What’s the Difference Between HMO and PPO Plans?
When you’re shopping for health insurance, you have a lot of options to choose from.
Knowing the differences between plans can help you choose the one that’s right for your health care needs and budget.
As you look at plans, you may notice that some plans are HMOs and some are PPOs, but what does that mean?
All these plans use a network of physicians, hospitals and other health care professionals to give you the highest quality care. The difference between them is the way you interact with those networks.
With an HMO plan, you pick one primary care provider. All your health care services go through that doctor. That means that you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance.
For example, if you get a skin rash, you wouldn’t go straight to a dermatologist. You would first go to your primary care provider, who‘d examine you. If your primary care provider can’t help you, he or she will give you a referral to a trusted dermatologist in your network that will.
One exception to this is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine services such as Pap tests, annual visits and obstetrical care.
Coordinating all your health care through your primary care provider means less paperwork and lower health care costs for everyone.
PPO plans give you flexibility. You don’t need a primary care provider. You can go to any health care professional you want without a referral — inside or outside of your network.
Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered.
With an HMO plan, you pick one primary care provider. All your health care services go through that doctor. That means that you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance.
For example, if you get a skin rash, you wouldn’t go straight to a dermatologist. You would first go to your primary care provider, who‘d examine you. If your primary care provider can’t help you, he or she will give you a referral to a trusted dermatologist in your network that will.
One exception to this is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine services such as Pap tests, annual visits and obstetrical care.
Coordinating all your health care through your primary care provider means less paperwork and lower health care costs for everyone.
PPO plans give you flexibility. You don’t need a primary care provider. You can go to any health care professional you want without a referral — inside or outside of your network.
Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered.
If you prefer to have your care coordinated through a single doctor, an HMO plan might be right for you. And if you want greater flexibility or if you see a lot of specialists, a PPO plan might be what you’re looking for.
For more information on HMO and PPO plans, check out our available individual and family plans.