Weekly Tips & Insights

HMO vs. PPO: What Patients Need to Know

Open enrollment began earlier this month (on October 15th) and runs until December 7th. This period of time allows insurance holders to make any necessary changes to their coverage. For seniors, knowing what's covered under their healthcare plan is crucial, but it can be overwhelming to sort through all the information.


Today, learn some of the key differences between an HMO plan and a PPO plan:

HMO (Health Maintenance Organization)

  • May be required to have a primary care physician (listed on patient's insurance ID card)

  • Referrals must come from a primary care physician

  • Copays often a required


PPO (Preferred Provider Organization)

  • More flexibility in seeing physicians or visiting hospitals

  • Fewer restrictions on out-of-network care

  • Sometimes covers the costs of visits to out-of-network providers


There are a few things seniors should consider when deciding which of these plans is best for them. HMO plans can be a great option for healthy seniors, as it allows them to get a nearly set price of care from a selected physician group. Also, HMOs are generally more affordable and have lower monthly premiums and annual deductibles.


A PPO plan can be a great option for seniors who need specific care, as referrals aren't required to see specialists. By the time a patient is in need of the services the VNA of Greater St. Louis provides, like hospice and palliative care, they typically have to see specialty physicians in addition to their primary care physician (i.e. cardiologists, pulmonologists, neurologists, etc.).


Though open enrollment is only during a certain period of the year, Medicare considers some circumstances, such as hospitalization, to be "qualifying events" that allow patients to switch or upgrade their healthcare plans outside of this enrollment period. If patients have experienced a change in life change or a shift in health status, it may be a good idea to look into different coverage options.


At the Visiting Nurse Association of Greater St. Louis, we understand some of the top concerns our patients have and do our best to provide them with the information, resources, and guidance they need to make the best decisions for their health. For more helpful information about insurance, check out our related articles:

Not All Medicare Is Created Equal

Medicare's New Rehabilitation Standards


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