How HMOs and PPOs Differs
The following outline compares some of the features of HMOs and PPOs. These are general rules and you should speak with your human resources office at work or directly with your health plan. If you are in the process of deciding between enrolling in a HMO or PPO, you often can compare the plans by going online to the plans.
Which health care providers must I choose?
· HMO: You must choose doctors, hospitals, and other providers in the HMO network.
· PPO: You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.
Do I need to have a primary care physician (PCP)?
· HMO: Yes, your HMO will not provide coverage if you do not have a PCP.
· PPO: No, you can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not “preferred” providers.
How do I see a specialist?
· HMO: You will need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.
· PPO: You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.
Do I have to file any insurance claims?
· HMO: All of the providers in the HMO network are required to file a claim to get paid. You do not have to file a claim, and your provider may not charge you directly or send you a bill.
· PPO: If you get your healthcare from a network provider you usually do not need to file a claim. However, if you go out of network for services you may have to pay the provider in full and then file a claim with the PPO to get reimbursed. The money you receive from the PPO will most likely be only part of the bill. You are responsible for any part of the doctor’s fee that the PPO does not pay.
How do I pay for services in the network?
· HMO: The only charges you should incur for in-network services are copayments for doctor’s visits and other services such as procedures and prescriptions.
· PPO: In most PPO networks you will only be responsible for the copayment. Some PPOs do have an annual deductable for any services, in network or out of network.
How do I pay for services out of the network?
· HMO: Except for certain types of care that may not be available from a network provider, you are not covered for any out-of-network services.
· PPO: If you choose to go outside the PPO network for your care, you will need to pay the provider and then get reimbursed by the PPO. Most likely, you will have to pay an annual deductable and coinsurance. For example, if the out-of-network doctor charged you $200 for a visit, you are responsible for the full amount if you have not met your deductable. If you have met the deductable, the PPO may pay 60%, or $120 and you will pay 40%, or $80.
