hmo vs ppo VS HDHP

HMO

The providers in HMO networks have negotiated rates that are lower for HMO plan members and still meet high quality standards. You can view the care reviews when searching for healthcare providers. Important things to know are:

• You (and enrolled family members) must choose a Primary Care Provider (PCP) when signing up.

• Each family member can have their own PCP, determined by their personal needs and preferences.

• Preventative services are covered at 100% without co-payments, co-insurances, or applied deductibles, as long as the provider is in the Blue Advantage HMO network. 

• Any visits to any other healthcare provider, such as a specialist, must be authorized and referred by the PCP, and in the Blue Advantage HMO network in order for insurance coverage to be applied to costs and payments. Services that do not require a referral include visits to participating OB-GYN's or gynecologist specialists and all emergency room services.

• Premiums (and consequently paycheck contributions) are lower under HMO plans. There is no ($0) annual deductible for the individual or family, and a lower Out of Pocket maximum. That means any services that are advised and directed by your medical care provider may be covered up to 100% - please see your Benefit Summary to see coverage, as not all items are covered.

• If you choose to see a healthcare provider outside the network or not authorized by the PCP, there will be NO coverage - meaning you will be responsible for the entire cost of medical services. 

PPO 

Under a PPO plan you can use any doctor, clinic, hospital or health care facility you want. You save money when you use the national network, but there are fewer restrictions on seeing non-network providers. There is higher flexibility with this plan and choosing your care providers, but it is at a higher cost. Important things to know are:

• There is no need to select a PCP or get referrals to see a specialist.

• Enrolled members can receive care from any healthcare provider - in or out of network. Out of network means the provider does not have a contract with BCBSIL. Out of network providers may charge more than network providers due to lack of negotiated pricing and there may be higher out of pocket or co-insurance costs.

• There will be copayments and deductibles applied to your care costs, along with possible co-insurance payments. There is an out-of-pocket limit for the plan year on how much you can pay.

• Preventative services are covered at 100% without co-payments, co-insurances, or applied deductibles if you choose in-network Blue Choice providers. If you go out of network, a coinsurance will apply.

• Deductibles will apply to various services and supplies, such as surgeries, inpatient hospital stays, and receiving medical equipment or devices.

• Some services may require approval to be covered - please see the Benefit Summary for details.

HDHP

An HDHP plan is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (also called your deductible). This plan covers in-network preventive care at 100% and include an annual limit on your out of pocket expenses. Important things to know are:

• Your medical expenses under this plan will be 100% out of pocket until you meet your deductible for the year.

• You can save money under this plan by visiting Tier 1 vs Tier 2 providers.

• A high deductible plan can be combined with a health savings account (HSA), for you to pay for certain medical expenses with money you set aside in your tax-free HSA. This is why it’s more commonly called an HSA-eligible plan. 

• Some services may not count towards your out of pocket limit - please see the Benefit Summary for details.

Click on the different Summary of benefits to see specific costs to prescriptions, co-pays, and more!