How to Compare PPO & HMO Coverages

A Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) take a managed care approach to health care and coverage, with networks of providers---including doctors, hospitals and other medical professionals---agreeing to render services for special rates. However, there are two key differences. An HMO usually requires care through a primary care physician (PCP). With a PPO, individuals can receive care from any provider without PCP coordination or referrals. Also, an HMO generally requires a network provider or it pays no benefits. A PPO pays benefits for in- and out-of-network care; however, benefits for out-of-network care is lower.

Things You'll Need

• Employer-provided benefits enrollment materials

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Instructions

• 1

  Determine estimated total costs for the HMO and PPO. Include the cost of coverage plus out-of-pocket costs. Out-of-pocket costs include all fees for care, including deductibles, copayments or coinsurance. Refer to employer-provided enrollment materials or contact a health plan company directly to obtain cost information.

• 2

  Check out quality information about the HMO's and PPO's processes, systems and care. Sometimes employers include access to this information via enrollment materials or tools. It is also available through the National Committee on Quality Assurance (NCQA) web site.

• 3

  Think about coverage needed and compare plan benefits. For example, if a covered individual needs chiropractic treatment, look at how both plans cover care and potential limits. Copays and the number of visits covered per year may vary by plan.