Open Enrollment

HMO vs. PPO

Choosing a health plan? Compare the low cost and strict rules of an HMO against the flexibility and higher premiums of a PPO.

HMO

Health Maintenance Org
Monthly PremiumLower $$
PCP Required? Yes
Specialist Referrals? Required
Out-of-Network No Coverage*
VS

PPO

Preferred Provider Org
Monthly PremiumHigher $$$
PCP Required? No
Specialist Referrals? Not Required
Out-of-Network Partial Coverage

The HMO "Gatekeeper" Model

An HMO keeps costs down by requiring you to stay within their network of doctors and facilities. They also require you to choose a Primary Care Physician (PCP).

  • Your PCP is the "gatekeeper" to all your healthcare.
  • If you need to see a dermatologist or a cardiologist, you must see your PCP first to get a referral.
  • If you go out-of-network (except for true medical emergencies), you pay 100% of the cost.

Best For: Healthy individuals who rarely see specialists, or families looking to save money on monthly premiums and are fine staying local for their care.

The PPO "Flexibility" Model

A PPO offers much more freedom but charges higher monthly premiums for that privilege.

  • You do not need a Primary Care Physician (PCP).
  • You can book an appointment directly with a specialist without needing a referral.
  • You can see out-of-network doctors, though you will pay a higher percentage of the cost than if you stayed in-network.

Best For: People who travel often, those managing chronic conditions who need frequent specialist visits, or those who want the freedom to choose any doctor they want.