Health Insurance FAQ

What is a PPO?

A Preferred Provider Organization (PPO) is a network of medical professionals that have a contract with an insurance provider. You may use any of the doctors or hospitals within the PPO network and do not need a referral to see a specialist within your PPO network.

What is a HMO?

A Health Maintenance Organization (HMO) requires a primary doctor to oversee all of your medical conditions. You select a Primary Care Physician (PCP) from a list of doctors within the HMO network. Your PCP can then prescribe any needed referrals to a medical specialist, who is usually within the HMO network.

What is a provider?

A provider is a specialist within a PPO network. You may see any provider within your PPO network without a referral.

Can I see a provider outside of my network?

PPO: Yes, but you will pay more for the service. A typical plan will pay 80-90% of the cost of service for a provider in-network. However, they usually only pay about 70% for a visit to a non-network provider.

HMO: Yes, but you will be responsible for 100% of the cost.

Can I see a specialist without seeing my PCP first?

PPO: Yes.

HMO: Except for emergency care, you will most likely be responsible for the entire bill if you do not receive a referral from your primary care physician first, even if the specialist is an in-network specialist.

What is a deductible?

A deductible is the amount of money you must pay before the insurance company will begin to pay for covered medical expenses. However, there are some types of visits that are usually covered, but require a co-payment. Most HMOs do not require a deductible.

What is a co-payment?

A co-payment is the amount of money that you must pay upon seeing a physician. The insurance company will pay part of the bill, and your co-payment is your responsibility.

PPO: Most policies require some sort of co-payment upon each visit.

HMO: Some HMO’s do not have co-payments when you see an in-network physician.

Should I go with a HMO or PPO?

There isn’t one correct answer to this question. With a PPO, you will have the flexibility to go to doctors whenever you need/want to without getting prior approval. But with this flexibility usually comes higher out of pocket expenses. However, with a HMO you will have very few out of pocket expenses when you see your PCP and any referred specialists.

If your not sure which plan is the right one for you and you live in California, give us a call or fill out our online quote request and we can get you on the right health insurance plan for you.