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HMO vs. PPO: What’s the difference?

Sep 06, 2024
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As if buying health insurance isn’t hard enough, what with all the confusing lingo, it can be a challenge just to figure out what all those initials stand for in the plan names.

Let us help you understand some of the basic differences between HMOs and PPOs. These are basically types of plan networks, which is important as you think about whether a plan will cover, or pay for, visits to the doctors, specialists, therapists, urgent care clinics, labs, pharmacies, hospitals and other providers you prefer.

Here’s a primer on the kinds of plan Community Health Options offers:

  • HMO stands for “Health Maintenance Organization,” which gives you access to a specific group of preferred providers who are part of a specific network and considered “in-network.” Generally, HMOs won’t provide coverage for those providers who are not in that network or considered “out-of-network,” except for an emergent condition in an emergency department.
  • PPO stands for “preferred provider organization,” and you usually pay less if you see an in-network preferred provider but can use out-of-network providers by paying a higher price.
  • HMO Tiered plans feature a network of preferred providers that meet or exceed Community Health Options quality, price and efficiency standards, offering higher quality at a lower cost, but allow Members can also receive care from standard providers at standard costs, but do not have out-of-network coverage.

Beyond selecting a plan type, you can also consider the category, or metal level, ranging from Bronze, which has the lowest premium but higher out-of-pocket costs, to Platinum, with a higher premium, and lower cost for medical care. Learn more about these levels here.

Want to talk with someone about which plan to choose for you and your family? Call us at (855) 624-6463 from 8 a.m. to 6 p.m., Monday through Friday, or email us and we’ll get back to you.

Follow @communityhealthoptions on TikTok for quick tips and tricks on how to buy and use a health plan. And don’t forget to follow Community Health Options on LinkedIn, Facebook or Instagram.

 

SEE ALSO

Can’t get in to see a doctor? Virtual care could be your best choice

Many of us are waiting weeks or months to book medical appointments. Or taking a long drive to get to the only provider taking new patients—often more than an hour away. And once in the office, chances are we’re spending more time in waiting rooms just for a routine appointment.

The national shortage of healthcare workers has been well-documented, and Maine is feeling it, too, with access to providers emerging as one of the greatest barriers to treatment. By the end of 2022, Maine had just 580 doctors practicing family medicine, an 18% decline from 2019, according to The Portland Press Herald, leaving fewer doctors for a growing population.

During the pandemic, patients discovered the convenience of telehealth and began meeting with their providers through a phone call or video chat from the comfort of their own homes. The concept certainly wasn’t new—Community Health Options Members had access to Amwell® behavioral telehealth well before Covid-19 struck.

That concept has expanded to virtual primary care, giving people the option through an online care team, expanding access to care. Alongside its traditional provider network, Community Health Options now offers Members 18 and older the option to choose a virtual-first primary care team through Firefly Health.

When it comes to health outcomes, many studies have shown patients miss fewer virtual appointments, helping them to stay on track with their health needs. And in a recent pilot program, Walmart employees with diabetes who used virtual care saw a 24% average reduction in glucose levels and patients with hypertension had a 14% reduction in blood pressure, the company said in 2023 when it expanded its program to Maine, among other states.

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