What is the difference between HMO and PPO health insurance plans?
Choosing the right health plan can be confusing. During open enrollment you can easily get lost in the array of coverage options. Attached is simple questionnaire that you can use when talking to your insurance agent to assist you in making the right choice for you and your family, based on your medical needs and budget. Click Here for an online comparison form.
Most options come down to basic types of health care plans - health maintenance organizations (HMO's), preferred provider organizations (PPO's) point-of-service (POS) plans, and fee-for-service (FFS) plans which are not a managed care product.
Health maintenance organization (HMO) plans
If you choose HMO insurance, you'll typically pay a small co-payment if you visit a physician or hospital within the plan network. HMO insurance often features lower premiums and co-pays than other plans.
However, HMO insurance is also among the least flexible types of health insurance plans. When you sign up for one of these plans, you must choose a primary care provider (PCP). This doctor will coordinate all of your medical care, including referrals to specialists, such as a dermatologist, cardiologist or surgeon. If you choose to seek treatment from a non-network physician, you will generally be required to pay most of the cost yourself.
By law, an HMO cannot require referrals for emergency care, so an HMO will pay for emergency room treatment without a referral. However; insurance companies have the option to deny an emergency room visit, if they deem it non-emergent. Please refer to your provider guides for what your policy may exclude.
It is important to verify with your insurance agent where you would have to travel for your blood work or any diagnostic testing. In some cases patients have to travel out of town for diagnostic testing, which can be costly and inconvenient. For example, at the standard cost per mile, a trip to a facility 30 miles away will cost $33.
Preferred provider organization (PPO) plans. Please contact your plan administrator and verify that you can be seen at Fallbrook Hospital. Always verify with your plan administrator prior to treatment of any plan and provider exclusions.
Unlike HMOs, PPO health insurance will cover some - but not all - of the cost of care administered by out-of-network providers.
If you select a PPO, you will have low co-payments as long as you see in-network physicians. Another advantage of PPO insurance is that unlike an HMO, you do not need a primary care physician's permission to see a specialist (as long as the specialist is in network).
However, PPO insurance plans also have a few disadvantages. Going out of network for your medical care is likely to cost you - either you'll have to pay a deductible or the difference between what the out-of-network physician and an in-network physician charges.
In summary, PPO health insurance offers a wider range of access than HMO insurance, but your out of pocket costs tend to be higher.
Point-of-service (POS) plans. Fallbrook Hospital accepts most POS plans. *Always verify with your plan administrator prior to treatment of any plan and provider exclusions.
Another type of health plan -- known as a point-of-service (POS) plan - offers a combination of PPO health insurance and HMO insurance services. In fact, the "point of service" in the name reflects the fact that you make your choice of whether to use HMO or PPO services each time you see a provider.
Generally, a POS has rules similar to HMO insurance, but a POS will allow you to see an out-of-network physician for a higher fee. Some HMOs actually include a POS plan so you can see out-of-network physicians.
Fee-For-Service (FFS) Plan. Fallbrook Hospital accepts most FFS plans. *Always verify with your plan administrator prior to treatment of any plan and provider exclusions. Fee-For-Service (FFS) health insurance plans are another name for traditional indemnity plans. Go to any doctor or hospital and receive the medical care you need, and you'll be reimbursed for a percentage of the cost.
There are no networks, no need for Primary Care Physicians, and no referrals necessary. All you have to do is make sure the medical service is covered by your FFS plan - and most services are covered. FFS plans can be more expensive, but do allow flexibility if your budget allows.