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Which one is right for you?

You have a lot of choice when it comes to picking a health insurance plan. You’ve probably heard the terms HMO and PPO a lot but it’s often hard to understand the differences in these two types of plans. Below is a simple comparison chart that lays out the basic features of HMOs and PPOs. Remember that there’s no right or wrong choice when it comes to selecting your health care plan. Having a strong understanding of these plans and how they work will help you in choosing the plan that’s best for you and your family.

What is a PPO and HMO?

Both PPO and HMO insurance plans offer similar coverage, but there are some important differences. Learn the differences so you can select the best option for you and your family.

HMO Health Maintenance Organization PPO Preferred Provider Organization
Do I need to designate a Primary Care Physician (PCP)?

YES

With most HMO plans, all of your healthcare services will be coordinated between you and your designated Primary Care Physician (PCP).

NO

A PPO plan does not require you to select a PCP. You can receive care from any doctor you choose, however you will save more money by choosing a doctor, specialist or hospital that is within your network.

Is a referral needed?

YES

As an example, with an HMO, if you have severe allergies and need to see an allergist, you will first schedule a visit with your PCP. Your doctor will then provide you with a referral for an in-network specialist.

NO

PPO plans do not require you to get a referral in order to see a specialist.

If I have a doctor or specialist who is out-of-network, will I still be able to see them and have my care covered?

NO

HMOs don’t offer coverage for care from an out-of-network physician, hospital or facility except in the case of a true medical emergency.

YES

With a PPO, you have the flexibility to visit providers, hospitals and facilities outside of your network. Keep in mind that visiting an out-of-network provider includes a higher fee and a separate deductible.

Will I have to file a claim?

NO

Since HMOs only allow you to see in-network providers, it’s likely you’ll never have to file a claim. This is because your insurance company pays the provider directly.

YES

In some cases with a PPO, you will have to pay a doctor for services directly and then file a claim to get reimbursed. This is most common when you seek a service from an out-of-network provider.

How much will it cost?

Lower Cost

HMO plans typically have lower monthly premiums and you can expect to pay less for out-of-pocket medical services. Both plans work on a combination of deductibles, cost-share or co-insurance and co-pays to pay for services.

Higher Cost

PPOs tend to have higher monthly premiums in exchange for the flexibility to choose providers both in- and out-of-network and without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.

Please visit our PPO and HMO overview pages for even more detailed information about each plan type.

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What is a PPO?

Explore PPO plans further with our detailed summary.

What is an HMO?

Get more detailed information about HMO plans to help decide which plan is right for you.

Looking for Medicare HMO or PPO plans?

Humana offers both HMO and PPO options under our Medicare Advantage plans.
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