PPO vs. HMO Insurance: What’s the Difference

By
Ejeta Benjamin
-

PPO vs. HMO Insurance: What’s the Difference – Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO) are two different types of insurance plans that cover either basic and specialized health or dental care. HMOs have very lower costs and specific a network of providers you must use, only covering out-of-network care in emergencies. PPOs are very flexible, letting you see out-of-network providers, but always very expensive.

PPO vs. HMO Insurance: What's the Difference

The main differences between these two plans are where you can get care and how they determine costs. Choosing the right plan between PPO and HMO will benefit in getting the right coverage at affordable prices.

What is PPO?

A PPO, fully referred to as preferred provider organization, offers more flexibility in choosing where you can receive care. You can visit out-of-network doctors and see specialists without needing a referral. With this plan, you can save money by using in-network providers, as your out-of-pocket costs will be lower and coverage more comprehensive.

If you receive care from out-of-network providers, expect higher out-of-pocket costs. Some services may be very expensive, and others might not be covered at all.

These plans have agreements with in-network providers to pay a set fee for each service. They also have a set rate for out-of-network services, but if the provider charges more than this rate, you may have to pay this difference.

HMO

An HMO, fully referred to as health maintenance organization is another type of health insurance plan that offers adequate care through certain network of doctors, hospitals, and other medical providers referred to as the in-network providers.

This plan usually cost less because they have agreements with these providers, leading to lower payments. Keep in mind that, if you decide to visit a provider outside the HMO network, the plan usually won’t cover the cost unless it’s an emergency.

You pay a monthly premium and copay for each visit if you are a member. You choose a primary care doctor who coordinates all your care. Keep in mind that, to see a specialist, you will need a referral from your primary care doctor.

PPO vs. HMO Health Insurance: The Key Difference

The Main difference between PPO and HMO plan is their cost and flexibility. Check the below for more explanation;

Cost

HMOs are generally more affordable than the PPOs, often having very low monthly premiums. Although, both types of plans may require you to meet a deductible before services can be covered but this is less common with HMOs.

While PPOs usually have higher monthly premiums, they do provide some coverage for out-of-network care. Generally speaking, HMOs typically don’t cover out-of-network providers unless it’s an emergency.

Flexibility

When it comes to flexibility, PPO surpasses HMOs. You can decide to see any doctor, whether they’re in-network or out-of-network, without needing approval or a referral from a primary care doctor. If you go for a PPO, you can keep your current doctor even if they’re not in-network.

It’s a trade-off: HMOs cost less but limit your choices for care. PPOs cost more but offers you with more options for where and from whom you receive care.

PPO vs. HMO Insurance: Pros and Cons

Knowing the advantages and disadvantages of HMOs and PPOs may help you in deciding the one to go for;

HMO pros;

  • Doctors can help in coordinating your car
  • Low monthly premiums
  • Lower prescription costs
  • Lower deductibles

HMO cons;

  • Limited Choice
  • Coverage is available for in-network providers only, apart from emergencies.
  • More costs when patient is in need of out of network care
  • No referrals required.

PPO;

  • More flexible
  • Wide range of providers
  • Coverage is available for both out-of network and in-network doctors
  • You can see a specialist without any referral

PPO cons

  • High Out of pocket costs
  • Very expensive premiums.
  • No doctors to help coordinate care

HMOs are perfect for people who want very cheap help insurance plans ad don’t need to out of network care. On the other hand, PPOs are good choice for individuals who want to get out of network care. And don’t want to depend on referrals to meet with specialists.

PPO vs. HMO Insurance: Which is better?

Deciding between an HMO and a PPO depends on the coverage you need and what matters the most to you. Here are some questions that can help you decide:

  • Do you prefer lower costs or more flexibility
  • Are low monthly premiums and copays very important to you?
  • How much is the out of pocket cost for the plan you chose?
  • Do you visit doctor frequently?
  • What medical services do you expect to need in the future?
  • Do you have any health condition that requires you seeing specialists frequently?
  • Is your doctor part of the plan’s network?
  • Do you want to keep using certain specialists, even if they’re not in-network?
  • Do you travel often and need the flexibility to see doctors wherever you go?

Answering the above questions will guide you toward the plan that suits you the most. Saving money with fewer choices (HMO) or having more options for care (PPO). The best health plan for you depends on your needs and priorities.