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Medicare HMO vs PPO

Choosing an insurance plan can be a minefield. There are many decisions to make in order to find a plan with the best coverage that fits an individual’s needs. One of these decisions is which type of plan makes the most sense: Medicare HMO vs PPO?

HMO

An HMO is a Health Maintenance Organization. The organization has a network of doctors, hospitals, and other healthcare providers. They provide services for a specific payment, which allows the organization to maintain lower costs for its members. Costs and choices are two factors that beneficiaries tend to appreciate HMOs versus other healthcare plans. HMOs are often less expensive with lower monthly premiums. However, they require referrals to use doctors other than the beneficiary’s primary care physician. HMOs do not offer coverage for out-of-network providers except for in the case of a true medical emergency.

PPO

PPOs are Preferred Provider Organizations. These offer a network of healthcare providers to use for the beneficiary at a certain cost. With a PPO, a beneficiary can choose to receive care from any healthcare provider regardless of if they are in the network. While PPOs do have higher monthly premiums, they offer flexibility that an HMO does not. They do not require that a beneficiary has a primary care physician or that they get referrals to see any healthcare provider. If a beneficiary wants to see a healthcare provider outside of the PPO network, they may have to pay the doctor upfront and then file a claim to get reimbursed from their insurance plan.

Insurance decisions must take a lot of factors into consideration. In general, however, an HMO may be a better choice for beneficiaries that need lower out-of-pocket costs. They tend to have lower deductibles and make sense if the beneficiary does not mind using a primary care physician as their primary healthcare provider for all of their needs. A PPO may be a better choice for beneficiaries who already have a healthcare team that they would like to keep, as well as the flexibility to see specialists at will. They can expect to pay higher costs for this flexibility.

Medicare HMO vs PPO: What’s the Difference?

Choosing an insurance plan can be a minefield. There are many decisions to make in order to find a plan with the best coverage that fits an individual’s needs. One of these decisions is which type of plan makes the most sense: an HMO or a PPO?

An HMO is a Health Maintenance Organization. The organization has a network of doctors, hospitals, and other healthcare providers. They provide services for a specific payment, which allows the organization to maintain lower costs for its members. Costs and choices are two factors that beneficiaries tend to appreciate HMOs versus other healthcare plans. HMOs are often less expensive with lower monthly premiums. However, they require referrals to use doctors other than the beneficiary’s primary care physician. HMOs do not offer coverage for out-of-network providers except for in the case of a true medical emergency.

PPOs are Preferred Provider Organizations. These offer a network of healthcare providers to use for the beneficiary at a certain cost. With a PPO, a beneficiary can choose to receive care from any healthcare provider regardless of if they are in the network. While PPOs do have higher monthly premiums, they offer flexibility that an HMO does not. They do not require that a beneficiary has a primary care physician or that they get referrals to see any healthcare provider. If a beneficiary wants to see a healthcare provider outside of the PPO network, they may have to pay the doctor upfront and then file a claim to get reimbursed from their insurance plan.

Deciding Between the Two

Insurance decisions must take a lot of factors into consideration. In general, however, an HMO may be a better choice for beneficiaries that need lower out-of-pocket costs. They tend to have lower deductibles and make sense if the beneficiary does not mind using a primary care physician as their primary healthcare provider for all of their needs. A PPO may be a better choice for beneficiaries who already have a healthcare team that they would like to keep, as well as the flexibility to see specialists at will. They can expect to pay higher costs for this flexibility.

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PPO

If you are or ever have been in the market for a healthcare plan you will most likely come across the term PPO.  A PPO is a preferred provider organization. These plans offer a network of healthcare providers for their members to use for medical care at a negotiated rate.  PPO plans allow members to see any in-network health care provider they choose without requiring a referral.

More PPO information:

If you choose to join a PPO, in most cases, you will not need to choose a primary care provider.  You will be able to use any provider within the company’s network of providers. All your in-network healthcare services will be covered at the negotiated rate.  You will also have the option of using out-of-network providers, although they will be covered at a lower rate. It is always a good idea to make sure your provider participates with your health plan in order to avoid receiving a higher than expected medical bill.

In most cases you will have a deductible to meet each year before your medical bills are covered by the insurance company.  There is also the matter of co-pays for certain services.  Some services will require you to pay a percentage of the total medical cost. These are things you should be aware of, if possible, before you go for medical care.

PPO Providers:

PPO plans have a number of in-network doctors and medical facilities you can choose from. In this way the plans are similar to HMOs.  It is always more cost effect to use an in-network provider when seeking medical treatment. Providers who participate with your insurance company have an agreement to accept lower payments and in return, receive access to patients who participate with the insurance company’s network.  One advantage to a PPO is that beneficiaries do receive coverage for some out-of-network care. If you decide to use an out-of-network provider you will most likely have to pay a higher rate for your care but the insurance carrier will pay some of the cost.

Another benefit of joining a PPO is that you will not be required to get a referral to see a specialist.  You can choose from any in-network provider for medical services

PPO plans might be a good fit for you if:

• You do not want to get a referral before seeing a specialist.
• Sometimes you want to use an out-of-network provider.
• It is important for you to have the choice of where you receive your medical care.

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