There are a lot of differences between a PPO and an HMO/DHMO, but the biggest differences are in how you access care and what providers you can access.
“PPO” means Preferred Provider Organization. A PPO is a healthcare or dental care network system where the providers are contracted with a carrier to provide care at a discount or for a fixed fee. Members can access care from PPO network contracted providers, or from non-contracted out-of-network providers.
“HMO” means Health Maintenance Organization. An HMO is a prepaid healthcare plan that offers members a variety of comprehensive healthcare services available from a specific group of contracted hospitals and medical professionals. Members must choose a Primary Care Physician (PCP) and/or Medical Group. If one is not chosen, the Anthem system will assign one based upon the member’s zip code.
“DHMO” means Dental Health Maintenance Organization. A DHMO is a prepaid dental care plan that provides a variety of comprehensive dental services through a network of dental providers. Members must choose a Primary Care Dentist (PCD). If a PCD is not chosen, the system will assign one based upon the member’s zip code.
If you elect PPO medical coverage, you can see any licensed physician or provider in the PPO-network or out-of-network. Of course, if you see an Anthem Blue Cross PPO-network medical provider or a Guardian PPO-network dental provider, the plan’s reimbursement will be greater than if you see an out-of-network provider.
If you elect HMO medical coverage, your non-emergency care is managed by a Primary Care Physician (PCP); Specialty care requires a referral from your PCP. Your Medical Group will refer you to providers within their group. You may choose a pediatrician for your child(ren) as their PCP. You do not need a referral from your PCP or prior approval from your health care plan to see a gynecologist or obstetrician, as long as those doctors are part of your Medical Group. You are generally limited to seeing only providers contracted with your Medical Group. Most Anthem Blue Cross HMO services have little to no out-of-pocket costs for the member