1. California Health Insurance
  2. Covered California
  3. Plans
  4. HMO vs PPO

HMO vs. PPO Plans

In California, everyone needs health insurance, but navigating your plan options can be confusing. Most health insurance plans in the state are either Health Maintenance Organization (HMO) plans or Preferred Provider Organization (PPO) plans. Though either plan can be a good option, your individual needs will impact which type of health insurance plan is right for you.

Choosing a Carrier Based on HMO Plans vs. PPO Plans

For many, the decision between Covered California health insurance companies comes down to this question: “What do you think of Kaiser Permanente?” Or, “What do you think of Covered California Kaiser Plans?” Do you want to lock yourself into California’s one-stop shop HMO, or do you want the ability to choose? Is an HMO or a PPO plan right for you?

HMO plans almost always cost less - they usually have lower monthly premiums and less out of pocket expense

What Are HMO Plans?

With an HMO plan, you will have a primary care physician (PCP) who you will visit when you’re sick and for your annual physicals. Though you can select your PCP, they need to be included in the HMO’s network of healthcare providers. If your PCP believes you should receive additional treatment, they will refer you to a specialist in your local network of providers.

An HMO plan offers financial advantages. HMO plans tend to be more affordable with lower monthly premiums and lower out-of-pocket costs — unless you see an out-of-network provider. You will also likely not have to file a claim, since you are seeing physicians in your network and your insurance provider will work with your healthcare providers directly. Your PCP will also take care of coordinating and scheduling the majority of your appointments so you don’t have to deal with this task yourself.

If you have a PPO Plan you will ultimately save money by choosing a doctor in the network

What Are PPO Plans?

A PPO plan is more flexible than an HMO, as you do not need to have a PCP and you can visit any provider or specialist you want. Note that you will save money when you select a physician in your network. Since you have more freedom and flexibility with a PPO plan, you will likely pay more for your monthly premium and pay higher out-of-pocket costs, especially if you visit an out-of-network provider.

If you want to stay with your doctor but have a new insurance provider, you may want to select a PPO plan. Keep in mind that if you choose this type of plan, coordinating and scheduling your appointments will be your responsibility.

Kaiser vs. Blue Shield

Kaiser and Blue Shield both offer excellent health insurance plans. If you want an HMO plan, we recommend Kaiser. If you want a PPO plan, we recommend Blue Shield.

Kaiser Permanente for HMO Plans

Some wouldn’t even consider anything but Kaiser Permanente health insurance coverage, California’s premier HMO. Individuals with Kaiser Permanente coverage love walking across the hall from their primary care physician to go see a specialist and then grabbing their prescription drugs on their way out the door. They love Kaiser’s electronic medical record system and how it keeps all their various healthcare providers in the loop regarding health conditions, medications, allergies, past medical history and more.

Kaiser offers services like disease management programs, 24/7 access to nurses over the phone, discounts on fitness programs and healthy lifestyle classes and programs. It’s a great system, and it works when it comes to offering high-quality health care at affordable prices.

Blue Shield/Blue Cross for PPO Plans

Others view the PCP of Kaiser Permanente and the other HMOs as a “gatekeeper” or a prison guard who is keeping them from going straight to a specialist when they deem it necessary. They say things like:

  • “I don’t want to be locked into the Kaiser system.”
  • “I like my current doctor, and I don’t want to change.”
  • “I want choice.”

That’s when it’s time to start looking at the PPOs. If you’re going PPO, that usually means you’ll be looking at Anthem Blue Cross Covered California and Covered California Blue Shield. In the PPO world, you’ll find more options and you’ll likely end up paying more money in monthly premiums to have this choice.

Individuals and families come in all shapes and sizes - and so do insurance plans.

Find the Right Plan for You With Health for California

At Health for California, we understand you have a lot of options when it comes to health care coverage. Since 2004, we’ve been helping Californians find plans through a variety of providers. We make it simple for you to get a quick quote for HMO, PPO and other plans based on your unique needs. To find affordable health insurance, get a free quote from us at Health for California today.