HMO Vs. PPO Plans
Regional Sales Manager David Russell clarifies the difference between an HMO plan and a PPO plan.
“Hey folks, David Russell here. I just wanted to give you a little bit of insight on the differences between an HMO and a PPO. So I’ll start by the definitions; An HMO is a network driven opportunity where you have to stay within a network of physicians that have a contract with certain carriers. The idea would be your primary care physician as the quarterback with an HMO plan, and your specialists are also going to be lined up in that network. So if you have to go see a specialist, sometimes referrals are needed, sometimes they’re not. But you have to stay within that list of doctors that have agreements with your carrier.
HMO: Care Coordination
The nice piece about this is called ‘Care Coordination’. So an example would be let’s say you go to the emergency room and are all the sudden prescribed a prescription. Well if you had any adverse reaction or drug sensitivity to that prescription, the doctors in the emergency room may not know that. So they’re going to prescribe you that prescription, you’re going to go get that filled, but if it happens that you have an allergic reaction or you can’t combine that drug with another, the pharmacist may not fill that drug for you. However, because your primary care physician is your care coordinator, he acts like the quarterback. He has a profile when you’re in the system of what you are currently taking and the computer will tell if there will be an adverse reaction from mixing two drugs. So, people like HMOs because of that care coordination.
PPO: In and Out of Network Coverage
A PPO is when you have in and out of network possibilities. So again, you’re going to have a network of doctors that have a signed agreement with carriers, and if you see a doctor on that list you are in network. But let’s say something happens where you’ll need to go outside of network and see a doctor that is not on that list. With a PPO, you have this option, the only difference is you’re now going to have a little bit higher cost share or co-payment to go see that out of network doctor. So instead of paying full price, you can still go see that physician. There is no care coordination, essentially. So, you manage your healthcare yourself.”