HMO vs. PPO
Both Medicare Advantage and ACA Marketplace plans can use HMO or PPO networks. The network affects which doctors and hospitals your plan covers and what you pay to see them.
HMO
You generally use doctors and hospitals in the plan’s network for routine care. Referral rules vary by plan. Some HMOs require a referral to see a specialist, while others do not. Emergency care is an exception to the network rule. Some plans have additional exceptions.
PPO
You can generally get covered care outside the network, but you usually pay more. You typically can see a specialist without a referral. Before going out of network, confirm what the plan pays and whether the provider will see you under that plan.
When an HMO can be the better value
When the same insurance company offers an HMO and a PPO, the HMO may have lower copays or a lower medical out-of-pocket limit. If the HMO includes the doctors and hospitals you use, you may get more for your money. Compare the actual costs of both plans.
Emergency surgery and surprise bills
Suppose you have emergency gallbladder surgery at an in-network hospital, but the anesthesiologist or pathologist is out of network. Having a PPO does not automatically make you responsible for that provider’s extra charges.
ACA and employer coverage. The No Surprises Act generally limits your cost to in-network cost-sharing for covered emergency services and protected care from out-of-network specialists at in-network hospitals, hospital outpatient departments, and ambulatory surgery centers. Protected ancillary services include anesthesia, pathology, and radiology. These protections apply to both HMOs and PPOs. Certain care after stabilization can have exceptions under strict notice and consent rules.
Medicare Advantage. Medicare Advantage HMOs and PPOs have separate Medicare billing protections. The No Surprises Act is not the law that supplies those protections. For covered Medicare services, noncontracted providers generally must accept the applicable Medicare payment plus permitted plan cost-sharing as payment in full.
Where a PPO can cost more
For routine covered care you choose outside the network, a PPO may charge a higher deductible, copay, or coinsurance. With ACA or employer coverage, an out-of-network office or facility may also balance bill you when surprise-billing protections do not apply. Medicare Advantage has different billing rules. Check the exact plan’s out-of-network costs and limits.
An HMO generally does not cover routine out-of-network care unless the plan allows or approves it. You could owe the full bill for care it does not cover. Some HMOs offer limited point-of-service benefits. An HMO does not guarantee you will never receive an incorrect bill.
If an unexpected bill arrives after emergency surgery, compare it with your insurer’s Explanation of Benefits before paying. Ask the insurer to review any out-of-network charges that appear inconsistent with your protections.
Check your doctors, specialists, and preferred hospital against the exact plan’s network. Plans from the same insurance company can use different networks.
Questions? Call or text Allen Insurance Agency at (985) 892-1862.
Medicare Advantage plan types · Marketplace plan types
Billing resources. CMS surprise-billing protections · Medicare Advantage noncontracted provider payments