Difference Between HMO and PPO

Edited by Diffzy | Updated on: April 30, 2023


Difference Between HMO and PPO

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Health insurance is one of the major and much-needed services in this age of uncertainty and rising health concerns. Several concepts have been developed throughout the years while considering the market need.

Insurance plans known as managed-care plans are those in which a network of paramedical personnel and insurance providers are constrained by a contract that governs how they supply insurance plans to consumers.

Two of the most well-known managed care insurance programs are HMO and PPO. Many consumers occasionally mix the two programs, minimizing their differences.


The primary distinction between an HMO and a PPO is that an HMO limits the use of medical services to those provided by its network, whereas a PPO does not impose any such restrictions. When compared to PPO, where the premium cost is rather high, the HMO plan's premium charge is on the lower end.

The major goal of these two programs is to offer the best health care available, both in terms of cost and quality.

Difference Between HMO and PPO in Tabular Form

Parameter of Comparison HMO PPO
Full-Form Health Maintenance Organization Preferred provider organization
Type of Plan Managed Care Managed Care
Premium charged Considerably Lower In comparison, on the upper end
Coverage provided Within the bounds of the network both inside and outside the network's immediate area
Claims required No Yes

What is HMO?

One of the health insurance programs that fall under the managed care umbrella is the health maintenance organization or HMO.

HMO is a plan with a lower premium that is often less expensive. In this plan, the customer chooses a plan based on how many different medical professionals and their competence will assist him in case of any medical issues. For an HMO to work at first, the patient must choose a primary care physician. This will be the top physician who will attend to the patient's immediate requirements before referring him to the specific expertise from the designated group exclusively.

Before the checkup, the insured must ask for authorization from the primary care physician if he believes a specialist is necessary. An HMO plan often serves those who live close to the services it offers.

HMO premiums are significantly less expensive than those of other plans. This is because the paramedical workers and other service providers are paid a set sum of money in advance.

Each visit, prescription, or test must be paid for in full by the covered party. also accompanied with an annual or monthly premium payment.

This plan has a stronger incentive to offer preventative care and immediate medical attention to its insured party.

For a monthly or yearly charge, health maintenance organizations (HMOs) offer health insurance coverage. An HMO restricts its members' access to healthcare to services delivered by a network of physicians and other healthcare professionals who have agreements with the HMO. Given that the healthcare providers benefit from having consumers referred to them, these contracts make it possible for rates to be cheaper than those for traditional health insurance. The members of the HMO are also subject to extra limitations.

Consider the cost of premiums, out-of-pocket expenses, any potential needs you may have for specialist medical care, and how essential it is to you to have your primary care physician when choosing an HMO insurance plan.

An HMO is a formalized governmental or private organization that offers its members both essential and supplementary healthcare services. The firm forms agreements with primary care doctors, medical centers, and specialists to ensure its network of healthcare professionals. The medical organizations that sign agreements with the HMO are compensated with an agreed-upon price in exchange for providing a variety of services to the HMO's members. An HMO can offer cheaper rates than other health insurance plans while still maintaining high standards of care from its network thanks to the negotiated payment.

The Health Maintenance Organization Act of 1973 created the HMO as we know it today. By defining HMOs as "a public or private institution formed to offer basic and additional health care to its members," the Act, signed by the late President Richard Nixon, defined the term. The law also mandates that plans offer basic healthcare to those who are covered in exchange for recurring, fixed premiums that are set "under a community rating."

Rules for HMO Subscribers

HMO members must only use doctors who are part of the organization's provider network to get care and services; they must pay a monthly or yearly premium to access medical services in the network. However, the HMO may cover some out-of-network services, such as emergency care and dialysis.

To be eligible for coverage under an HMO, a person may need to reside or work within the plan's service region. When a subscriber obtains emergency treatment outside the HMO network area, the HMO could pay the costs. However, HMO members must pay out-of-pocket for non-emergency, out-of-network treatment.

With an HMO, there are often low or no deductibles in addition to low rates. Instead, a co-pay is required for each clinical visit, test, or prescription at the organization. HMOs often include modest co-pays ($5, $10, or $20 per treatment on average), which reduce out-of-pocket costs and make HMO plans accessible to families and companies.

  • A network or organization that offers health insurance coverage in exchange for a monthly or yearly charge is known as a health maintenance organization (HMO).
  • An HMO is a collection of health insurance companies that restrict coverage to medical services delivered by physicians and other providers who have agreements with the HMO.
  • These agreements provide reduced rates since healthcare providers benefit from patient referrals, but they also impose more limitations on HMO members.
  • Participants in HMO plans must first get medical care services from a designated provider known as the primary care physician (PCP).
  • HMO alternatives include preferred provider organizations (PPOs) and point-of-service (POS) programs for healthcare.

What is PPO?

The most well-known managed care health insurance program is the Preferred Provider Organization (PPO). With networks of paramedics, the insurance company has a contract for a set sum of money. To have access to a certain grid of such medical amenities, the insured party must pay a premium. A person who is insured is free to choose any doctor in his network.

In this scenario, the insured party will choose the service they need and the provider from among the group. Even when the insured person seeks medical attention outside the network, the PPO plan supports and offers coverage in those situations. The terms of the plan govern how much external coverage is allowed.

The insurance provider will next assist in scheduling the appointment and determining the cost by their agreement and the insured party's coverage.

PPO typically assesses a set fee for each medical visit made by the covered party. On occasion, the entire claim is reduced by another sum. Its hefty premium fee and both of these characteristics make it an expensive plan.

PPOs have a wide network, which gives them flexibility because the insured person may get insurance-covered medical care whenever and wherever it is needed.

PPO Insurance Features

Plan Network

PPO health plans include a network of medical providers you may choose from, which is one of its key characteristics. Working with network members will help you save your medical expenses since these providers have agreed to drop their fees and offer discounts in exchange for joining the network. Health insurance companies might save money in addition to you. You often have a bigger network of providers when you have PPO coverage, even if the network might vary from insurer to insurer or plan to plan.

Choice of Medical Providers

A PPO medical plan's potential for allowing you to interact with doctors outside of the network while maintaining coverage is another unique aspect. Working with out-of-network medical providers may result in greater costs, but coverage will still be provided. However, HMOs frequently do not pay for services offered by providers outside of the network.

Primary Care Physician

The majority of PPOs don't require a referral to see a specialist from your Primary Care Physician (PCP). In other words, you may visit a specialist without needing a referral since you know your insurance will pay for it. On the other hand, for the specialist expenses to be reimbursed by an HMO, you often need a reference from a PCP.

Plan Costs

PPOs typically cost more from a financial standpoint than an HMO plan would. When compared to HMOs, the benefits of having better rates, broader coverage, and the freedom to visit the doctor of your choice translate into higher monthly premiums. Deductibles may also be required to pay for your insurance.

How Does PPO Medical Plan Work?

If you have a PPO medical plan, you may go to an in-network doctor or hospital you want with the knowledge that the plan will pay for their services.

In addition, you don't need a recommendation from a primary care physician to select to work with any of the network's specialists. Because PPOs are flexible, you can also work with a physician who is not in your network, but you'll need to make sure the provider accepts your health plan first. A PPO plan will likely need you to pay a yearly deductible before being covered.

In rare circumstances, you could also be required to make a co-payment for particular treatments or to foot a specific portion of your medical expenditures. Many people choose a PPO plan because they have the choice to select their physician from within or outside the PPO network and don't have to wait for a referral before visiting a specialist, even though PPOs are often more expensive than HMOs.

PPOs offer you access to a network of healthcare providers for your medical needs. The PPO health plan creates a network of service providers by entering into contracts with various medical and health care providers. Usually, to join the network, the service providers will agree to reduce their pricing. Because of this, interacting with medical providers inside the network typically results in lower costs than working with physicians outside of it. In the 2018 Employer, Health Benefits Survey by the Kaiser Family Foundation, 49 percent of employees was enrolled in PPOs, while just 16 percent were enrolled in HMOs (Health Maintenance Organizations).

Main Differences Between HMO and PPO in Points

  1. PPO is a more expensive plan since its premium is higher than that of HMO in comparison.
  2. While PPO allows for the use of amenities from doctors outside the network, HMO is a rigorous plan that only pays the cost of using facilities within the network's bracket.
  3. A reference from the primary care physician is necessary for an HMO to schedule an appointment with a specialist; however, with a PPO, no referral is necessary from any doctor, making the whole network available to the covered person.
  4. In an HMO, the insured person is required to pay a minimal fee, which varies depending on the visit, for each visit. When enrolled in a PPO, the covered party pays a set fee for each visit.
  5. In contrast to a PPO, which has a broader network operating at a greater scale and occasionally encompassing many states and municipalities, an HMO works within a small location inside a network of circumscribed service providers.
  6. PPO contains annual deductions from the total amount of coverage, whereas HMO does not.
  7. While PPO will often pay the cost of such a journey to the extent of the insured person's coverage, HMO will not provide any coverage if someone seeks medical attention outside of the system.


Managed care programs now have a far better reputation than traditional insurance programs. Despite sharing the same cover, HMO and PPO plans have some significant distinctions. Therefore, before making a final choice, one should evaluate their demands, the level of coverage, and the price they can pay.


  1. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1520976
  2. https://europepmc.org/abstract/med/10129445


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"Difference Between HMO and PPO." Diffzy.com, 2024. Sun. 21 Apr. 2024. <https://www.diffzy.com/article/difference-between-hmo-and-ppo-638>.

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