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What are the Differences Between PPO & HMO Insurances?

You want to select the type of insurance plan that best meets your health needs, allows you to see your preferred doctors, and is within 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”, and pays for medical bills of providers within that network. You’ll need a primary care doctor to refer you to specialists within your HMO network. Many choose an HMO 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 insurance plans require pre-authorizations for services. For more info about pre-authorizations, please visit the FAQ For Insurance And Billing.

What is a PPO Insurance Plan?

PPO plans give you more flexibility in deciding which healthcare providers you want to visit, 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 of managing your care without a primary care doctor (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.

List of health insurance plans we accept

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.