PPO Plans are generally more expensive and offer access to more doctors.  HMO Plans are often less expensive because your care is dictated by a Primary Care Physician and a limited network of doctors. However, both plan types have their benefits and it is important to understand the differences so you too can choose the best plan for you.

HMO Plans have a “Primary Care Physician” Dictate Your Care

The Primary Care Physician is your point of contact for all of your healthcare needs.  This doctor  will help you select your specialty doctors within your network.  A patient would first visit their Primary Care Doctor to explain their ailments and ask for treatment. This doctor would then refer that patient to a specialist of their choosing that can help.  

With a PPO plan, you can go straight to a specialist without seeing a PCP.  In fact, you can even choose which specialist you’d like to visit. You can visit an in network doctor and receive care at an in network price.  Or you can find a doctor out of your network and pay out of network prices for that visit.  With a PPO, you have a lot more freedom to choose your care.

PPOs have In Network and Out of Network Benefits

Doctors partner with insurance carriers to decide on which networks they will participate in. It is a nice benefit to have access to more doctors. It is important to be careful where you get your care because in network doctors will charge you much less than out of network doctors.  For example, a doctor may decide they wish to participate as an in network doctor for the Blue Shield PPO but then choose to bill out of network prices for patients with UnitedHealthcare’s PPO. 

If you wish to get the most out of your PPO, it is important to verify you are visiting doctors within your network. It is a good practice to call your potential doctor’s office and ask specifically “Will I be in network with your office?”

When selecting a Medicare plan, it is often said that Advantage Plans are similar to HMO plans and Supplement Insurance plans are more similar to PPO plans.  I completely agree.  Supplement Insurance offers a robust network of doctors all over the United States.  If you select an Advantage plan, you’ll join a network of doctors local to you.  If you need help evaluating providers and carriers in San Diego, HealthyMarks Medicare is a great team happy to provide you with their services free of charge.


HMO Details

  • Patients have a primary care physician who helps make decisions on your care.
  • If you have an ailment, you will visit this doctor who can send you to a specialist.  
  • You have no out of network benefits with an HMO plan.

PPO Details

  • There is no need to have a primary care physician. 
  • You can choose which doctors and specialists you wish to visit.
  • Your insurance carrier will pay a small portion of the costs for out of network benefits.