HPV, MMR, and tetanus)
- cancer screenings like mammograms, colonoscopies, and pap smears
- blood pressure, cholesterol, and diabetes (glucose) testing
- mental health (depression screening and behavioral counseling)
After paying the plan deductible and maximum out-of-pocket limit, your clients’ plan covers 100% of covered medical services for the remainder of the plan year.
A Good Choice for Healthy Employees: An HDHP can be a frugal choice for those who are generally healthy and rarely visit the doctor other than for routine check-ups. An added benefit is that HDHPs offer tax advantages when paired with a Health Savings Account (HSA).
Balancing Costs and Risks: While your clients pay less each month on HDHP premiums, they also take on the added risk of potentially thousands of dollars for care before the insurance plan begins to pay. The minimum annual deductible for an HDHP in 2026 is $1,700 for self-only coverage and $3,400 for family coverage.
The 2026 maximum out-of-pocket expense limit (including deductibles, copays, and coinsurance – but not premiums) is $8,500 for self-only coverage and $17,000 for family coverage.
Tax Advantages: By pairing an HDHP with an HSA, your client enjoys a triple tax advantage. 1) Contributions are made pre-tax (or are tax-deductible). 2) Funds grow tax-free. 3) Withdrawals for qualified medical expenses are also tax-free. Another advantage is that employees own their HSAs. The accounts go with them if they change jobs or retire. There is also no “use it or lose it” rule like with a Flexible Spending Account (FSA). Unused funds roll out year after year, which allows balances to grow over time.
Compare Health Plans Side-by-Side with WBQuote
Your Word & Brown representative can help you run side-by-side quote comparisons to make it easier for clients to select a plan that addresses employees’ health care needs while still controlling costs for their business.
Our proprietary WBQuote platform highlights:
- Plan benefits
- Deductibles and out-of-pocket costs
- Provider network
- ACA Metal Tiers (Bronze, Silver, Gold, Platinum)
Plus, the recently redesigned WBQuote includes an improved, more polished appearance featuring:
- Cleaner layouts
- Clearer organization
- Improved presentation
WBQuote delivers exactly what you and your clients want when comparing plan options and costs.
30+ Carriers Available Through Word & Brown
When you write business through Word & Brown, you have access to coverage for your California and Nevada clients from a diverse roster of 30+ regional and national health and ancillary carriers and administrators, including some of the most-recognized names in the business. Go online to view our current carrier lineup. We’ll work with you to help you find the right match for your clients’ budget and employees’ health care and ancillary needs.
Why Partner with Word & Brown as Your General Agency
Of course, there are many other reasons besides quoting and product roster to choose us as your GA partner:
- Reduced admin burden: We’ll relieve you of many routine administrative tasks. That includes reviewing and scrubbing cases to ensure expedited carrier processing and timely issue of ID cards.
- Enrollment expertise: We will streamline your enrollments using digital tools like Ease and Employee Navigator – and we offer enrollers to work alongside you (or in your place), in-person or virtually.
- Carrier escalation: We have the experience and carrier connections you and your clients want. If you have an issue, we will intervene on your behalf. Our reps’ calls, emails, and texts get prompt answers. That means you get what you need to resolve issues quickly and efficiently for your clients.
Capitalize on our 40+ years of experience in the insurance industry. Contact your W&B representative today to find out how we can help you address your clients’ needs with one or more of the many solutions in our portfolio. If you are not already working with us, register online to get started or reach out to Jim Pippins, our Senior Director of Broker Success.
Frequently Asked Questions: HMO vs. PPO vs. EPO Health Plans
What is the main difference between an HMO and a PPO? An HMO requires members to use in-network providers and get referrals from a primary care physician to see a specialist, while a PPO allows both in-network and out-of-network care with no referrals required. PPOs offer more flexibility but typically cost more.
Is an EPO cheaper than a PPO? Yes, generally. EPOs offer moderate premiums that are higher than an HMO but lower than a PPO, while still allowing members to see specialists without a referral — similar to a PPO, but without out-of-network coverage.
Do I need a referral to see a specialist with a POS plan? Usually, yes. A POS plan requires a primary care physician and typically requires a referral to see a specialist, though it also allows out-of-network care at a higher cost, unlike an HMO.
What is a good HDHP deductible for 2026? For 2026, the minimum annual deductible to qualify as an HDHP is $1,700 for self-only coverage and $3,400 for family coverage, with a maximum out-of-pocket limit of $8,500 and $17,000, respectively.
Can an HDHP be paired with an HSA? Yes. Pairing an HDHP with a Health Savings Account (HSA) gives employees a triple tax advantage: pre-tax contributions, tax-free growth, and tax-free withdrawals for qualified medical expenses, with funds that roll over year to year and stay with the employee if they change jobs.
Which health plan type is best for a small business with a healthy workforce? An HDHP paired with an HSA is often a strong fit for generally healthy employees who want lower monthly premiums and are comfortable taking on more upfront cost-sharing in exchange for long-term tax-advantaged savings.
