You may have noticed on your current insurance card that you see the acronym HMO or PPO, but you’re not entirely sure as to what they each mean.
Generally, the difference between HMO’s and PPO’s include the size of the network (number of primary doctors, specialist, and hospitals), restrictions to see your specialist, plan cost, and coverage out-of-network.
HMO- Health Maintenance Organization
With an HMO you must only use doctors, specialist, and hospitals within a plan’s network unless it is an emergency. These doctors have agreed to lower their rates for plan members. Under an HMO you do not have access to use out-of-network providers and hospitals.
In most HMO’s the following generally applies:
- You may have to select a primary care doctor who will act as your quarterback. He or she oversees which treatments you may need.
- You may be required to obtain a referral from your primary doctor to see a specialist.
- If you obtain services from a doctor, specialist, or hospital (non-emergency) that is not in your plan’s network, you will not have coverage. Meaning you will be responsible for 100% of charges.
- Typically, co-pays and deductibles are lower in an HMO and generally have a zero premium.
PPO – Preferred Provider Organization
PPO plans generally offer its members more freedom. Freedom to see doctors that are inside the plan’s network, but usually if you decide to go out-of-network, you will pay a higher out-of-pocket cost.
In most PPO’s the following generally applies
- No referrals needed. You can go directly to the doctor or specialist directly, without the need to get a referral from your primary doctor.
- You can visit doctors, specialist, and hospitals that are out-of-network, but you will pay a higher out-of-pocket cost. We usually recommend staying in-network to keep cost low.
- PPO’s may have a monthly premium and in-network providers typically cost more than an HMO.
No Comments