Updated August 2026 for the current plan year.
The letters on a health plan, HMO, PPO, POS, EPO, describe one thing: how the plan handles its network of doctors. That is it. They are not quality ratings and they do not tell you what the plan covers. Two plans with identical benefits can behave completely differently depending on those three letters.
Here is what each one actually means for how you get care in South Carolina.
HMO: one network, referrals required
You pick a primary care physician, and they coordinate your care. Seeing a specialist generally requires a referral from that doctor first.
The trade is strict: outside the network, an HMO typically pays nothing except in a true emergency. Not a smaller share, nothing. In exchange, HMOs usually carry the lowest premiums, and on the South Carolina Marketplace they are the most common structure you will see.
An HMO works well when your doctors are already in the network and you are comfortable routing through a primary care physician. It works badly when you travel often or have a specialist you will not give up.
PPO: broader access, higher premium
No referral needed. See a specialist directly. And out-of-network care is actually covered, just at a lower rate, so going outside the network costs more instead of costing everything.
You pay for that flexibility in premium. PPOs are the most expensive structure and have become less common on the individual Marketplace than they are in employer plans, so do not assume one is available at the price you are hoping for.
POS: a referral-based plan with an out-of-network door
A Point of Service plan sits between the two. You have a primary care physician and generally need referrals like an HMO, but the plan pays something out of network like a PPO.
It is a reasonable middle when you want the lower cost structure but need a real option for care outside the network.
EPO: no referrals, no out-of-network
An Exclusive Provider Organization flips POS around. No referral required to see a specialist, but out-of-network care is not covered. If you want direct specialist access and your providers are all in one network, an EPO can cost less than a PPO for similar convenience.
HDHP and HSA: a financing question, not a network one
A High Deductible Health Plan can be an HMO, PPO, or EPO underneath. The distinguishing feature is the deductible, and whether it is HSA-qualified.
A Health Savings Account is the real reason to consider one. Contributions are tax-deductible, growth is untaxed, withdrawals for qualified medical expenses are untaxed, and the balance is yours permanently. It is not use-it-or-lose-it like an FSA. For a healthy household that can absorb a large deductible in a bad year, that combination is hard to beat. For a household that cannot cover the deductible, it is a gamble.
Catastrophic plans have an eligibility rule
These carry low premiums and very high deductibles, and they cover the same preventive services and essential health benefits once you hit that deductible.
The catch that gets skipped: you generally have to be under 30, or qualify for a hardship or affordability exemption, to buy one. They also cannot be paired with a premium tax credit. If you qualify for help paying for coverage, a subsidized bronze plan often ends up cheaper than a catastrophic plan, which surprises people every year.
Metal levels are a separate decision
Bronze, silver, gold, and platinum describe how you and the plan split costs, not which doctors you can see. You choose a plan type and a metal level, and they are independent.
One thing worth knowing: cost-sharing reductions, which lower your deductible and out-of-pocket costs if your income qualifies, are only available on silver plans. Someone eligible for that help who buys bronze to save on premium can leave real money behind.
How to actually choose
Start with your doctors, not the premium. Pull up the plan’s provider directory and check the specific physicians and hospital you use. Then check the drug formulary against your actual prescriptions, not a general assumption. Then compare total cost: premium plus deductible plus the copays you realistically expect, rather than premium alone.
That last step is where most of the money is, and it is the one people skip.
For 2027 coverage, Open Enrollment runs November 1 through December 15, 2026. Our Open Enrollment guide covers the deadlines, and if your income is anywhere near the subsidy cutoff, how the credits and repayment rules work matters more this year than it used to.
Frequently asked questions
What is the real difference between an HMO and a PPO? Two things: whether you need a referral to see a specialist, and whether out-of-network care is covered at all. HMOs generally require a referral and pay nothing out of network except emergencies. PPOs skip the referral and pay something out of network, and cost more each month for that flexibility.
Which plan type is cheapest? HMOs usually carry the lowest premium, and on the South Carolina Marketplace they are the most common option. But the cheapest premium is not always the lowest total cost. If the HMO network excludes the doctor or hospital you actually use, the savings disappear the first time you go out of network.
Can anyone buy a catastrophic plan? No. Catastrophic plans are generally limited to people under 30, or to those who qualify for a hardship or affordability exemption. They also do not work with premium tax credits, so for many people a subsidized bronze plan ends up costing less.
Does the metal level change the network? No, and this is a common mix-up. Bronze, silver, gold, and platinum describe how you and the plan split costs, not which doctors are in network. The plan type is what governs the network. You pick both, and they are separate decisions.
Want someone to check your doctors against the actual networks? Call or text 803-848-0089, or start on our health insurance page. We will run your providers and prescriptions against the plans available to you before you enroll, at no cost.
