HMO or PPO – Which is best for me?

 

An HMO is a Health Maintenance Organization, while a PPO is a Preferred Provider Network. Traditionally, HMOs tend to be more affordable, but you’ll usually get less coverage and more restrictions. PPOs are generally considered more flexible and provide greater coverage, but cost more and usually have a deductible.

Question HMO Health Maintenance Organization PPO Preferred Provider Organization
How much will this plan cost? Lower cost HMO plans typically have lower monthly premiums. You can also expect to pay less out-of-pocket. Higher cost PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out-of-network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
Do I have to use a primary care physician (PCP)? Yes. With most HMO plans, all of your healthcare services are coordinated by your designated PCP. No. PPO plans do not require referrals for any services.
Do I have to get referrals to use another doctor? No. While most HMOs require you to obtain a referral to see Specialists. But at Clarion Health, you don't have to. No. PPO plans do not require referrals for any services.
If I have a doctor or a specialist who is out-of-network, will I still be able to see them and have the costs covered? No. HMOs don’t offer coverage for care from out-of-network healthcare providers. The only exception is for medical emergencies or urgently needed services. Yes. With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
Will I need to file claims? No. Since HMOs only allow you to visit in-network providers, it’s likely you’ll never have to file a claim. This is because your insurance company pays the providers directly. Yes. In some cases, you will have to pay a doctor for services directly, And then file a claim to get reimbursed. This is most common when you seek services from out-of-network providers.

Generally speaking, an HMO might make sense if lower costs are most important and if you don’t mind using a PCP to manage your care. A PPO may be better if you already have a doctor or medical team that you want to keep, but who don’t belong to your plan network.

The best way to maximize your coverage with a Medicare Advantage Plan is to get all of your coverage from contracted network providers, regardless of whether you are in an HMO or PPO.  Several years ago, many PPO plans had much larger physician networks which covered all the states in the United States.  These PPO plans are called National PPO plans.  As cost became an issue, these networks grew smaller and only serviced say a particular state.  These PPO plans were referred to as Regional PPO plans.  Today PPO networks have gotten even smaller and oftentimes cover the same or have a smaller service area than traditional HMOs.  These PPO networks are called Local PPO networks.  Why is the network size important?  The smaller the PPO network, the higher your cost share would be with the product you selected.

With Clarion Health, that has changed — we offer the best of both worlds. Get the cost savings of an HMO combined with the broad network, and greater coverage of a PPO. We’re Clarion Health and we’re answering the call.

Enrollment Periods

There are several enrollment periods each year.

When you decide how you want to get your Medicare coverage you might choose a Medicare Advantage Plan (Part C) and/or Medicare prescription drug coverage (Part D).

Be aware that there are specific times each year when you can sign up for these plans, as well as make changes to coverage you already have. And you don’t need to sign up for Medicare each year. However, each year you will have a chance to review your coverage and change plans. There are 2 separate enrollment periods each year:

Annual Enrollment Period (AEP): October 15th – December 7th
Medicare Advantage Open Enrollment Period (OEP): January 1 — March 31
Annual Enrollment Period (AEP): October 15th – December 7th.

During the Medicare Annual Enrollment Period, also know as the Medicare Annual Election Period, you can change to a different type of Medicare plan, switch Medicare Advantage plans, or change your prescription drug coverage.

The Medicare Annual Enrollment Period, or AEP, runs from October 15th to December 7th every year.

During the Annual Enrollment Period, you can:

  • Switch from Medicare Advantage (Part C) to Original Medicare Parts A and B
  • Go from Original Medicare to Medicare Advantage
  • Change from one Medicare Advantage plan to another
  • Sign up for a Medicare Part D prescription drug plan
  • Change from one Part D prescription plan to another
  • Cancel your prescription drug coverage
Medicare Advantage Open Enrollment Period (OEP): January 1 — March 31.

During this enrollment period, you can:

  • Switch to another Medicare Advantage Plan (with or without drug coverage) if you’re in a Medicare Advantage Plan (with or without drug coverage)
  • Disenroll from your Medicare Advantage Plan and return to Original Medicare. If you choose to do so, you’ll be able to join a Medicare Prescription Drug Plan.
  • Change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months you have Medicare as long as you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period.

But you cannot:

  • Switch from Original Medicare to a Medicare Advantage Plan.
  • Join a Medicare Prescription Drug Plan if you’re in Original Medicare.
  • Switch from one Medicare Prescription Drug Plan to another if you’re in Original Medicare.