How do you decide between HMO and PPO?
Asked by: Nona Kuhn | Last update: January 10, 2026Score: 4.2/5 (21 votes)
Is it better to choose PPO or HMO?
PPOs Usually Win on Choice and Flexibility
If flexibility and choice are important to you, a PPO plan could be the better choice. Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.
Why would a person choose a PPO over and HMO?
A PPO plan provides more flexibility in choosing your health care providers, but it may cost more than an HMO. Key areas to remember: Your maximum copay or coinsurance is less when you stay in network for services. You can see a specialist and access many types of services without a referral.
What are the disadvantages of HMO?
- If you need specialized care, you will need a referral from your primary care physician to an in-network provider.
- Must see in-network providers for care-less flexibility than a PPO plan.
What is the downside to a PPO plan?
Cons of PPO Plans
Less Coordination: Without a primary care doctor managing your healthcare, there's less oversight, and it can be harder to keep track of your treatments and appointments.
PPO vs HMO: What's the Difference?
Why don't doctors like HMOs?
HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.
Does PPO have a deductible?
Deductibles: PPO plans usually come with a deductible. This means you pay for care and services until the deductible is met. Then your plan starts sharing costs.
Why are people against HMO?
HMOs tend to have higher maintenance costs than a standard buy-to-let since many people share them and often have a higher turnover of tenants. Wear and tear can be higher. Some tenant types, such as students, typically involve HMO landlords with more maintenance and repair issues than, say, a family tenant would.
What is the primary problem with an HMO?
Without a referral, you don't have permission for those services, and the HMO won't pay for them. The benefit of this system is fewer unnecessary services. The drawback is that you have to see multiple providers (a primary care provider before a specialist) and pay copays or other cost-sharing for each visit.
What's the most likely reason a patient's HMO won't pay?
If you have an HMO or EPO, with very few exceptions, your coverage is limited to in-network providers that your health plan has a contract with. Your health insurance won't pay if you use an out-of-network provider.
Why would you want a PPO?
Why would I choose a PPO? You have a doctor you like and you want to keep this doctor, and the doctor is in the PPO network. You want to see specialists and other providers without having to get referrals and pre-approval first. You want more of a choice of doctors and hospitals you can go to.
What is a PPO in a nutshell?
PPO is an abbreviation for Preferred Provider Organization. It is a type of medical insurance plan that allows its participants to seek medical care from any doctor in or out of the network. However, you need to pay slightly high charges to doctors that are out of network.
Why do many patients prefer a PPO?
PPO plans give you more choices when picking health care providers than other types of insurance. In a PPO plan, you have a network of “preferred” providers. These include doctors and specialists who can offer care at the lowest out-of-pocket cost, compared to out-of-network providers.
Is Blue Cross cheaper than Blue Shield?
Depending on your region, the cheapest California health plan might be offered by Anthem Blue Cross or by Blue Shield of California. However, the rates tend to be about the same. The big difference is network. Which plan offers the most doctors, hospitals and medical provider networks?
What is the primary reason persons choose to enroll in a PPO plan instead of an HMO?
A PPO plan can be a better choice compared with an HMO if you need flexibility in which health care providers you see. More flexibility to use providers both in-network and out-of-network. You can usually visit specialists without a referral, including out-of-network specialists.
What is the downside to a HMO?
Cons Explained
No specialist visits without a referral: You'll need referrals for any specialists if you want your HMO to pay for those visits. If you need to visit a rheumatologist or a dermatologist, for example, your PCP must make a referral before you can see one for the plan to pay for your visit.
Why do people not like HMO plans?
On major disadvantage is that it is difficult to get any specialized care because the members must get a referral first. Any kind of care that is sought that is not a referral or an emergency is not covered.
What is a drawback to HMO insurance?
Limited provider options
For you to receive covered care, you must see professionals within this group. This lack of flexibility is a disadvantage of HMO insurance plans because, without easily accessible in-network providers, covered care will also be inaccessible.
Why do HMOs have such a bad reputation?
Sadly, many HMOs are run by either incompetent or corrupt bureaucracies, thereby compromising necessary patient care in lieu of their bottom-line. That said, some HMOs are better than others, and both patients and doctors must do their due diligence to determine whether or not to participate.
Why are PPOS better than HMOs?
Preferred provider organizations (PPO) offer a network of healthcare providers to use for your medical care at a certain rate. Unlike HMO, a PPO offers you the freedom to receive care from any healthcare provider—in or out of your network.
What are three disadvantages of a PPO?
- Higher monthly premium.
- Higher out of pocket expenses.
- Must monitor in-network vs out-of network to control cost.
Is Blue Cross Blue Shield a PPO?
Preferred Provider Organization (PPO)
However, BCBS still pays more to in-network providers than out-of-network providers. People who are part of a PPO do not need a physician's referral to consult with a specialist. PPOs also usually offer drug coverage. Learn about Medicare referrals.
Do you pay out-of-pocket for PPO?
PPOs set two annual limits on your out-of-pocket costs. One limit is for in-network costs and the other is for combined in-network and out-of-network costs. These limits may protect you from excessive costs if you need a lot of care or expensive treatments.