Anthem Blue Cross HMO vs PPO: Understanding the Key Differences

When enrolling in an Anthem Blue Cross health insurance plan in California, you’ll have the choice between HMO and PPO plans. But what exactly is the difference between Anthem’s HMO and PPO offerings?

This guide will explain the key distinctions between Anthem Blue Cross HMO and PPO plans so you can determine which type of plan makes the most sense for your health and budget needs.

HMO vs PPO Overview

First, let’s briefly summarize how HMO and PPO plans differ:

HMO (Health Maintenance Organization)

  • Requires selection of a primary care physician (PCP) who coordinates care
  • Must get referrals from PCP to see specialists
  • Only covers in-network providers except in emergencies
  • Copays for services; no claim forms

PPO (Preferred Provider Organization)

  • Does not require PCP selection or referrals
  • Out-of-network care is covered but with higher costs
  • Pay deductibles and coinsurance; may need to file claims
  • More flexibility in provider choice

So in general, HMO plans offer lower premiums but less flexibility, while PPO plans cost more but provide more choice of providers. But how do Anthem’s specific HMO and PPO options compare?

Comparing Anthem Blue Cross HMO and PPO

Anthem Blue Cross offers a range of HMO and PPO plans in California’s individual/family and employer-based markets. Here is how some key features compare between Anthem’s HMO and PPO offerings:

Provider Networks

  • HMO: Must use Anthem’s HMO network except in emergencies.

  • PPO: Can use Anthem’s broader PPO network which includes providers not in the HMO network. Also covers out-of-network providers at higher cost.

Primary Care Physician

  • HMO: Must select an in-network PCP who coordinates care.

  • PPO: No need to select a PCP.

Referrals to Specialists

  • HMO: PCP referral required to see network specialists.

  • PPO: No referrals needed to see any in-network specialist.

Prior Authorizations

  • HMO: Some services require authorization from HMO before receiving care.

  • PPO: Out-of-network services may require prior authorization.

Cost Sharing Differences

  • HMO: Copays for office visits, ER care, prescriptions. No deductible.

  • PPO: Pay deductible and coinsurance for services. Copays may also apply.

  • Both have out-of-pocket maximums which limit your total costs for covered care.

Claims Processing

  • HMO: Rarely need to file claim forms.

  • PPO: Must file claim forms for out-of-network services.

Next we’ll look at some specific Anthem plan examples to further compare the HMO and PPO options.

Comparing Sample Anthem Blue Cross HMO and PPO Plans

To make the HMO vs PPO differences more concrete, let’s look at some sample Anthem plans available in the California marketplace.

Here are some details for sample Anthem Blue Cross HMO and PPO plans:

Anthem MediBlue Access (HMO)

  • $0 premium, $0 deductible
  • Primary care visit copay: $20
  • Specialist visit copay: $55
  • $350 per day up to 5 days for hospitalization
  • $400 copay for ER visit
  • $16 copay for generic drugs

Anthem Blue Cross PPO (Gold Plan)

  • $389 monthly premium
  • $500 deductible
  • Primary care: $30 after deductible
  • Specialist: $65 after deductible
  • 20% coinsurance after deductible for hospitalization
  • $350 copay + 20% coinsurance for ER
  • $16 copay for generic drugs

For this particular set of sample plans, we can see some tradeoffs:

  • The HMO has lower upfront costs with no premium or deductible.

  • But the PPO provides more provider choice flexibility and lower copays for specialists.

  • The HMO covers hospitalization at fixed copay, while the PPO plan has 20% coinsurance.

  • The PPO will likely cost more for frequent outpatient services due to the deductible.

So for some members the HMO may provide the best value, while others may prefer the open access of the PPO depending on their expected utilization.

Pros and Cons of Anthem Blue Cross HMO vs PPO

Finally, let’s summarize some of the key pros and cons of Anthem’s HMO and PPO plan types:

Anthem Blue Cross HMO Pros

  • Lower premiums than PPOs
  • No deductibles generally
  • Lower specialist visit copays than PPOs
  • No claim forms to file for covered services

Anthem Blue Cross HMO Cons

  • Limited provider network
  • Must choose a PCP to coordinate care
  • Referrals required for specialists
  • Pre-authorization needed for some services

Anthem Blue Cross PPO Pros

  • Wider provider network including out-of-network option
  • No PCP selection or referrals required
  • Nationwide coverage for urgent/emergency care

Anthem Blue Cross PPO Cons

  • Higher monthly premiums
  • Must pay deductible and coinsurance costs
  • Higher specialist copays than HMO
  • Must file claim forms for out-of-network services

The right choice comes down to your priorities and health care needs. For some, an HMO offers simplicity and lower costs. For others, a PPO provides more control and access.

Finding the Right Anthem Plan

When choosing between Anthem Blue Cross HMO and PPO plans, consider factors like:

  • Your budget and willingness to pay higher premiums
  • Preferred providers and network adequacy
  • Healthcare needs and expected utilization
  • Desire for coordination of care vs flexibility

Use Anthem’s website tools to search for in-network doctors, estimate costs, and compare plans side-by-side. This will give you a better idea of how the HMO vs PPO decision aligns with your specific health care situation.

An insurance broker can also help you analyze the HMO and PPO options available from Anthem based on your circumstances, preferences, and anticipated needs. This can provide valuable insight as you make this important health coverage decision.

The Bottom Line

While Anthem Blue Cross offers both HMO and PPO options, there are important tradeoffs to understand between these two plan types. In general, HMOs offer affordability and simplicity while PPOs provide greater choice and flexibility. Consider your budget, provider needs, and willingness to coordinate care as you decide which route is a better fit.

What is an HMO, PPO, HDHP or EPO


What is the difference between Anthem PPO and HMO?

PPO plans tend to have somewhat higher costs than HMO plans, but they generally have larger networks. You also have the flexibility to see doctors out of the network at an additional cost. HMO plan costs tend to be lower than PPO plans as long as you receive care within the network.

Which is better an HMO or PPO plan?

HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.

Why do doctors prefer PPO?

HMO plans might involve more bureaucracy and can limit doctors’ ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.

Is Anthem Blue Cross Partnership a PPO or HMO?

Medi-Cal Access Program Anthem contracts with the state of California to provide services to eligible members through our PPO or HMO, based on where the member lives.

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