HMO vs PPO

By Ed Crowe | General Articles | 0 comment | 28 May, 2019 | 0

HMO vs PPO

How do HMO and PPO Plans differ?

There are many choices to make when it comes to your health insurance. You may be familiar with the terms HMO and PPO. You may not know what the letters stand for or what the differences in the plans are. Let’s start by telling you what these initials mean. An HMO is a Health Maintenance Organization. A PPO is a Preferred Provider Organization. We will give some information about HMO vs PPO plans in this post. Note: Medicare Advantage plans also have HMO and PPO plans designs. The information is applicable to Medicare MA and MAPD plans as well.

We have listed some information about each type of plan below:

HMO vs PPO:

If you opt for an HMO, you will have to use specific in-network facilities as well as doctors. This network is made up of health care providers who have agreed to accept lower payment rates from members while meeting quality standards put in place by the insurance company. Medical care under an HMO plan is covered only when you use an in-network provider. There is very little opportunity to use the services of an out-of-network provider.

More HMO information:

The premium for these plans is usually lower for HMO plans.
In most cases, the deductible is either low or there is none
You will need to choose a primary care provider (PCP)with most of the HMO plans. This provider decides what medical care you need. This means that provider will have to decided if you need to see another doctor for any reason.
Usually, if you need a specialist your PCP will have to refer you to them. If your PCP does not give you a referral, your medical expense may not be covered.
- There are Open Access HMO plans that do not require a referral to see a specialist
If you use a doctor who is not in the network, you will have to pay the entire cost out-of-pocket because, there is no insurance coverage.
- A medically necessary emergency room visit is in network on an HMO plan

HMO vs PPO:

If you choose a PPO plan, you will also have a network of providers. The difference with these plans and an HMO is you can go to certain out-of-network providers. The plan will pay less towards your medical expense than an in network provider; but at least it will pay part of your cost.

More PPO information:

The premiums for these plans are usually higher than with an HMO.
In most cases, there is a deductible.
You do not need a referral from your PCP before going to any doctor or specialist.
If you need to use a provider who is not in network, you may have some of your expense covered. Keep in mind, you will have better coverage using in-network providers.

The decision to choose one health care plan over another depends on many factors. These factors include your health, your budget and the network of providers available for each plan.