Most people looking for insurance policies are usually torn between HMO vs PPO insurance. While these groups all provide health care insurance, there are disparities between them and the services they render.
These differences make them completely different from one another, even when their goal remains ultimately the same.
It’s these disparities that we’d be looking at in hope of demystifying what the two groups are for. We hope that this will help you make the best decision in terms of choosing which group you’d buy from.
Meanwhile, take a look at our table of content for what to expect in this post.
Table of contents
What Is HMO Insurance?
Health Maintenance Organization (HMO) is an acronym for Health Maintenance Organization. A Health Maintenance Organization (HMO) is a group of doctors, hospitals, and other healthcare providers who have agreed to work together to offer care at a lower cost.
HMOs may require you to choose a primary care physician (also known as a primary care provider or PCP) who can refer you to specialists as needed to keep expenses down.
Except for emergency treatment, which may be covered out-of-network, an HMO plan will only pay for services from health care providers in the HMO network. Lab procedures, like a blood sample or a urine test, are also confined to the HMO network’s one laboratory provider.
HMO plans are typically less expensive than PPO plans, with lower monthly payments, making them perfect if your preferred providers are already in the network, or if you receive the majority of your treatment close to home.
Preferred Provider Organization is an acronym for Preferred Provider Organization.
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What Is PPO Insurance
Preferred Provider Organization is an acronym for Preferred Provider Organization. A Preferred Provider Organization, like an HMO, is a group of doctors, hospitals, and other healthcare providers who agree to offer services at a set price.
You are not restricted to in-network providers, unlike an HMO, albeit your copay or out-of-pocket fee for out-of-network visits may be greater than for in-network providers.
In return for more flexibility, PPO plans usually have higher monthly fees. You don’t need to keep a primary care physician if you have a PPO, and you can see any doctor you want, including specialists, at any time. This also means that you can get medical help wherever you are when traveling.
In addition, PPO plans give laboratory service providers greater options. When you need lab work done, you can use a PPO network to choose the most convenient location.
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What You Should Consider Before Choosing HMO VS PPO Insurance
Whether you’re thinking of choosing HMO over PPO, or the other way round, you should consider these things:
Are you looking for a way to reduce your monthly payment?
The monthly costs of the HMO and PPO plans are compared. Consider an HMO plan if you require a cheaper monthly premium.
If the cost of the plan is the biggest issue for you here, then you should definitely choose A HMO over a PPO plan.
Do You Prefer To Stay Close To Home or Travel Frequently?
If your job requires you to travel a lot and your profession or hobbies expose you to high-risk activities, getting PPO insurance would be your best option.
A PPO insurance would also be good if you’re a traveler with a chronic illness, that requires constant medical care.
However, If you require a lot of specialized care, such as for a rare or chronic ailment, you may prefer the convenience of selecting experts and seeing them straight away that an HMO plan provides.
An HMO is more likely to provide the correct coverage for you if you usually seek treatment in your home city or from your family physician.
If You Already Have a Favorite Doctor, Does The Plan You’re Considering Include Visits With Him or Her?
While some HMO plans have a larger network than many other HMOs, the PPO plans still cover more health care providers in their network.
If you want to keep your current doctor, check whether he or she is in-network under an HMO, a PPO, or both.
Choosing the proper health plan can provide you peace of mind, knowing that your medical needs are covered by your insurance.
What Is the Difference Between an HMO and a PPO?
The following are the main distinctions between an HMO and a PPO plan:
#1. Patients with an HMO must see their primary care physician first (PCP). If your primary care physician is unable to address your condition, they will refer you to an in-network specialist.
You can see a specialist without a referral if you have a PPO plan. (There are certain exceptions, such as in-network visits to a gynecologist or obstetrician for routine care.)
#2. To receive coverage under an HMO plan, you must stay within your network of providers. Patients with a PPO plan still have a network of doctors to choose from, but they aren’t limited to seeing only those doctors. You are free to see whichever healthcare provider you like.
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What this Means
If you stay in your HMO’s network, you may expect the most comprehensive insurance coverage for the treatments you receive in accordance with your plan.
When you leave your network, your coverage vanishes. With a PPO, you can go to doctors who aren’t in your network and still get coverage, but not as much as if you stayed in your network.
What Kinds of Services Are Included? HMO VS PPO Insurance
The services that are covered differ from one plan to the next. If a plan is sold on an Affordable Care Act (ACA) marketplace, it must provide preventative care (such as checkups, physicals, and vaccines), as well as emergency and maternity services. The ten key benefits are the names given to these services.
Filing a Claim HMO VS PPO Insurance
The amount of legwork required on both sides is another distinction between an HMO and a PPO. Patients don’t need to file a claim with an HMO because the insurance company pays the healthcare provider directly.
A patient with a PPO, on the other hand, may be required to pay out-of-network physicians first before filing a claim with their insurance carrier for reimbursement.
Conclusion
If you’ve read this post to this point, I believe you would have understood the difference between HMO VS PPO Insurance.
I also believe that understanding the difference would help you make the best decision for yourself.
Good luck.
References
- Individual.carefirst.com– HMO vs. PPO
- Healthmarkets.com– Difference between HMO and PPO
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