YOU ASK:

Why an employee might select a PPO health insurance benefit over an HMO?

WE ANSWER:

A PPO health insurance can provide more flexibility for an employee and this may be one good reason why an employee may prefer a PPO plan over an HMO plan.

Below is a table outlining the basic differences of the two kinds of plans:

PPOs HMOs
Choice of health care providers You can choose from their existing network but you also have the option to go outside the network (you will need to pay more for services outside, though). You are required to choose providers that are in the HMO network. If you opt to get treatment from a doctor outside the network, you will not receive anything for your claims.
Need for a Primary Care Physician You have the freedom to get treatment from any physician you choose. Again, it will just be more expensive to get the treatment from a doctor outside of the network. You have to have a primary care physician within the HMO network. If you need treatments that the primary care physician can't give, you will need to get a referral in order for you to get those treatments.
Specialists There's no need to have a referral. However, you may need prior approval from the insurance company to ensure that the treatment is indeed covered. Your PCP has to give you a referral before you can see a specialist that is also in the network.
Insurance claims If you get your treatments within the network, you don't need to file anything.
If you get treatments outside of the network, you may need to pay for these first and then claim for reimbursement from the insurance company.
You don't have to file a claim or pay anything. The providers will be the ones who will file for payment, except if there is a limit and the insured is required to pay the balance for the service.

With these distinctions, you can decide whether you, as an employee, will prefer one kind of plan over the other. With the freedom provided by PPOs as opposed to HMOs, it will be simpler for the HR department to administer any claims that you may have.

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