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Question
Health maintenance organization (HMO)
Preferred provider organization (PPO)
How much will the plan cost?
Lower cost
HMO plans typically have lower monthly premiums and out of pocket expenses.
Higher cost
PPOs usually have higher monthly premiums in exchange for the flexibility to use medical providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
Do I have to use a primary care physician (PCP)?
Yes
With most HMO plans, most virtually all medical services are coordinated by your PCP (primary care physician).
NO
PPO plans do not require referrals for medical services.
Do I have to get referrals to visits a specialist doctor?
Yes
With an HMO, you must first schedule an appointment with your PCP and he or she will provide a referral to an in-network specialist.
NO
PPO plans do not require referrals for any services
If I have a doctor or a specialist who is out of network, will I still be able to see him or her and have the costs covered?
No
HMOs don’t offer coverage for care from out-of-network healthcare providers. The only exception is for medical emergencies.
Yes
With a PPO, you have the flexibility to visit providers outside of the network. However, visiting an out-of-network provider will include a higher cost share/ copay.
Will I need to file claims?
No
Since HMOs only allow you to visit in-network providers, it’s probably that you’ll rarely have to file a claim. The insurance company pays the provider directly.
Yes
In some cases, you will have to pay a doctor for services directly and then file a claim to get reimbursed. This is most likely to be the case only when you seek services from out-of-network providers.
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HMO vs PPO: Frequently Asked Questions

Quick answers to help you pick the right type of health plan.

What is an HMO plan?+
A Health Maintenance Organization (HMO) keeps your costs lower by using a network of local doctors and hospitals. You pick a primary care physician (PCP) who coordinates your care and provides referrals to specialists. Care is generally covered only when you stay in-network (except in emergencies).
What is a PPO plan?+
A Preferred Provider Organization (PPO) gives you more flexibility. You can see any doctor or specialist without a referral, and you get some coverage for out-of-network care — usually at a higher cost. PPOs typically carry higher premiums in exchange for that freedom.
HMO vs PPO — what is the main difference?+
HMOs cost less but require you to stay in-network and get referrals through a primary care doctor. PPOs cost more but let you see specialists directly and use out-of-network providers. It comes down to whether you value lower cost (HMO) or more choice (PPO).
Do I need a referral to see a specialist?+
With an HMO, yes — your primary care physician refers you to in-network specialists. With a PPO, no — you can book specialists directly, in or out of network.
Which plan is more affordable?+
HMO plans usually have lower monthly premiums and lower out-of-pocket costs, which makes them popular if you are comfortable staying within a network. PPO plans cost more but offer wider access to providers.
Which plan should I choose?+
If you want to save money and do not mind using a set network with a primary doctor, an HMO is a great fit. If you travel often, want to keep specific doctors, or value seeing specialists without referrals, a PPO may be worth the higher cost. Get a free quote to compare real plans and prices.

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