Fair Care Project
Challenging the Status Quo of Healthcare

To HMO or PPO…now that’s the question

By - Erik
03/07/19 12:44
You have a choice of several types of plans once it comes to medical insurance. The health maintenance organization (HMO) and Preferred Provider Organization (PPO) are two of the usual suspects you have learned about. The main distinction between HMO and PPO programs typically includes the magnitude of the policy network, the potential to see specialists, the price of plans and coverage for out of network providers.

Now let us take a gander at each type of insurance more intently to see if they are the same, how they are clearly distinct and what you can do pick a new plan that catches your eye.

An HMO provides you with access inside its provider network with specific health providers. A network comprises providers many of whom have consented to drop their prices and satisfy quality requirements for policy members. However, contrary to PPO planning, HMO planning only covers care if you ever see a physician in that HMO network. 

There are few ways to schedule a visit with a non-network provider. Although there are usually more coverage restrictions than most other policies, such as only allowing individual appointments, examinations or interventions.

Another critical point about HMOs could be that some plans encourage you to assign a primary care physician (PCP), that will figure out what treatment you need.

With some plans, if you see a consultant or get a unique test performed, you may need to cover a PCP referral.

If you choose to seek medical attention outside of the HMO network, you don't have to pay the full cost of healthcare services.
Premiums for HMO plans are usually much lower and can have perks like no deductible or a low deductible.

PPO Medical insurance policies offer greater versatility when selecting a medical professional or doctor's office. They also incorporate a system of providers, but again the view of non-network providers is less constrained. Also, if you ever see a non-network provider, the PPO insurance company will pay, albeit at a lower rate.

One major perk is that you can see a physician or specialist without going to your primary care physician first for a referral.

You may see a physician or to a clinic beyond the network. However, if you remain in the PPO system, your perks may be smarter.

Insurance rates are generally higher, and perhaps a deductible is typical.
HMO vs. PPO: When comparing the two, you will notice that HMO tends to be cheaper, but usually you also have less coverage and also more constraint. PPOs may be more versatile and cover more, but will have a higher premium and is a high highly probable to have a deductible. Here is a synopsis of a few of the main points of contrast.

But which plan is better?

It isn't about what's cheaper, but what would be healthier for you. Consider the pros and cons of each type, together with your specific situation, when you have a voice in the matter among these two types of plans. In general, prices for HMO plans will all be lower, since premiums are generally lower and deductibles are low or are just not entirely applicable. 

Thus, you may consider taking an HMO plan seriously when your own economic situation establishes that the expense is by far the most crucial. However, the compromise would be flexibility. For most HMOs, you must choose a PCP, if you want to see a specialist, you have to get a referral from your PCP. If you wish to have versatility and options, a PPO might be the direction to go. Furthermore, PPOs are usually covered by outside network suppliers, although they are less frequent than those of in-network suppliers. Outsourcing coverage with HMOs is generally confined to emergencies; non-emergency things are usually but usually not covered.

Look up your provider network for specific plans to see whether your chosen providers are in the system as you will save money by staying in the network. The PPO plan will better offer your chances because PPO networks try very hard to be more extensive, but before you choose, you can do the background reading. You might still find that the specific HMO plan you are considering includes or at least enough of your preferred providers to fit your needs

Original Post

Middle of the week seemed like an appropriate time to write a very brief and generalized explanation of HMO’s versus PPO’s. This is far from a comprehensive review or explanation but should give you an idea of the main difference between the two in a very short period. Got 1 minute?

I often get asked by friends or family for a simple breakdown of an HMO versus a PPO insurance plan. In its most basic form, an HMO is cheaper but comes with some caveats. One caveat, the one that has pushed me away from HMO’s is the notion that your primary care physician has a much more significant role in your medical decision making. It also brings insurance companies into a much more substantial role in your medical decision making. This is how they screw y- I mean this is how they do it.

In an HMO you are required to see your primary care physician, who mind you must be “in-network” to be covered, and your physician gives you, the patient, a referral to go see a specialist that you require care from. Essentially Mostly, let us say you are suffering from migraines. In an HMO plan you would have to see your primary care physician first, and then, if they give a referral to see a specialist, the insurance company decides if the visit to the specialty physician is medically necessary. A great example of an HMO is Kaiser. When you are a Kaiser member, you are required to use their physicians and facilities if you want their interventions to be covered under your HMO insurance plan.

A Preferred Provider Plan, or PPO, often has much higher premiums, but comes with extra “perks.” One example is that you can go directly to the specialist without your primary care providers referral. You also have the option of seeing providers that might not be in the “Tier I” network so you can for the most part keep your doc.

In summation, HMO’s are cheaper but more restrictive on who or what kind of doctor you can see. Both types of plans will cover the emergency room visits, and most will have a special urgent care rate.