It’s almost Open Enrollment season for the Marketplace, and it’s the time of year where we all get confused about what kind of health insurance we should have. I am writing a series of articles to answer questions about why Direct Primary Care works so well with certain kinds of health insurance. This second article is about Direct Primary Care and how it works with PPO vs HMO insurance.
When you look at your insurance options on the Marketplace, you might see that some plans are HMO plans and some are PPO plans. The HMO plans are cheaper than the PPO plans.
Health Maintenance Organization (HMO)
An HMO is a Health Maintenance Organization. Doctors basically sign a contract with an HMO (up here, common HMOs are through Blue Cross) and agree to see patients who are part of that particular HMO. Many physicians up here do contract with the major HMO plans. However, these plans can limit who you can see “out of network” which can make it harder to go see a particular specialist if that specialist has not signed a contract with your HMO.
Physicians at Direct Primary Care clinics like NorthCountry Health do NOT contract with HMOs. We don’t contract with any insurance companies. Many insurance plans will still let us order tests for you or refer you to specialists, but HMO plans may consider DPC physicians to be “out of network” and may not let us order tests. Thus, if you intend to join a Direct Primary Care practice, choosing a non-HMO insurance plan may be worth the extra money. You could always see an in-network physician and have them order the test that you need but that can get expensive and cumbersome.
As I tell my kids, there are no guarantees in this world. It is very possible that I will be able to order referrals for you and your HMO will be fine with letting me do so. My research into the Direct Primary Care world has taught me that HMO plans are a little pickier.
Preferred Provider Organization (PPO)
A PPO is a Preferred Provider Organization. Once again, doctors basically sign a contract with a PPO (up here, common PPOs are through Blue Cross or Blue Care) and agree to see patients who are part of that particular PPO. There is a little more flexibility with “out of network” providers and generally, PPO plans allow your Direct Primary Care physician to order tests and referrals. Physicians at NorthCountry Health DPC do not contract with PPO plans or any insurance plans—we just act as “ordering and referring” physicians.
Once again, though, there are no guarantees on this. The research I have done into PPO plans and Direct Primary Care suggest that they are a better fit.
Take Home Message
If you are shopping for insurance on healthcare.gov, I suggest you check out the website soon and run the cost estimator to see what you might pay based on your income and number of people in your household. Look at the difference in price between the HMO and PPO plans being offered and see how a PPO plan might work for you when paired with membership at NorthCountry Health Direct Primary Care. Additionally, check out my other posts on high deductibles and HSAs!