HMO vs. PPO: What’s the difference?

Sep 06, 2024

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As if buying health insurance isn’t hard enough, what with all the confusing lingo, it can be a challenge just to figure out what all those initials stand for in the plan names.

Let us help you understand some of the basic differences between HMOs and PPOs. These are basically types of plan networks, which is important as you think about whether a plan will cover, or pay for, visits to the doctors, specialists, therapists, urgent care clinics, labs, pharmacies, hospitals and other providers you prefer.

Here’s a primer on the kinds of plan Community Health Options offers:

HMO stands for “Health Maintenance Organization,” which gives you access to a specific group of preferred providers who are part of a specific network and considered “in-network.” Generally, HMOs won’t provide coverage for those providers who are not in that network or considered “out-of-network,” except for an emergent condition in an emergency department.
PPO stands for “preferred provider organization,” and you usually pay less if you see an in-network preferred provider but can use out-of-network providers by paying a higher price.
HMO Tiered plans feature a network of preferred providers that meet or exceed Community Health Options quality, price and efficiency standards, offering higher quality at a lower cost, but allow Members can also receive care from standard providers at standard costs, but do not have out-of-network coverage.

Beyond selecting a plan type, you can also consider the category, or metal level, ranging from Bronze, which has the lowest premium but higher out-of-pocket costs, to Platinum, with a higher premium, and lower cost for medical care. Learn more about these levels here.

Want to talk with someone about which plan to choose for you and your family? Call us at (855) 624-6463 from 8 a.m. to 6 p.m., Monday through Friday, or email us and we’ll get back to you.

Follow @communityhealthoptions on TikTok for quick tips and tricks on how to buy and use a health plan. And don’t forget to follow Community Health Options on LinkedIn, Facebook or Instagram.

The most important part of a health plan won’t be found in the Schedule of Benefits

Earlier this year, a Community Health Options Member gave birth to a premature baby. Thankfully, the newborn received the best possible care at a big city hospital, but Mom and Dad lived two hours away with two more children to care for, putting incredible strain on the whole family, on top of having a new baby with complex medical needs.

Our care managers began looking for a solution to end the family’s four-hour commute. Once the baby was stabilized and doing well, we worked with the family, the hospital and their pediatrician to move the newborn closer to home, transferring his care to the same pediatrician who would hopefully care for him the rest of his long and healthy childhood.

HMO vs. PPO: What’s the difference?

The most important part of a health plan won’t be found in the Schedule of Benefits The most important part of a health plan won’t be found in the Schedule of Benefits

The most important part of a health plan won’t be found in the Schedule of Benefits