To HMO or PPO…now that’s the question

Middle of the week seemed like an appropriate time to write a very brief and generalized explanation of HMO’s versus PPO’s. This is far from a comprehensive review or explanation but should give you an idea of the main difference between the two in a very short period. Got 1 minute?

I often get asked by friends or family for a simple breakdown of an HMO versus a PPO insurance plan. In its most basic form, an HMO is cheaper but comes with some caveats. One caveat, the one that has pushed me away from HMO’s is the notion that your primary care physician has a much more significant role in your medical decision making. It also brings insurance companies into a much more substantial role in your medical decision making. This is how they screw y- I mean this is how they do it.

Image Courtesy of Blue Cross Blue Shield of Michigan

In an HMO you are required to see your primary care physician, who mind you must be “in-network” to be covered, and your physician gives you, the patient, a referral to go see a specialist that you require care from. Essentially Mostly, let us say you are suffering from migraines. In an HMO plan you would have to see your primary care physician first, and then, if they give a referral to see a specialist, the insurance company decides if the visit to the specialty physician is medically necessary. A great example of an HMO is Kaiser. When you are a Kaiser member, you are required to use their physicians and facilities if you want their interventions to be covered under your HMO insurance plan.

A Preferred Provider Plan, or PPO, often has much higher premiums, but comes with extra “perks.” One example is that you can go directly to the specialist without your primary care providers referral. You also have the option of seeing providers that might not be in the “Tier I” network so you can for the most part keep your doc

In summation, HMO’s are cheaper but more restrictive on who or what kind of doctor you can see. Both types of plans will cover the emergency room visits, and most will have a special urgent care rate.