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HMO vs. PPO Comparison Chart

Below is a chart outlining the differences between an HMO and a PPO plan.

  HMO- Health Maintenance Organization PPO- Preferred Provider Organzation
Do I need to designate a Primary Care Physician (PCP)? YES
With most HMO plans, all of your healthcare services will be coordinated between you and your designated Primary Care Physician (PCP).

NO
A PPO plan does not require you to select a PCP. You can receive care from any doctor you choose, however you will save more money by choosing a doctor, specialist or hospital that is within your network.

Is a referral needed? YES
As an example, with an HMO, if you have severe allergies and need to see an allergist, you will first schedule a visit with your PCP. Your doctor will then provide you with a referral for an in-network specialist.
NO
PPO plans do not require you to get a referral in order to see a specialist.

If I have a doctor or specialist who is out-of-network, will I still be able to see them and have my care covered? NO
HMOs don’t offer coverage for care from an out-of-network physician, hospital or facility except in the case of a true medical emergency.

YES
With a PPO, you have the flexibility to visit providers, hospitals and facilities outside of your network. Keep in mind that visiting an out-of-network provider includes a higher fee and a separate deductible.
Will I have to file a claim? NO
Since HMOs only allow you to see 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 with a PPO, 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 a service from an out-of-network provider.
How much will it cost? Lower Cost
HMO plans typically have lower monthly premiums and you can expect to pay less for out-of-pocket medical services. Both plans work on a combination of deductibles, cost-share or co-insurance and co-pays to pay for services.
Higher Cost
PPOs tend to have higher monthly premiums in exchange for the flexibility to choose providers both in- and out-of-network and without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
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