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Trying to navigate your medicare healthcare options? Understanding the difference between HMOs and PPOs is crucial in making the right healthcare choices for yourself and your family. We break down both coverage plans and dive into their advantages and disadvantages below.

HMO Vs. PPO

Health Maintenance Organization (HMO) plans cover medical care to patients who visit “in-network” providers. Occasionally an HMO will refer patients to providers outside the HMO network coverage area for specialist needs. Those with HMO coverage have one primary doctor who refers them to specialists within the network.

Preferred Provider Organization (PPO) plans allow patients more freedom in choosing their healthcare providers. Unlike an HMO plan, patients with PPO coverage can more readily see specialists both in- and out-of-network, and they do not require a doctor’s referral to see a specialist.

HMO Plans: Advantages and Disadvantages

Depending on your healthcare needs, an HMO plan may be the right plan for you. Advantages of this coverage option include:

Lower Costs: Comparatively to PPO plans, HMO plans have lower monthly premiums as well as lower out-of-pocket costs for prescriptions. They are generally less expensive than PPO plans by most measures. Deductibles are common costs of HMO plans that apply before insurance coverage kicks in.
Convenience: Another benefit of HMO plans is their relative convenience. Since doctors and specialists are part of the same plan network, keeping track of medical treatments and costs is more simplified for those with HMO coverage.

A significant disadvantage of HMO coverage is:

Less Flexibility: Except in the case of a medical emergency, patients must stay in-network for care. This also includes lab work, such as a drug test. Depending on health needs, lifestyle, and location, these restrictions can prove difficult for some. Additionally, making the change to an HMO plan often requires patients to stop seeing their current doctor and switch to a primary care doctor in their network.

PPO Plans: Advantages and Disadvantages

A major advantage of PPO coverage is:

Greater Flexibility: PPO plans patients with the ability to see doctors and specialists out of their network, though costs may be higher than in-network specialists. PPO coverage does not require a doctor referral to see specialists, and lab work can be completed in- or out-of-network.

Disadvantages of PPO plans include:

Higher Premiums: Comparatively to HMO plans, PPO coverage is more expensive, with higher monthly premiums and out-of-pocket costs, such as deductibles.
Patient Responsibility: Those with PPO plans must pay the full cost of treatment and file claims for medical care when they go out-of-network. In addition, patients have more responsibility for their own care in coordinating with their primary care doctor when going out of network.

Work With Medicare Professionals at VibrantUSA

Choosing between an HMO and PPO can be confusing, so consider talking to VibrantUSA. As an independent Medicare insurance agency, we are able to choose from more than 50 Medicare health insurance plans from more than 30 insurance companies/carriers. When it comes to your health care and what plans offer, it’s best to have all of the information you need.

The best part? You won’t have to pay a dime, a nickel, or one red cent for our services. We’ll take the time to learn about you and find the best plans available for the right price.

Whether it’s explaining Original Medicare (Part A and B), what Medicare Advantage plans are, or if your health benefits will include prescriptions, we’re here for you. Learn more about how our free services in Washington and Oregon can help you understand your Medicare options by requesting an appointment today.

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