Christine Gibson
As Medicare Advantage Plans grow in popularity, many people still do not understand the difference between an HMO health insurance plan and a PPO health insurance plan. There are pros and cons to both types of plans.
An HMO health insurance plan is a Health Maintenance Organization. HMO plans have a network of doctors, clinics and hospitals that they cover. Except in the case of an emergency, an HMO health insurance plan will generally not provide coverage outside of their network.
HMO health insurance plans gained really bad reputations in the late 1980s and early 1990s. Consumers often found their doctors were not in the network because the HMO networks were so small at the time. Another poor aspect of the then HMO plans was that a consumer’s primary care doctor was responsible for maintaining their patient’s health care. That meant that anytime a consumer/patient needed a specialist, they were required to obtain a referral from their primary care doctor. The primary care doctor was considered the patient/consumer’s health care “gatekeeper” per se.
The insurance companies, however, have made vast improvements to these HMO health insurance plans. They have expanded their network of doctors, clinics and hospitals. For most of the larger HMO health insurance plans offered in Western North Carolina currently, you would be hard pressed to find that your doctor is not in network.
On many of the HMO health insurance plans, consumers are no longer required to have a referral from their primary care doctor to see a specialist. However, it is important to keep in mind that the specialist doctor may require a referral from the primary care or another doctor.
A PPO health insurance plan is considered Preferred Provider Organization. A PPO health insurance plan also has a defined network of preferred doctors, clinics and hospitals. A PPO health insurance plan will allow their consumers/patients to access services out of their network and partially cover the cost. The copays for services within the network are typically lower than the copays for services accessed out of network.
When comparing an HMO versus a PPO, it is important to look at the network as well as the premium cost, copays and maximum-out-of-pocket costs you could be subjected to throughout the year. It is advantageous for you to work closely with an agent to compare these aspects of available health insurance plans to find a plan that fits your needs.
Christine Gibson is a State Licensed Insurance Agent who helps local residents with Health and Medicare Insurance questions in Waynesville. For more information, call 828-246-9950.
Originally printed in Positively Haywood by Vicinitus; vicinitus.com