What is the difference between hmo and ppo insurance plans

Which plan is right for me?

What is an HMO?

A Health Maintenance Organization (HMO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. It usually has lower monthly premiums than a PPO or an EPO health plan. An HMO may be right for you if you’re comfortable choosing a Primary Care Provider (PCP) to coordinate your health care and are willing to pay a higher deductible to get a lower monthly health insurance premium.

What is a PPO?

A Preferred Provider Organization (PPO), is a type of health plan that offers a larger network so you have more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. If you're willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and health care options, you may want to choose a PPO health plan.

What is an EPO?

An Exclusive Provider Organization (EPO), is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan.

HMO, EPO, and PPO Frequently Asked Questions

What’s the difference between in-network coverage and out-of-network coverage?

Each time you seek medical care, you can choose your doctor. You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs. That’s because participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher or your visit may not be covered.

What if I need to be admitted to the hospital?

In an emergency1, your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance or pre-certified. This allows Cigna to determine if the services are covered by your plan. Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections. Depending on your plan, you may be eligible for additional coverage.

Who is responsible for getting pre-certification?

Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor is in the Cigna network, they will arrange for pre-certification. If you use an out-of-network doctor, you are responsible for making the arrangements. Your plan materials will identify which procedures require pre-certification.

How do I find out if my doctor is in the Cigna plan’s network before I enroll?

It’s quick and easy to search for participating doctors, specialists, pharmacies, hospitals, and facilities to match your needs.

1. Visit the Find a Doctor page.
2. Choose a directory:
   1. If you're a Cigna customer,log in to myCignato quickly see in-network providers.
   2. If you're not a Cigna customer yet, select the type of plan you're enrolling in.
3. Once on the provider directory, enter your search location, select the plan type, and enter the search terms in the search box related to type of provider or facility you're looking for.
4. Your search results will show the in-network providers based on your search criteria, along with other details that can help you when enrolling.

Understanding the Advantages & Disadvantages of Different Insurance Plans

One of the big decisions every American must make is what type of health insurance to select that best meets their health needs, allows them to see their preferred doctors, and is within their budget. The 2 primary options are PPO insurance and HMO insurance plans. “PPO” stands for “preferred provider organization" and “HMO” means “health maintenance organization.” But what do they mean?

Although there is no cut-and-dry answer to which insurance works for everyone, there are clear advantages and disadvantages to each type of insurance plan that can guide you in making the decision that works best for your needs.

What Is an HMO Insurance Plan?

HMO insurance gives policyholders access to specific physicians and hospitals within the network it allows you to see, and your medical bills are only covered if you see providers within that network. Although this limits your options for which providers you can see, you’ll still need a primary care doctor to refer you to specialists within your HMO network. Many choose an HMO insurance plan simply because the monthly premium is lower than PPOs, and the out-of-pocket costs are lower. It is worth noting you will still be able to go to your nearest emergency room and receive coverage in the event of a medical emergency.

Typically, HMO insuarance plans require pre-authoriazations for services.

What Is a PPO Insurance Plan?

PPO plans give you much more flexibility in deciding which healthcare providers you can see and be covered, but care is still usually more affordable if you stay within the network of providers your policy covers. You will not need a primary care doctor’s referral to a specialist; rather, you can book an appointment with a specialist physician on your own, including out-of-network specialists (although you will typically pay more out-of-pocket for out-of-network specialists). Some decide PPO is not the best option because the monthly premiums are typically higher, and out-of-pocket costs are higher. You might also feel the responsibility for managing your care without a primary care doctor’s help (if you decide not to have one) is too much of a burden.

Should I Get an HMO or a PPO Plan?

While you weigh your options between signing up for an HMO or PPO plan, many people like you have the same question: Which is the right choice for yourself and/or your family? The main question you’ll have to ask yourself is whether cost or flexibility is more important to you.

The primary differences between HMO and PPO plans are:

• Cost: HMOs have lower monthly premiums, lower out-of-pocket costs, and sometimes there is no deductible (a set dollar amount you must pay out-of-pocket before your insurance starts paying doctors’ bills). PPOs typically have higher monthly premiums, higher out-of-pocket costs, and have a deductible you must reach before they pay for your healthcare bills.
• Network coverage: With an HMO plan, you can only see in-network providers unless it is a medical emergency. PPO plans give you much more flexibility to see providers both in- and out-of-network.
• Referrals: HMO policyholders must have a referral from their primary care doctor to see an in-network specialist. With PPO plans, policyholders don’t require specialist referrals, and they are not required to have a primary care doctor.

Insurance Plans We Accept at Ridgecrest Regional Hospital

We accept all major PPO insurance plans, and we are in-network with:

• Aetna
• Americas Choice Provider Network
• Anthem Blue Cross
• Anthem Blue Cross CA Exchange
• Beech Street
• Blue Cross (including FEP)
• Blue Shield
• Blue Shield CA Exchange
• Blue Shield of CA/VA
• Cigna
• CMSP
• Core Choice
• Coventry/First Health
• Coventry/Mail Handlers
• GEHA
• Health Net
• Health Net MediCare
• Health Net Medi-Cal
• Health Net Tricare
• Health Net WC
• Health Smart
• Interplan
• Integrated Healthplan
• Kern Health Network
• Multiplan
• Networks By Design
• Pacificare
• PHCS
• Prime Health Services
• Three Rivers
• TriWest
• UFCW
• United Healthcare Medicare
• United Healthcare

Please note: We do not currently accept HMO insurance plans. However, in the case that you receive care under a HMO plan at RRH you may be required to obtain a pre-authorization from your HMO.

If you qualify for free assistance from one of the many government programs, such as Medi-Cal, SSI, Healthy families, or others, our qualified staff can help walk you through the process of seeing if you can submit healthcare bills using these programs. Please call beforehand for further information.

For further information about insurance and billing from our hospital, please click hereor contact us at (760) 499-3189 to speak to a member of our staff.