What’s the difference between HMO and PPO plans?
Who is this for?
This information can help you if you're shopping for health insurance and want to learn how HMO and PPO plans are different.
When you’re shopping for health insurance, you have a lot of options to choose from.
Knowing the differences between plans can help you choose the one that’s right for your health care needs and budget.
As you look at plans, you may notice that some plans are HMOs and some are PPOs, but what does that mean?
- HMO stands for health maintenance organization.
- PPO stands for preferred provider organization.
All these plans use a network of physicians, hospitals and other health care professionals to give you the highest quality care. The difference between them is the way you interact with those networks.
With an HMO plan, you pick one primary care physician. All your health care services go through that doctor. That means that you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance.
For example, if you get a skin rash, you wouldn’t go straight to a dermatologist. You would first go to your primary care physician, who‘d examine you. If your primary care physician can’t help you, he or she will give you a referral to a trusted dermatologist in your network that will.
One exception to this is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine services such as Pap tests, annual well-woman visits and obstetrical care.
Coordinating all your health care through your primary care physician means less paperwork and lower health care costs for everyone.
PPO plans
PPO plans give you flexibility. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network.
Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered.
Which one is right for me?
If you prefer to have your care coordinated through a single doctor, an HMO plan might be right for you. And if you want greater flexibility or if you see a lot of specialists, a PPO plan might be what you’re looking for.
For more information on HMO and PPO plans, check out our available individual and family 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.
- Visit the Find a Doctor page.
- Choose a directory:
- If you're a Cigna customer,log in to myCignato quickly see in-network providers.
- If you're not a Cigna customer yet, select the type of plan you're enrolling in.
- 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.
- Your search results will show the in-network providers based on your search criteria, along with other details that can help you when enrolling.