What is the difference between a PPO and an HMO?

The difference between a PPO, or Preferred Provider Organization, and an HMO, or Health Maintenance Organization, primarily lies in their structures, costs, and flexibility in choosing healthcare providers. A PPO typically offers more flexibility when it comes to choosing healthcare providers. Members of a PPO plan can see any doctor or specialist without needing a referral, which allows for easier access to a wider network of providers. However, to maximize benefits, it is often more cost-effective for members to use providers within the PPO's network. While these plans often have higher premiums compared to HMO plans, they tend to come with deductibles and co-insurance that can vary based on whether the services are obtained from in-network or out-of-network providers. On the other hand, an HMO plan requires members to select a primary care physician, who acts as a gatekeeper for accessing specialty care. This means that in order to see a specialist or obtain certain services, a referral from a primary care physician is generally necessary. HMO plans typically have lower premiums and out-of-pocket costs compared to PPOs, but they also offer less flexibility since members must use the HMO's network of doctors and facilities to receive coverage. Overall, the choice between a PPO and an HMO will depend on individual preferences regarding flexibility, cost, and the level of care desired. For those who value seeing specialists without referrals, a PPO may be the better option, whereas individuals seeking lower costs and who do not mind a more structured healthcare approach may prefer an HMO plan. Further information about each plan type, as well as specific options available, can be found on Wellmark Blue Cross/Blue Shield's website.