HMO or PPO? It’s a question of choice and flexibility.
Published by
Ese Omwanor
on
I frequently find myself in the patient waiting areas at doctor’s offices. It’s where I glean insight into topics I might need to speak to as a Provider Relations Manager. Most often I get questions about coverage and authorizations. But as we grow our commercial business, some folks want to make sure they understand the different products that we offer, since each product has its own rules. A good example is the difference between an HMO and a PPO plan.
Why are PPO Plans Popular?
The Health Maintenance Organization (HMO) plan has reigned supreme for the last few decades. Increasingly, however, more mobile and even remote workforces are choosing Preferred Provider Organization (PPO) plans. PPOs can offer an excellent solution for those employees who travel often, have college students living in other geographic regions, or hold the policy for dependents residing outside of the HMO enrollment area.
PPO plans have less administrative requirements – referrals are not required, so a patient can make appointments with specialists without involving a PCP. While we encourage all patients to have a PCP, we don’t require that they must select one in the insurance company system.
HMO and PPO Plans: How They Compare
| HMO | PPO | |
|---|---|---|
| Costs | Lower premiums and out-of-pocket costs | Higher premium and out-of-pocket costs in exchange for the flexibility of going in or out of network without referrals |
| PCP Requirement | Members must select an in-network PCP responsible for coordinating the member’s health needs. | A PCP is not required. |
| Referral Requirement | Referrals from the PCP are required for most specialist care. | Referrals are not required. |
| In-Network Coverage | Members are required to stay within the HMO network. | Members receive in-network coverage for services rendered by a provider in the PPO network. |
| Out-of-network coverage | Only emergency services are approved outside the service area. | Out of network coverage is available, generally at a higher cost share depending on the member’s benefit plan. |
PPO Plus: A Plan for Patients Who Want More Choices
NHP’s PPO Plus plan provides the flexibility that patients with complex living and working arrangements need. PPO Plus members:
- Receive in-network coverage when they see a provider in NHP’s PPO Plus provider network.
- Can see an out-of-network provider at a higher cost share.
- Are not restricted to the MA service area due to NHP’s partnership with MultiPlan to provide national coverage.
Questions? Please contact providerservice@nhp.org or your provider relations manager for more information.
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Care management