FAQ

HMO vs PPO: Differences, Similarities & Things to Consider | CareFirst BlueCross BlueShield

To choose the plan that’s right for you, consider the price and flexibility you need in a health plan. These are the differences between an hmo and a ppo.

what are the differences between hmo and ppo plans?

Choosing between an hmo or ppo health plan doesn’t have to be complicated. the main differences between the two are the size of the health care provider network, the flexibility of coverage or payment assistance for in-network versus out-of-network doctors, and the monthly payment.

Reading: What does hmo insurance cover

An hmo plan’s monthly payment is lower than a ppo plan with a comparable deductible and out-of-pocket maximum.

carefirst ppo plans offer a large network of providers. In exchange for a lower monthly payment, an HMO offers a narrower network of available doctors, hospitals, and specialists. carefirst has built its plans with patients’ freedom to see the doctor of their choice in mind, and the hmo plan still covers a larger network of doctors than many other health insurance providers.

in depth: hmos

hmo stands for health maintenance organization. A health maintenance organization is a network of doctors, hospitals, and other health care providers that agree to provide care at a reduced rate. To keep costs down, HMOS may ask you to select a Primary Care Physician (sometimes called a Primary Care Provider, or PCP), who can refer you to specialists when needed.

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An hmo plan will only pay for care from health care providers in the hmo network, except for emergency care, which may be covered out-of-network. lab tests, such as a blood draw or urinalysis, are also limited to a lab provider covered by the hmo network.

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hmo plans are generally less expensive than ppo plans, with lower monthly payments, making them ideal if your favorite doctors are already in network or you get most of your care close to home.

in depth: ppos

ppo stands for preferred provider organization. Like an HMO, a Preferred Provider Organization is a network of doctors, hospitals, and health care providers that agree to provide care at a certain rate. Unlike an hmo, you are not limited to in-network providers, although your copay or out-of-pocket cost for out-of-network visits may be higher than for in-network providers.

PPO plans generally require higher monthly payments in exchange for greater flexibility. With a PPO, you don’t need to keep a primary care doctor and you can see a different doctor of your choice at any time, including specialists. This also means when you’re on the go, you can get care wherever you are.

In addition, ppo plans offer more options for lab service providers. when you need to do lab work, you can choose the most convenient location within a ppo network.

things to consider when choosing between hmo and ppo:

To choose the right plan for you and your family, you may want to consider the following:

need a lower monthly payment?

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compare the monthly cost of hmo and ppo plans. if you need a lower monthly rate, consider an hmo plan.

Do you stay close to home or do you travel a lot?

if you travel frequently and are more likely to need care while away from home, especially if you live with a chronic condition or enjoy high-risk hobbies such as certain sports, you may need a ppo to provide you with the best coverage for your needs.

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If you need a lot of specialty care, say you’re managing a rare or chronic condition, you may also prefer the ease of choosing specialists and seeing them right away that you get with an hmo plan.

If you receive care primarily in your hometown or primarily from your family doctor, an hmo is more likely to provide adequate coverage.

if you already have a doctor you like, does the plan you’re considering cover visits to him or her?

While carefirst hmo plans have especially large networks compared to many other hmos, ppo plans still offer in-network coverage for more health care providers. If you want to keep your doctor, you can determine if he or she is in-network under an HMO plan, a PPO plan, or both.

Choosing the right health plan can give you peace of mind, knowing your insurance plan covers your health needs.

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