PPO

HMO

Which health providers must I choose?

Whenever possible you should choose doctors, hospitals, and other providers that contract with the PPO network.

You must choose doctors, hospitals, and other providers that contract with the HMO network.

Do I need to have a primary care provider (PCP)?

No. You can receive care from any doctor you choose but you will pay more for out-of-network providers.

Yes. Your HMO will not provide coverage if you do not have a designated PCP or medical group.

How do I see a specialist?

You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. Also, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.

You need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.

Do I have to file a claim for in-network services? 

No, claims are filed on your behalf by the providers.

No, as HMOs don’t typically have claims filing processes. 

Do I have to file a claim for out-of-network services? 

Yes.  You may have to pay the provider in full and then file a claim with the health plan to get reimbursed.

N/A.  However, if you receive emergency care from an outside facility, you may be required to coordinate payment with your HMO plan.

Can I seek care out of my service area?

Yes. Most PPOs have a nationwide network, meaning that you can find in-network providers in most states.

No. All care must be rendered within your Primary Medical Group, or pre-authorized by them.

How is Kaiser different?? 

N/A

Kaiser requires that you go to a Kaiser facility in your service area. Care outside of Kaiser is only covered in a life-threatening emergency.