Which plan is right for me?What is an HMO?A Health Maintenance Organization (HMO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. It usually has lower monthly premiums than a PPO or an EPO health plan. An HMO may be right for you if you’re comfortable choosing a Primary Care Provider (PCP) to coordinate your health care and are willing to pay a higher deductible to get a lower monthly health insurance premium. Show
What is a PPO?A Preferred Provider Organization (PPO), is a type of health plan that offers a larger network so you have more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. If you're willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and health care options, you may want to choose a PPO health plan. What is an EPO?An Exclusive Provider Organization (EPO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan. HMO, EPO, and PPO Frequently Asked QuestionsWhat’s the difference between in-network coverage and out-of-network coverage?Each time you seek medical care, you can choose your doctor. You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs. That’s because participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher or your visit may not be covered. What if I need to be admitted to the hospital?In an emergency1, your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance or pre-certified. This allows Cigna to determine if the services are covered by your plan. Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections. Depending on your plan, you may be eligible for additional coverage. Who is responsible for getting pre-certification?Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor is in the Cigna network, they will arrange for pre-certification. If you use an out-of-network doctor, you are responsible for making the arrangements. Your plan materials will identify which procedures require pre-certification. How do I find out if my doctor is in the Cigna plan’s network before I enroll?It’s quick and easy to search for participating doctors, specialists, pharmacies, hospitals, and facilities to match your needs.
Key takeaways:
 To choose the health insurance that will give you the most coverage at the best price, it helps to understand the contrasts between the two most common types of health plans: HMOs and PPOs. The main differences have to do with their rules about enrollment eligibility and provider coverage. What is the difference between an HMO and a PPO?Health maintenance organization (HMO) plans and preferred provider organization (PPO) plans are types of managed care health insurance. Of the two, HMOs have clearer boundaries around their benefits. An HMO covers enrollees only if they use the doctors, hospitals, and other healthcare providers in the HMO’s network. Some HMOs also require you to live or work within the plan’s service area. HMO plans typically direct you to choose a primary care doctor who is contracted to or employed by the plan. Your primary care physician (PCP) acts as the manager of your healthcare services. When you need to see a specialist, you must first get a referral from the PCP. With a PPO plan, you have more flexibility in choosing healthcare providers. Your cost-sharing percentages and copays are lower for in-network providers, but most PPOs partially cover out-of-network care as well. PPO plans rarely require a referral from a PCP for you to see a specialist. You can choose any doctor you like. However, if you visit an out-of-network doctor, hospital, or other healthcare provider, you’ll typically be charged a higher copay or coinsurance rate. HMO vs. PPO costOn average, HMOs charge slightly lower premiums than PPOs, according to the Kaiser Family Foundation (KFF). Its 2021 Employer Health Benefits Survey examined premiums for different types of job-based insurance plans. Some of the results are shown in the table below.
Depending on your selected plan type and coverage level, you may also have to pay additional costs, including:
What are the pros and cons of an HMO?The main selling point of HMO plans is that they’re inexpensive by comparison. You can pay lower prices for your healthcare as long as you use the services of doctors, hospitals, and other healthcare providers in the HMO plan’s network. Often, HMO premiums and deductibles are lower, too. Some HMOs have no deductible at all. According to KFF’s data on employer-based health plans, 43% of HMO enrollees with individual coverage don’t have a deductible. That’s the case for only 15% of PPO enrollees. If you need a specialist, your PCP refers you to one in the network. This ensures the PCP is aware of all your conditions and treatments and can discuss them with you as a whole. Even so, HMOs have some drawbacks. One is that you’ll have to pay the full fee to see an out-of-network provider. The only times you can get a break on the price of out-of-network care are these exceptions:
Also, HMO plans require you to select a primary care physician within the plan’s provider network. If your current doctors aren’t in the HMO network but you wish to keep seeing them, the HMO won’t cover those visits. In some areas, networks contain a small share of local providers. This means your options for covered specialist care may be limited. You may also have to wait a long time for an appointment. HMO advantages
HMO disadvantages
What are the pros and cons of a PPO?PPOs give you flexibility in choosing healthcare providers. You’re not required to select a PCP from the PPO’s network. You can choose your own specialist without a referral from your primary care doctor. The PPO will partially cover your visits to your favorite doctors, even if they’re out of network. But keep in mind that you’ll pay less for covered services when you visit providers within the PPO’s network. The price difference depends on the PPO health plan. You may still receive a negotiated rate on an out-of-network provider — or you could get stuck paying the entire bill. Unlike an HMO, a PPO doesn’t restrict coverage to a specific service area. If you get ill or injured while traveling and must use an out-of-network provider, your PPO plan will probably still pay some of the cost. PPO advantages
PPO disadvantages
Which is better: HMO or PPO?The choice of HMO vs. PPO should depend on your particular healthcare situation and requirements. Are you and your family members healthy, rarely seeing a doctor beyond routine checkups? If so, the limited network of an HMO plan can provide the care you need at a comparatively low price. On the other hand, if you have chronic or unusual health issues, you may want the flexibility of a PPO. That way, you can choose your own doctors and specialists. If those providers are out of network, though, you’ll pay more per visit. The bottom lineBefore you enroll in an HMO or a PPO, make sure you know each plan’s rules about coverage. Look at deductibles, premiums, and prices for in-network and out-of-network providers. Check to see if your doctors are in the plan's provider network. You can minimize costs in an PPO by using in-network doctors, hospitals, and healthcare providers. GoodRx Health has strict sourcing policies and relies on primary sources such as medical organizations, governmental agencies, academic institutions, and peer-reviewed scientific journals. Learn more about how we ensure our content is accurate, thorough, and unbiased by reading our editorial guidelines. Was this page helpful?Subscribe and save.Get prescription saving tips and more from GoodRx Health. Enter your email to sign up. By signing up, I agree to GoodRx's Terms and Privacy Policy, and to receive marketing messages from GoodRx. Which one is better HMO or PPO?PPOs Usually Win on Choice and Flexibility
Additionally, PPOs will generally have some coverage for out-of-network providers, should you want or need to see one. With HMOs, out-of-network coverage will usually be limited to emergencies; non-emergency services are not usually covered at all.
What are the 3 differences between HMO and PPO?Choosing between an HMO or a PPO health plan doesn't have to be complicated. The main differences between the two are the size of the health care provider network, the flexibility of coverage or payment assistance for doctors in-network vs out-of-network, and the monthly payment.
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What is the difference between hmo and ppo health plans
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