I'm choosing a plan
HMO or PPO — which fits me?
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An HMO keeps you inside its network, usually needs referrals, and often costs less. A PPO lets you see out-of-network doctors without a referral, at a higher share of the cost.
What to do
- List every doctor, hospital and specialist you see now, and check each one in the plan's provider directory for next year.
- Ask whether you need a referral from your primary care doctor to see a specialist. Most HMOs require one; PPOs usually do not.
- If you travel or live part of the year in another state, check what the plan covers there. An HMO usually covers only emergency and urgent care outside its area.
- Compare the total yearly cost, not just the premium: add the deductible and the out-of-pocket maximum.
What to say
Is my current doctor in this plan's network, and do I need a referral to see a specialist? What is covered if I get care outside the network?
Ask the plan, not the doctor's front desk, and ask them to confirm in writing.
What to watch out for
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Assuming a PPO covers every doctor at the same price. Out-of-network care costs more, often with its own deductible, and an out-of-network doctor can bill you the difference between their charge and what the plan allows.
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The right plan depends on your doctors, your medications, how often you travel and how you like to get care. We look at your options with you and point out what the plan summaries don't make obvious, so you choose with confidence.
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The rule behind it
HMO (health maintenance organization) and PPO (preferred provider organization) describe how a plan uses its network, not how good the care is. An HMO generally covers out-of-network care only in an emergency; a PPO covers it at a higher cost, without a referral. The No Surprises Act, a federal law since 2022, protects you on either plan type for emergency care and for out-of-network doctors at an in-network hospital or surgery center.
Sources
- HealthCare.gov — Health insurance plan and network types
- HealthCare.gov glossary — Health Maintenance Organization (HMO)
- Medicare.gov — Health Maintenance Organization (HMO) plans
- HealthCare.gov glossary — Balance billing
- CMS.gov — Medical bill rights (No Surprises Act)
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
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