HMO Vs PPO

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HMO vs PPO

BASIC Concepts

HMO – Health Maintenance Organization

PPO – Preferred Provider Organization

First of all HMO or PPO are Payer like Blue Cross Blue shield , United Healthcare, Anthem , Aetna, Humana, Cigna etc. that sells HMO and OR PPO plans. Plan is nothing but health Insurance Policy.
HMO or PPO has type of health insurance policy or plan.

HMO is restricted health plan where every member must has to go first the Primary Care Physician (PCP) for treatment. Patient does not go directly to any other provider other than PCP. PCP must refer to see any other physician or other Hospital.Referral are necessary for HMO plans. Every member has to select the Primary Care Physician. That PCP may be Individual Practitioner or group of physician (provider group). HMO plans are cheaper than PPO plans as it has lots of restrictions.

PPO is most flexible plan where member need NOT to go to primary care physician (PCP) for treatment. Member can visit to any specialist or hospital without any referral. PPO are costlier than HMO plans.

Advance Concepts:

HMO:  Although by definition for HMO patient first need to see by PCP but there are some situation where it is not needed like Emergency services. Some other service like Gynecologist or obstetrician services it need not be PCP, any other providers in the network patient can go without the referral. HMO Plans does not cover out of networks treatments and patient is liable for payment.

HMO plans has its own set of HMO providers network having less providers or hospitals than PPO networks.

PPO: Members can visit in-network and out of network providers. Unlike HMO, when PPO member visit out of network cost of treatment will be higher but it would not be denied but in case of HMO it will be denied. PPO plans has PPO providers networks providers

POS -Place or Service - Hybrid plan of HMO and PPO – Does not require referral for specialist visit

EPO – Exclusive Provider Organization – Hybrid plan of HMO and PPO – Out of network visit is covered with higher cost share.

POS and EPO varies a lot from payer to payer, please read payer specific service to their website for what service are covered or not and what are the conditions.

POS and EPO plan are not sold very much.

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