Four letters that decide whether you can keep your doctor, whether you need a referral, and what happens when you get sick two states away.
Name the doctors you refuse to give up, then check the network. Every other decision on this page comes after that one.
A PPO gives you the widest doctor access and no referral gatekeeping. An HMO is usually cheapest but locks you into one network with a required primary care doctor. An EPO sits in the middle. A POS is an HMO that will let you go out of network if you accept the cost.
| PPO | HMO | EPO | POS | |
|---|---|---|---|---|
| Referral needed to see a specialist | No | Yes | No | Yes |
| Primary care doctor required | No | Yes | No | Yes |
| Out of network coverage | Yes, at a higher share | Emergencies only | Emergencies only | Yes, at a higher share |
| Network size | Widest | Narrowest | Narrow to moderate | Narrow, with an exit |
| Travel and out of state care | Strongest | Weakest | Limited | Limited |
| Typical premium | Higher | Lowest | Moderate | Moderate |
| Paperwork burden on you | Lowest | Higher | Low | Highest |
| Best for | People who want their own doctors, travel, or already have specialists | People on a tight premium budget who stay local | People who want no referrals but will accept a smaller network | People who want an HMO price with an escape hatch |
Structures vary by carrier and by state. This table describes how these plan types generally behave, not the terms of any specific policy. Your actual network, referral rules, and cost sharing come from the plan documents.
The comparison above tells you how the plan types differ from each other. This is the part that moved underneath all of them at once, and it changes which trade-off is sensible rather than which plan type is.
The enhanced premium tax credits expired going into 2026. Four numbers describe what followed.
A high-deductible plan is a bet that you will not need much care this year, bought with a lower premium. The bet is only sensible if you could actually write a cheque for the deductible tomorrow.
Average marketplace deductibles rose 37% in one year, from $2,759 to $3,786 per person — over a thousand dollars more.[1] A household that could comfortably absorb a 2024 deductible is not automatically a household that can absorb a 2026 one. If you chose a high-deductible plan two years ago and have not revisited it, that is worth doing before the next renewal.
Narrow-network products — HMO and EPO — save money precisely because they restrict where you can go. That saving is real, and so is the penalty for guessing wrong about your own providers. With deductibles a thousand dollars higher, an out-of-network surprise now lands on top of a larger first-dollar cost rather than instead of one.
The practical step has not changed: write down every doctor and facility your household actually uses, by name, and check them against the specific plan’s directory before you enroll. In Tampa Bay, where households routinely span several unaffiliated hospital systems, that check is the whole decision.
Not evenly. Households above 400% of the federal poverty level were roughly 7% of 2025 marketplace enrollment but nearly 48% of the decline going into 2026,[1] because above that line the premium tax credit is not reduced — it is absent entirely. For 2026 coverage the line is $62,600 for one person and $128,600 for a family of four.[4] If you are under it and have never had the credit calculated, that is the first thing to do and it costs nothing.
A PPO is a preferred provider organization. You pick any doctor you want. In network costs less, out of network costs more, but out of network is still covered. No referral, no gatekeeper, no permission slip to see a cardiologist. This is where most of my clients land, and it is not an accident. The people who come to me usually already have a doctor they like, a specialist they are mid treatment with, or a job that puts them in another state ten weeks a year. All three of those break an HMO.
A health maintenance organization is the cheapest premium on the page, and there is a reason for that. You choose a primary care doctor, that doctor has to refer you before a specialist will see you, and outside the network you have essentially no coverage except a true emergency. If you live in one metro, stay in one metro, and your doctors are all inside that network, an HMO can be a perfectly rational choice. If any of those three things is not true, the savings evaporate the first time you get a surprise bill.
An exclusive provider organization is the compromise. No referrals, which is the part people actually hate about HMOs, but no out of network coverage either. It works well when the network happens to contain your doctors. Check that before you sign, not after.
A point of service plan is an HMO with a door in the back wall. You still pick a primary care doctor and you still need referrals, but you can go outside the network if you are willing to pay a meaningfully larger share. It is the most paperwork heavy of the four, because using that back door usually means you file the claim yourself.
Do not start with the premium. Start with three questions. One: name the doctors you refuse to give up, then check whether they are in the network. Two: ask whether you travel, live in two places, or have a kid at college in another state. Three: ask whether anyone in the household is in active treatment with a specialist right now. If the answer to two or three is yes, a narrow network plan is going to cost you more than it saves, no matter what the monthly number says.
Figures and rules on this page last verified against the primary sources on August 13, 2026
Scotty Jaymes Insurance is a private, independent insurance agency. We are not affiliated with, endorsed by, or connected to any government agency, the federal Medicare or Medicaid programs, or any state or federal health insurance marketplace including Healthcare.gov. Regulatory summaries are general information, current as at the verification date shown, and are not legal or tax advice. Rules change and vary by state and by plan. Plan availability, benefits and pricing vary by state and by applicant.
There is no universally best plan type. A PPO is the most flexible and the most forgiving of real life, and it is where most of my clients end up. An HMO is the cheapest and works fine if you stay local and your doctors are all in the network. The right answer depends on your doctors, your travel, and whether anyone in the house is in active treatment.
Preferred provider organization. The carrier negotiates discounted rates with a preferred network of doctors and hospitals. You pay less inside that network, more outside it, but outside is still covered rather than excluded.
No. That is the defining feature. You can book a specialist directly without going through a primary care doctor first.
Referrals. An EPO drops the referral requirement, so you can see a specialist directly. Both restrict you to the network for anything other than an emergency.
Only if you stay inside the network all year. One out of network specialist visit, one urgent care trip while traveling, or one hospital that is not contracted can erase a year of premium savings in a single bill. Compare total expected cost, not just the monthly number.
Usually at renewal, and sometimes sooner if you have a qualifying life event. Private plans do not run on the marketplace calendar, so the timing rules are different. Call me and I will tell you what your actual window looks like.
One call. Licensed producer, not a call center. If your current plan is still the better deal, I will tell you that.
Under-65 coverage only. We do not sell Medicare.