Individual and Family

HMO vs PPO for Individual Health Insurance

Published on March 23, 2018

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Updated June 14, 2018. 
Who doesn’t like having choices in life? However, when it comes to choosing medical health insurance, the options can quickly become confusing. HMO vs PPO? Catastrophic plans vs qualified health plans? With so many options, you might feel a bit overwhelmed; fortunately, there is a bit of good news. Buying health insurance doesn’t have to be complicated—you can get quotes from all different kinds of plans on eHealth, and you can see an outline of the benefits for both HMO and PPO plans.

Do you know the difference between HMO and PPO plans?

Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) are two of the most popular types of major medical health insurance plans. The major differences between HMO vs PPO plans can be found in the:

  • Size of the network
  • The cost of the plan
  • The ability to see specialists without referrals
  • The size of the in-network
  • The coverage for out-of-network services

The big difference between HMO and PPO for many individuals and families, is the primary care doctor. With an HMO, you will have a primary care doctor whom you and your family go through for most medical services. If you want to see a specialist for any reason, you will need a referral from your primary care doctor, which means an extra office visit. The trade off is that oftentimes HMO plans have lower premiums, but every plan is different, so visiting eHealth and seeing plan details might help you decide between an HMO vs PPO plan.
Some families or individuals might not care about having a primary care doctor as their outlet to all other medical services—deciding between an HMO vs PPO is very specific to each family or individual’s needs.

Understanding the key features of HMO vs PPO plans

By definition HMO plans offer an entire network of various health care providers who can offer you their services. These health care providers include a selected Primary Care Provider (PCP) who will be assigned to you and your family. It is important to note that your PCP will be responsible for coordinating your health care services, especially if you need appointments with specialists. If you do need to see an in-network specialist, then your PCP will have to make a referral before your plan will cover the visit.
Another difference between HMO vs PPO plans can be found in the types of fees. HMOs typically require copayment fees for every type of non-preventive medical visit. HMO plans also give members access to in-network doctors and hospitals. This network is comprised of providers who offer lower rates to plan members, while still meeting set quality standards. However, if you choose to see an out-of-network provider, then your HMO plan might not cover the costs of your visit.
Unlike an HMO, a PPO plan allows members to see any health care provider who is within the insurance company’s network, without a referral. The latter rule even applies to specialists. The lack of PCP referral requirements makes this the preferred type of plan for individuals who need to regularly visit specialists. There are also fewer restrictions on seeing out-of-network providers. Additionally, members are not required to choose a PCP. Like HMO plans, a PPO plan will typically have copayments on non-preventive medical care. However, many PPO plans will also have an annual deductible and higher premiums.

Main differences between HMO and PPO plans

When it comes to HMO vs PPO there are a few additional key feature differences that you should consider before you select a plan.

PPO plans HMO plans
May offer more flexibility when it is time to choose a doctor or hospital Tend to be more affordable with lower premiums and a lower (or no) annual deductible
Often have fewer restrictions on seeing out-of-network providers Require PCP referrals to see specialists for non-emergency medical needs
Sometimes cover the costs of visits to out-of-network providers Offer a list of network providers, including specialists. However, if you opt to see a doctor outside of the network, then there will be no coverage and you will have to pay for the entire visit

HMO vs PPO: Keep your future needs in mind

Deciding between an HMO vs PPO will depend on your current and anticipated future health-care needs. You will have to weigh the pros and cons of HMO vs PPO plans to make the decision that is right for you and your family. While paying the lowest premium might seem ideal now, you could want more flexibility a lower deductible later.Before you decide between HMO vs PPO, make sure that you review the list of in-network providers for your area. You should also carefully assess your income, check the availability of HMOs in your local area, and determine if you will need to see specialists in the upcoming year.
By taking the latter steps to understand the differences between HMO vs PPO plans, you will be armed with the information needed to make the right choice for you and your family. Visit eHealth.com to get free quotes on plans available to you.When choosing which type of plan you want, remember that each plan has its own terms and limitations, so be sure to check the official plan documents to understand how that specific plan works.  This article is only for general education.

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