Covered California and ACA related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the ACA and Covered California knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

What is the Difference Between an EPO and HMO?

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Question: Based on your answer to a recent question, an EPO sounds a lot like an HMO. What’s the difference?

Answer; Yes, but it’s also like a PPO in some ways. An EPO is like an HMO in that their networks are exclusive and do not provide out of network coverage except for emergencies. EPO’s are like PPOs in that they are regulated by the Dept. of Insurance (DOI) while HMO are regulated by Dept. of Managed Health Care (DMHC). EPOs are like PPOs in that they traditionally offer coinsurance plans while HMO’s usually offer copay plans. This later distinction is becoming less defined in the Exchange.

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I believe another difference is that while an HMO has a gatekeeper, the EPO does not.

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