Health insurance can be confusing, especially when you start looking at all the different plan types like HMOs and PPOs. Florida Blue offers both HMO and PPO plans to meet the diverse needs of Floridians. But what exactly is the difference between an HMO and a PPO plan from Florida Blue?
In this comprehensive guide, we’ll explain key differences between Florida Blue HMO and PPO plans to help you determine which type of plan makes the most sense for your health and budget needs.
HMO vs PPO: How They Work
The main difference between HMO and PPO plans comes down to how you access care.
HMO plans feature set networks of doctors, hospitals and other providers. Except for emergencies, your care is only covered if you see in-network providers. You may also need referrals from a primary care doctor to see specialists.
PPO plans offer larger provider networks. You can see any provider you want, but you’ll pay less when you stay in-network. No referrals are required to see specialists.
Let’s explore how this works in more detail:
HMO Plan Networks
With an HMO plan from Florida Blue, you must choose a primary care physician (PCP) from the plan’s network. This doctor will be your main point of contact for care.
Your PCP coordinates your overall care, including:
- Annual checkups and preventive care
- Diagnosis and treatment when you’re sick or injured
- Managing any chronic conditions
- Referrals to see specialists
Except for emergencies, your medical care is only covered if you get it from doctors, hospitals and other providers in your HMO’s network. This includes care you access through referrals from your PCP.
If you need to see a specialist like a cardiologist or dermatologist, your PCP will refer you to an in-network specialist. Without a referral, care from that specialist won’t be covered by your HMO plan.
The benefit of this limited network is that your out-of-pocket costs are generally lower when you stay in-network. Copays and coinsurance are lower with HMO plans compared to PPOs.
But the trade-off is less flexibility in choosing your providers. You can only switch PCPs at certain times of the year, and changing networks means switching plans.
PPO Plan Networks
PPO plans give you more freedom and flexibility to direct your own care.
With a PPO from Florida Blue, there’s no need to choose a PCP or get referrals to see specialists. You can see any licensed provider you want, including:
- Primary care doctors
- Specialists like cardiologists, dermatologists, etc.
- Imaging centers
- Any other licensed provider
PPO networks also tend to be broader, giving you more providers to choose from. And unlike HMO networks with regional limitations, PPO provider networks are statewide.
This flexibility comes with a trade-off. Your out-of-pocket costs are generally higher with a PPO plan. Deductibles, copays, and coinsurance are usually higher compared to HMO plans.
However, PPO plans do offer incentives to stay in-network. When you get care from providers in your plan’s network, you’ll pay the lowest price. Your costs go up when you see out-of-network providers.
For example, say you need a routine doctor’s visit for a sinus infection. The table below shows typical costs with Florida Blue HMO vs PPO plans:
As you can see, staying in-network with a PPO costs a little more than an HMO copay. But going out-of-network leads to significantly higher coinsurance costs.
So in exchange for network flexibility, PPO plans incentivize you to stay in-network when possible to keep costs down. But the choice is ultimately up to you.
Florida Blue HMO Plans
Florida Blue offers several HMO plans to choose from:
myBlue HMO – Our lowest premium HMO great for healthy individuals. Features set copays and hospital per day maximums.
BlueCare HMO – A robust benefit HMO with copays for office visits and urgent care. Hospitalization has a deductible and coinsurance.
SimplyBlue HMO – Includes copays for office visits and urgent care plus fixed costs for hospitalization and surgery.
BlueMedicare HMO – Medicare Advantage plans designed for individuals eligible for Original Medicare Parts A and B.
Let’s look at some key features of Florida Blue HMO plans:
Set copays for office visits – You’ll pay a fixed copay like $25 or $50 when you see your PCP or a specialist. Copays don’t change depending on the complexity of the visit.
Urgent care benefits – HMO plans offer copays for urgent care centers, keeping your costs low for immediate care needs.
Preventive care at no cost – All our HMO plans cover preventive services like annual checkups, screenings, and immunizations at no cost when you see in-network providers.
Option for hospital per day maximums – Our myBlue HMO offers set dollar limits per day for hospitalization instead of coinsurance. This provides cost predictability.
Regional provider networks – HMO provider networks are organized regionally so you can find care close to home. You must live in the network service area to enroll.
Referrals required for specialists – You’ll need a referral from your PCP before you can see most specialists to have coverage under your HMO plan.
No out-of-network coverage – Unless it’s an emergency, care from providers outside your HMO’s network is not covered. This includes specialists you see without a referral.
Prescription drug coverage – Most Florida Blue HMO plans offer integrated prescription benefits with copays for common generic and brand name drugs.
So in a nutshell, HMO plans offer rich benefits with copays and predictable costs when you get care from your plan’s network providers. Just keep referrals and the limited network in mind when accessing care.
Florida Blue PPO Plans
On the PPO side, Florida Blue offers these plan options:
BlueOptions PPO – Our most popular PPO with a choice of deductibles and coinsurance options. Gives you flexibility in choosing providers.
BlueSelect PPO – An alternative with set dollar copays for office visits and hospitalization. Still offers out-of-network coverage.
BlueMedicare PPO – Medicare Advantage plans with worldwide emergency and urgent care coverage plus dental, vision, hearing and fitness benefits.
Here are some of the defining features of Florida Blue PPO plans:
No referrals needed – You can self-refer to any licensed specialist when you need care.
Nationwide network – See any provider in Florida Blue’s large statewide PPO network and you’ll get the lowest costs.
Out-of-network coverage – PPO plans cover care from providers outside of their network, although your share of costs is higher.
Preventive care covered in full – Like HMOs, preventive services are covered at no charge when delivered by in-network providers.
Various deductible options – You can choose a lower or higher annual deductible when you first enroll in a BlueOptions PPO plan.
Coinsurance for services – Once you meet your deductible, you’ll pay a percentage of costs for covered services instead of fixed copays. Coinsurance offers flexibility but less predictability.
Prescription drug coverage – Most PPO plans include prescription benefits with copays or coinsurance for medications after your deductible.
No service area limitations – You can enroll in a Florida Blue PPO plan regardless of where you live in Florida.
The takeaway with PPO plans is that you’ll pay higher monthly premiums in return for more choice in your providers, including the ability to go outside your plan’s network. You just have to balance that flexibility against potentially higher out-of-pocket costs.
HMO vs PPO: Cost Differences
Cost is often one of the biggest factors when choosing a health plan. How do HMO and PPO plan costs from Florida Blue compare?
In general, HMO plans will have lower premiums and overall out-of-pocket costs, while PPO plans have higher premiums but provide more flexibility.
Here’s a breakdown of how costs typically differ:
Monthly premiums – Premiums are usually lower for HMO plans than comparable PPO plans. You’re paying for that limited provider network.
Deductibles – HMO plans often have lower or no deductibles. PPO deductibles can be in the thousands for individual coverage.
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