HMOs and PPOs: Picking a Health Insurance Plan

Healthcare is a fundamental part of people’s lives, providing comprehensive, advanced, and life-enhancing support to restore or maintain their health and well-being. In the US, it’s often one of the most expensive parts of living. And every year, millions of individuals and families stand at a crossroads and face a critical decision. Out of HMOs and PPOs, which health insurance plan will best fit their needs? 

Health insurance can be a confusing and complex topic to navigate, especially during the open enrollment season. There are two primary types of health insurance plans available in the US: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Both offer a variety of benefits and drawbacks. So, it’s crucial to understand the key differences between them before you arrive at an informed decision.

HMO and PPO: What’s the Difference?

While there is some overlap between HMOs and PPOs, the differences between the two matter.

Health Maintenance Organizations (HMOs)

An HMO plan is a type of managed care plan. This means that the insurance company contracts with a group of doctors and hospitals to provide care for its members. The main advantage of an HMO is that it usually costs less than a PPO plan. The trade-off, however, is that you’ll have less flexibility in choosing your doctors, treatments, and prescriptions. 

Cost-cutting with an HMO plan isn’t necessarily bad. Doctors contracted by HMOs receive incentives to take good care of you and ensure that your care is efficient and appropriate. This could mean that your primary care physician can act as a gatekeeper, ensuring you don’t have any unnecessary visits to specialists and receive unneeded procedures and treatments. 

However, with reduced expenses, HMOs can generally decide to limit your care to what they think is medically necessary. So, when you sign up for an HMO at a lower price, you’re essentially giving control back to the HMO and taking it away from you and, potentially, your doctor.

Of course, not all HMO plans are the same. Some offer more coverage and flexibility than others. Some HMO plans will cover out-of-network care in certain situations, while others will not. It’s essential to read the fine print and understand what your HMO plan covers before enrolling. 

If you’re a healthy individual who never gets sick, never needs special treatment for something complex, and never needs the choice of where to go and what to have, then an HMO might be for you. Otherwise, you might want to consider a PPO.

A male patient consulting with a doctor

Preferred Provider Organizations (PPOs)

A PPO plan is also a managed care plan, but it offers more flexibility than an HMO. With a PPO, you have greater freedom in choosing your doctors and hospitals. If you have a preferred provider that isn’t in the HMO network with a PPO plan, you can still receive some level of coverage (albeit at a reduced rate). 

With a PPO plan, you don’t need to get prior authorization from your primary care doctor to see a specialist. This can save time if you have a condition that requires prompt attention from a specialist. 

Moreover, PPO plans will typically offer more comprehensive coverage than HMO plans. This means you’ll be covered by a wider range of services and treatments. 

However, it’s important to remember that PPO plans tend to be more expensive than HMO plans. This is because insurance companies pass on the cost of providing greater freedom and flexibility back to the consumer. 

In addition, PPO plans can have higher deductibles and coinsurance rates than HMO plans. With the recent global economic crisis, it can be harder for individuals and families to pay these out-of-pocket costs.

Be Careful When Choosing a Health Insurance Plan

HMOs and PPOs both offer their own unique benefits. Let’s consider some of the drawbacks.

Disadvantages of an HMO Plan

HMO plans may save you money on monthly premiums, but they also have some potential downsides. The first is that they’re often limited by geography and restrict your choice of doctors and hospitals. If you have a preferred provider or medical center that isn’t in the HMO network, you may be responsible for a greater portion of the bill. Some HMO plans will only reimburse a certain percentage of the costs, leaving you to foot the rest of the bill. 

Another downside is that you usually need to get prior authorization from your primary care doctor in order to see a specialist. This can be especially frustrating if you have a condition that requires urgent care from a specialist.

Some HMO plans can also have a limited formulary or a list of usually cheaper drugs covered by the plan. This can be a problem if you have a chronic condition that requires expensive medication, not on the formulary. 

Moreover, if you go to the emergency room and have an HMO plan, the decision of whether or not you should be admitted may ultimately be up to a representative of the insurance company, not the emergency medicine doctor.

Emergency foom treatment may not be covered in an HMO

Disadvantages of a PPO Plan

While a PPO plan offers more freedom and flexibility than an HMO plan, there are some potential downsides that you should also be aware of. Besides being generally more expensive than HMO plans, having a PPO plan may also subject you to unnecessary tests and procedures. 

Some health care providers may be more likely to order tests or recommend procedures if they know that the insurance company will pay for them. This can lead to higher out-of-pocket costs, even if you have insurance. 

In addition, seeing specialists for routine care may not always be necessary. You may be better off seeing your primary care doctor, who can refer you to a specialist if necessary. This is why it’s crucial to establish a solid relationship with your PCP, as they can see the bigger picture of your health and make recommendations accordingly. 

Finally, even though you have the freedom to see any provider with a PPO plan, it’s still essential to check that they’re in-network. Otherwise, you may be responsible for a bigger portion of the bill.

person using calculator on smartphone

The Bottom Line in Picking a Health Insurance Plan

If you’re trying to decide between an HMO and PPO plan, it’s important to weigh the pros and cons of each type of plan. Health insurance is a complex topic, and there is no one-size-fits-all solution. Consider your needs and budget and the needs of your family. Being an informed consumer and understanding the risks and benefits of each type of plan can help you make an informed decision for your situation. HMOs and PPOs can both protect you but in different ways.

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Jonathan Baktari MD

Jonathan Baktari, MD brings over 20 years of clinical, administrative and entrepreneurial experience to lead the current e7 Health team. He has been a triple board-certified physician with specialties in internal medicine, pulmonary and critical care medicine. He has been the Medical Director of The Valley Health Systems, Anthem Blue Cross Blue Shield, Culinary Health Fund and currently is the CEO of two healthcare companies.
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