Question:
I need to ask if someone can explain to me the difference between a PPO and an HMO??

I truly don't know which one I have! I am insured with United Health Care, through Delta Airlines (hubby's insurance).I have looked through all the Q& A pages and no where can I find where the difference between the two is explained. Thanks!    — jane W. (posted on January 5, 2001)

January 5, 2001
This is my understanding - I hope its correct: With an HMO you have to see a primary care physician to be referred to specialists, With a PPO you see whoever you want directly. Thats the basic explanation - it gets a little more complex based upon the terms of your coverage.
   — [Anonymous]

January 5, 2001
an HMO you have a book of doctors and you have to have the insurance company approve you to go to someone outside of you book, a ppo has a book of doctors also, but you have the freedom to go outside of that book without a referral, but normally the payment percentages are a little lower...
   — Jack N.

January 5, 2001
HMO you have to have a in network primary physician which is known as a gatekeeper. In order to see a specialist you have to have referral from that primary physician, the HMO will pay for your visit with the referral. The PPO is that you also can any doctor and you don't need a referral to see a specialist and you can go out of network. With a HMO you have to stay in network. With a PPO if you go out of network you have to pay a deductable and co insurance to meet an out of pocket expense. Usually with a PPO you have a 70/30 where as if you go outside the network of Doctors the insurance company will pay 70% of your bill once you met the deductable and you still have to pay the 30% that is left. I hope this didn't confuse you. I use to process insurance claims.
   — Sharon T.

Click Here to Return