HMO and PPO plans are common insurance options that feature networks of approved healthcare providers. But they differ significantly in how they operate and control costs. Here’s how to determine which type of medical coverage you have.
What is an HMO Health Plan?
HMO stands for health maintenance organization. This type of health insurance plan provides medical care through a closed network of physicians, hospitals, and other providers.
Some key features of HMO plans:
- Requires selecting a primary care physician (PCP) to coordinate care
- Referrals required to see specialists
- No out-of-network coverage except emergencies
- Copays for office visits and prescriptions
- Typically lower monthly premiums than PPOs
The restricted provider network allows HMOs to control costs and minimize expensive claims. But it means limited flexibility in choosing doctors.
What is a PPO Health Plan?
PPO stands for preferred provider organization. Like an HMO, PPOs contract with a set network of medical providers. But they operate with more flexibility.
Key features of PPOs:
- No need to choose just one PCP
- See specialists without referrals
- Out-of-network care allowed but costs more
- Deductibles apply along with copays/coinsurance
- Monthly premiums tend to be higher than HMOs
PPO members pay more for the convenience of a larger provider network and the freedom to choose any doctor.
Ways to Check If You Have an HMO or PPO
If you’re unsure whether your health plan is an HMO or PPO, there are a few easy ways to verify:
Check Your Insurance Card
Turn over your medical insurance card. Toward the bottom, you should see a label such as “Insurance Plan: HMO” or “Insurance Plan: PPO.” This makes it easy to identify at a glance.
Look for Key Plan Features
Compare your plan’s operations against the distinguishing features of HMOs and PPOs outlined above. This often makes the type quickly apparent.
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Do you need a primary care physician and referrals? If so, you have an HMO.
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Does your plan cover out-of-network providers? Then it’s likely a PPO.
Call Customer Service
Don’t hesitate to phone up your insurance company’s customer service line and simply ask whether you have an HMO or PPO plan. The representative can provide a definitive answer.
Check Paperwork from Enrollment
Dig back into the paperwork you received when originally enrolling in the health plan. The overview of benefits likely confirms outright whether it is an HMO or PPO.
Ask Your Employer
If your workplace provides the health insurance, reach out to HR or the benefits administrator to inquire. As the policyholder, your employer has all the plan details.
HMO vs. PPO Comparison Chart
Here is a helpful at-a-glance comparison of key differences between HMO and PPO plans:
| Feature | HMO | PPO |
|---|---|---|
| Monthly Premiums | Lower | Higher |
| Provider Network | Limited | Broad |
| PCP Required | Yes | No |
| Referrals for Specialists | Required | Not Required |
| Out-of-Network Care | Not Covered | Covered but Costs More |
| claims Paperwork | Rarely | More Often for Out-of-Network Care |
Finding In-Network Providers
Once you’ve identified the type of health plan you have, it’s important to know which doctors and facilities are in your network.
HMOs
Since HMOs only cover in-network care, it’s essential to verify providers are participating before every visit. Check the HMO’s website or call customer service for the most updated directory.
PPOs
While PPOs allow out-of-network access, you’ll pay significantly more in deductibles and coinsurance when using non-preferred providers. Check your PPO’s online provider search tool regularly.
Changing Doctors with HMO and PPO Plans
The ability to change doctors depends on your health plan:
HMOs
You can change primary care physicians within the HMO’s network at any time. Just contact customer service to update your designated PCP. Switching networks requires changing health plans.
PPOs
You can visit any participating PPO provider without restrictions. No need to officially change primary doctors – just book appointments with whichever in-network physicians you prefer.
Choosing Between HMO and PPO Plans
When selecting health insurance, weigh what’s most important – lower costs or greater provider choice?
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HMOs are best if you want: Low premiums, copays for most services, limited provider network
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PPOs are best if you want: Freedom to choose any doctor, access out-of-network providers, no referrals required
Think about your priorities as a healthcare consumer before deciding between HMO vs. PPO. And consult a licensed agent if you have any questions!
Frequently Asked Questions
How do I know which doctors are in my plan network?
Both HMOs and PPOs publish up-to-date provider directories on their websites. You can also call customer service for help locating in-network physicians and hospitals.
Can I change my primary doctor with an HMO?
Yes, you can change your designated PCP at any time by contacting your HMO insurance company. Let them know the name of your new doctor.
Do PPO plans have deductibles?
Yes, PPOs typically have high annual deductibles of $1,000 or more. You must pay out-of-pocket up to the deductible amount before coverage kicks in.
What if there are no specialists in my HMO network?
If no in-network specialists exist for a condition, the HMO must allow you to visit an out-of-network provider at no extra cost.
Can I use out-of-state providers with an HMO?
It depends. Some HMOs offer nationwide coverage, allowing you to use in-network providers anywhere. Others are regional or local. Check with your insurer.
The Bottom Line
Verify whether you have an HMO or PPO plan so you can take maximum advantage of your benefits and avoid costly surprises. Check your insurance card, paperwork, call your insurer, and evaluate how the plan operates. Knowing your health insurance coverage inside and out is vital for navigating care confidently.
What is an HMO, PPO, HDHP or EPO
FAQ
How can you tell the difference between an HMO and a PPO?
What is the difference between a PPO and a HMO authorization?
Why do doctors prefer PPO?