There are a lot of decisions to make when it comes to choosing a health insurance plan. One of the first decisions you will need to make is which type of plan is right for you.
You’ve probably heard the terms health maintenance organization (HMO) and preferred provider organization (PPO), but do you really understand the differences between the two?
Which one is cheaper? Which one provides the coverage you need?
To help you decide, we’ve created a simple comparison chart that lays out the basic features of HMOs and PPOs. Once you have a better understanding of each plan type and how it works, it will be much easier to choose the plan that’s best for you and your family.
HMO vs. PPO: What’s the difference?
HMO vs. PPO: What’s the difference?
Compare Plans Select plan Select 2 or more plans Compare plans How much will this plan cost? Lower costHMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. Higher cost
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. Do I have to use a primary care physician (PCP)? Yes
With most HMO plans, all of your healthcare services are coordinated by your designated PCP. No
PPO plans do not require referrals for any services. Do I have to get referrals to use another doctor? Yes
With an HMO, you must first schedule an appointment with your PCP and he or she will provide a referral to an in-network specialist. No
PPO plans do not require referrals for any services. If I have a doctor or a specialist who is out of network, will I still be able to see him or her and have the costs covered? No
HMOs don’t offer coverage for care from out-of-network healthcare providers. The only exception is for true medical emergencies. Yes
With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible. Will I need to file claims? No
Since HMOs only allow you to visit in-network providers, it’s likely you’ll never have to file a claim. This is because your insurance company pays the provider directly. Yes
In some cases, you will have to pay a doctor for services directly and then file a claim to get reimbursed. This is most common when you seek services from out-of-network providers.
Generally speaking, an HMO might make sense if lower costs are most important and if you don’t mind using a PCP to manage your care. A PPO may be better if you already have a doctor or medical team that you want to keep but doesn’t belong to your plan network.
Medicare HMO & PPO
Medicare also has both PPO and HMO options. If you are eligible or over the age of 65, you might want to check out Humana’s Medicare PPO plan or Humana’s Medicare HMO plan.
Humana Dental & Vision
Dental and vision coverage are also available in both PPO and HMO plans. You can learn more about Humana’s dental plans, and Humana’s vision plans.
Making your decision
Now that you understand the major differences between the two types of insurance, you may have an idea of which one makes the most sense in your situation.
If you are ready to purchase an individual medical plan, go to eHealth.com. There you will find information about all of the plans available in your area. Then you can sign up for the insurance that makes the most sense for you.
But if you’re still undecided about individual medical plans and would like even more information to make your decision, please visit our PPO overview page or our HMO overview page.
Humana answers your Medicare questions
One of the big decisions every American must make is what type of health insurance to select that best meets their health needs, allows them to see their preferred doctors, and is within their budget. The 2 primary options are PPO insurance and HMO insurance plans. “PPO” stands for “preferred provider organization" and “HMO” means “health maintenance organization.” But what do they mean?
Although there is no cut-and-dry answer to which insurance works for everyone, there are clear advantages and disadvantages to each type of insurance plan that can guide you in making the decision that works best for your needs.
What Is an HMO Insurance Plan?
HMO insurance gives policyholders access to specific physicians and hospitals within the network it allows you to see, and your medical bills are only covered if you see providers within that network. Although this limits your options for which providers you can see, you’ll still need a primary care doctor to refer you to specialists within your HMO network. Many choose an HMO insurance plan simply because the monthly premium is lower than PPOs, and the out-of-pocket costs are lower. It is worth noting you will still be able to go to your nearest emergency room and receive coverage in the event of a medical emergency.
Typically, HMO insuarance plans require pre-authoriazations for services.
What Is a PPO Insurance Plan?
PPO plans give you much more flexibility in deciding which healthcare providers you can see and be covered, but care is still usually more affordable if you stay within the network of providers your policy covers. You will not need a primary care doctor’s referral to a specialist; rather, you can book an appointment with a specialist physician on your own, including out-of-network specialists (although you will typically pay more out-of-pocket for out-of-network specialists). Some decide PPO is not the best option because the monthly premiums are typically higher, and out-of-pocket costs are higher. You might also feel the responsibility for managing your care without a primary care doctor’s help (if you decide not to have one) is too much of a burden.
Should I Get an HMO or a PPO Plan?
While you weigh your options between signing up for an HMO or PPO plan, many people like you have the same question: Which is the right choice for yourself and/or your family? The main question you’ll have to ask yourself is whether cost or flexibility is more important to you.
The primary differences between HMO and PPO plans are:
- Cost: HMOs have lower monthly premiums, lower out-of-pocket costs, and sometimes there is no deductible (a set dollar amount you must pay out-of-pocket before your insurance starts paying doctors’ bills). PPOs typically have higher monthly premiums, higher out-of-pocket costs, and have a deductible you must reach before they pay for your healthcare bills.
- Network coverage: With an HMO plan, you can only see in-network providers unless it is a medical emergency. PPO plans give you much more flexibility to see providers both in- and out-of-network.
- Referrals: HMO policyholders must have a referral from their primary care doctor to see an in-network specialist. With PPO plans, policyholders don’t require specialist referrals, and they are not required to have a primary care doctor.
Insurance Plans We Accept at Ridgecrest Regional Hospital
We accept all major PPO insurance plans, and we are in-network with:
- Aetna
- Americas Choice Provider Network
- Anthem Blue Cross
- Anthem Blue Cross CA Exchange
- Beech Street
- Blue Cross (including FEP)
- Blue Shield
- Blue Shield CA Exchange
- Blue Shield of CA/VA
- Cigna
- CMSP
- Core Choice
- Coventry/First Health
- Coventry/Mail Handlers
- GEHA
- Health Net
- Health Net MediCare
- Health Net Medi-Cal
- Health Net Tricare
- Health Net WC
- Health Smart
- Interplan
- Integrated Healthplan
- Kern Health Network
- Multiplan
- Networks By Design
- Pacificare
- PHCS
- Prime Health Services
- Three Rivers
- TriWest
- UFCW
- United Healthcare Medicare
- United Healthcare
Please note: We do not currently accept HMO insurance plans. However, in the case that you receive care under a HMO plan at RRH you may be required to obtain a pre-authorization from your HMO.
If you qualify for free assistance from one of the many government programs, such as Medi-Cal, SSI, Healthy families, or others, our qualified staff can help walk you through the process of seeing if you can submit healthcare bills using these programs. Please call beforehand for further information.
For further information about insurance and billing from our hospital, please click here or contact us at (760) 499-3189 to speak to a member of our staff.