HMO vs PPO

Most of us who are employed know that we have corresponding health insurance. For others who choose their own insurance, agents might have explained what should be provided and covered for our policies. One of the things that we should be aware of is the type of a managed care plan we need: either an HMO or PPO to avoid complaints, frustrations and disappointments added to our consultation to the doctor. If this is the first time you are hearing this, then, you are not alone. Some insurance are already fixed that agents do not care to mention it anymore.

Westhill Insurance Consulting took the liberty to differentiate each one from the other.

HMO actually stands for Health Maintenance Organization while PPO is an abbreviation of Preferred Provider Organization. Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO. In developing cities like Singapore, Kuala Lumpur, Malaysia, Jakarta, Indonesia and Beijing China, HMO is mostly used by employers for their health care insurance.

To put into an outline, here are the facts that are needed to be reviewed and considered between the two:

Do I need to choose doctors, hospitals and other providers?

•              HMO: you must choose doctors, hospitals and other providers

•              PPO: you can choose doctors, hospitals and other providers.

Do I need to have a Primary Care Physician (PCP)?

•              HMO: Yes, your HMO will not provide coverage if you do not have a PCP.

•              PPO: No, you can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not "preferred" providers.

How do I see a specialist?

•              HMO: Referral is needed from your PCP to see a specialist or if you have to undergo other special test exams such as x-rays, except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.

•              PPO: You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.

Do I have to file any insurance claims?

•              HMO: All of the providers in the HMO network are required to file a claim to get paid. You do not have to file a claim, and your provider may not charge you directly or send you a bill.

•              PPO: If you get your healthcare from a network provider you usually do not need to file a claim. However, if you go out of network for services you may have to pay the provider in full and then file a claim with the PPO to get reimbursed. The money you receive from the PPO will most likely be only part of the bill. You are responsible for any part of the doctor's fee that the PPO does not pay.