The choice between HMOs and PPOs explained

There is something deeply annoying when people in a particular trade or industry start using jargon and letters to talk to us. What is wrong with the English language? Why must they hide the meaning? Why do they believe we will be impressed? The insurance industry is one of the worst offenders. By the time the experts have finished describing the different health plans and the lawyers have wrapped everything in obscurity, we seem left with a take-it-or-leave it choice.

The essence of all plans is a definition of the healthcare professionals available to deliver the care should you need it. The wider the choice you have, the higher the premiums you will be required to pay. With a Health Maintenance Organization, a group of healthcare providers contracts with an insurance company to deliver services to the policy holders. Because the insurance company guarantees a high volume of business to the group, the rate for the services is lower than usual and so the premium rates charged and copayments are also lower. Access to the services is controlled by a primary care physician. He or she will refer you on to other members of the group for different specialist services. If you want to go outside the group, you will have to pay the difference between the HMO rate and the actual cost of your own choice doctor. Although this is the cheapest form of plan, the lowness of the fees charged by the group encourages members to see as many patients as possible every day.

A Preferred Provider Organization also contracts with an insurance company, but the relationship is less restrictive and the rates are slightly higher. In this plan, you are free to choose any doctor within the group without having to get a referral. If you decide to see someone outside the group, you will have to pay the out-of-pocket expenses. Here, you are paying slightly more to have more control over your treatment options. So, for example, if your own doctor is not a member of an HMO, you would have to change. With a PPO, you can continue to see your own doctor.

All health insurance decisions are a balancing of costs and benefits. In this case, the choice between an HMO and PPO comes down to what you can afford and whether you prefer more control over the care you and your family receive. It is fair to say that the majority pick the cheaper option of an HMO and then complain about the restrictions. This does not mean the quality of the care is worse than in a PPO. It simply reflects most people’s preference to make their own informed decisions. Perhaps it is cynical but, whichever you pick, it is better than not having insurance. When the choice is offered through your employer, look carefully at the cost differences in copayments and out-of-pocket expenses. If you are paying privately, get the maximum number of health insurance quotes. When you see a wide range of offers, it is easier to find the best deal.