The Differences Between HMOs and PPOs

Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) are two of the most popular choices for health care plans. Both offer a wide array of benefits, including access to a wide variety of medical professionals, coverage for a variety of treatments and services, and discounts on many medical expenditures. Each type of health plan has its own unique advantages and disadvantages, so it's important to understand the differences between the two in order to make an informed choice.

The Basics: What Are HMOs and PPOs?

A Health Maintenance Organization (HMO) is a managed care organization that operates a network of healthcare providers and facilitates the delivery of health services among members in the network. HMOs typically require members to obtain all of their care from doctors and other providers that are part of the HMO's network, as well as refer to specialists that are in-network as well. Depending on the plan, in-network care providers are typically covered at a higher rate than out-of-network providers.
 
A Preferred Provider Organization (PPO) is similar to an HMO except that PPOs generally offer more flexibility with regard to the choice of providers. While PPOs do typically require members to obtain care from providers within their network in order to receive discounted rates, members are usually still able to obtain care from out-of-network providers, albeit at a higher rate than if they were to obtain care from an in-network provider.

Costs: How Much Do HMOs and PPOs Cost?

The cost of HMO and PPO plans vary depending on the plan, but they typically have similar monthly premiums and out-of-pocket expenses, such as co-pays. HMO plans typically have lower out-of-pocket costs, as members only pay when they visit an in-network provider, while members of PPO plans may be required to pay a copayment or co-insurance even when seeking care from an in-network provider. This is why HMO plans are often considered to be more cost-effective than PPO plans. Furthermore, out-of-pocket costs for HMO plans can also be limited if the plan has an annual cap on out-of-pocket expenses.

Coverage: What Does each Plan Cover?

The coverage of HMO and PPO plans vary, but both typically cover basic medical services such as doctor’s visits, prescription drugs, hospitalization and preventive care. However, HMO plans typically have more limitations on the types of providers that are covered and require members to obtain referrals to specialists from their primary care physician.
 
PPO plans typically offer a broader range of choices when it comes to providers, including specialists, and do not typically require members to obtain referrals prior to seeking specialist care. Furthermore, PPO plans also typically offer coverage for out-of-network providers, though members may be required to pay a higher rate for out-of-network services.

Choice of Providers: What Provider Choices Does Each Plan Offer?

HMO plans typically require members to obtain care from providers that are within the plan's network. These providers are typically reviewed and approved by the HMO and members generally receive greater coverage for care from in-network providers than they do from out-of-network providers. Furthermore, HMO plans typically require members to obtain referrals to specialists from their primary care physicians prior to receiving care from a specialist.

PPO plans also typically have networks of providers that are approved by the plan but members are typically allowed to obtain care from out-of-network providers as well. While members may have to pay a higher rate for out-of-network care, they typically do not have to obtain referrals prior to seeking specialist care.

Summary

HMOs and PPOs are two of the most popular choices when it comes to health care plans. HMOs typically offer lower out-of-pocket costs, as members only pay when they visit an in-network provider, but usually require referrals to specialists from their primary care physician. PPOs usually offer more flexibility when it comes to provider choice, allowing members to obtain care from both in-network and out-of-network providers, albeit at a higher rate for out-of-network services. Both types of plans cover basic medical services and usually have similar monthly premiums and out-of-pocket expenses. However, it is important for individuals to understand the differences in order to make an informed decision when selecting a health plan.