HMO or PPO?

[TheNewGirl 1,514]

Hubby and I both have open enrollment at our jobs in November. I have myself and the kids on mine, which is an HMO. Co-pays are good, ER visits (wwe've had about 5 in the last 5 years (since kids were born) are not too $$$, and the location is great. If you go to the doctor and you need labs done/pharm pick up, everything is in the same building, BAM! you're done you go home. I pay a certain $$$ out of every check, pre-tax.

 

Hubby belongs to a PPO. His is free, nothing to pay every month. However, when he DOES go to the doctor, it's $$$. He has to pick up Rx at various locations, has to drive to other places to get labs/specialist work (MRI's, Ultrasounds, whatever) done. ER vists are $$$ (we paid around $500 back in 2002 when he got sick and needed IV fluids). He has serious illnesses that run in his family, and he himself has a compromised immune system (he does get different vaccines etc, to try and eliminate illnesses like menengitis, flu, etc.) If anyone in our family were to get very ill, it would likely be him. Anytime he gets a cold or the stomach flu, it's 100 times worse than me or the kids.

 

My thoughts...although his insurance is free every month, him being a part of my HMO would be better. IMO, it's better to pay $75 for an ER visit and forget about it, rather than pay your $25 co-pay, then get a $500 bill in the mail a week or so later. My c-sections cost $250/each, while his knee surgery cost us over $1000 (bills for various things were arriving MONTHS after the fact).

 

Thoughts? Discuss?

 

I have often heard that HMO's are great for people who are prone to get sick more often...and PPO's are for those who don't get sick that often. If I add hubby to my HMO plan, of course my monthly dues go up, however, I would rather pay that then be hit with a HUGE bill later on. I guess it's all about monthly cash flow and all of that...but what are your thoughts.

 

Sorry for being so wordy.

[Strike 5,648]

Fock it. I'm just waiting for Hillary to give me the quality health care I'm entitled to.

[heavy-set 39]

FU

[kutulu 1,685]

Which one has a better mental health pla? That's your answer.

[Brown Eyed Girl 1]

My company offers both, and although I feel that a PPO would tend to provide better quality care, it has always been more cost effective for me to select the HMO for the same reasons you have indicated that you do.

 

It makes the best financial sense, IMO (especially if you have young children who are in and out of the doctors office frequently)... but certainly you would benefit from it with your husband's situation.

Certainly something you should consider.

[Let Da Big Dog Eat 41]

Whichever one considers breast implants for you a "necessary expense."

 

I was in an HMO for a couple years. Got a finger mashed in a door and the nail was full of blood and throbbing. The "Dr's Assistant" who first saw me said they wouldn't drill the nail to release the pressure. Told her that if I don't see a real Dr who knows what he's talking about in 10 minutes, I'm going to the Emergency Room where they'll take care of it immediately. Just as I was opening the door to leave the exam room he & A$$. show up. He looks down at my finger and says to her "we need to drain that."

 

HMO, NEVAH again. Waiting hours to see some ignorant focktard is not for me.

[Baby Jesus 0]

Go with the HMO for all the reasons you mentioned. The only advantage to a PPO is being able to go to a Dr. out of network. If there is a Dr. that you absolutely have to see, your first route should be to ask him to get a contract with your carrier. When I worked at a health insurance company, I saw it done all the time.

 

Insurance companies have totally shifted the market to PPO because it reduces their burden in relation to that of HMOs. Looks like you're getting similar care, but the costs are nowhere near the same. Especially if you actually use your plan - and families tend to do that.

[jerryskids 6,889]

Long ago I was in an HMO. You had to go to a primary physician for all referrals to specialists. And those referrals were often difficult to get. I'm currently in a PPO and can go to any specialist I want. I don't have an HMO option currently so I can't really compare, but I definitely like the way my PPO works more than the HMO.

[TheNewGirl 1,514]

Thanks for the serious responses.

 

For what it's worth, I have never had a problem with my HMO, and haven't had to wait hours to see someone. It's a HUGE HMO out here, and I've been witht hem since birth. No problems for me, or my kids...or my parents even for that matter, they belong to the same HMO, too.

[jerryskids 6,889]

Thanks for the serious responses.

 

For what it's worth, I have never had a problem with my HMO, and haven't had to wait hours to see someone. It's a HUGE HMO out here, and I've been witht hem since birth. No problems for me, or my kids...or my parents even for that matter, they belong to the same HMO, too.

Mine was Intergroup, which made landmark legal status by actually being sued by the doctors who worked there because they weren't allowed to provide adequate medical coverage to their patients. So my experience could be skewed.

[TheNewGirl 1,514]

Mine was Intergroup, which made landmark legal status by actually being sued by the doctors who worked there because they weren't allowed to provide adequate medical coverage to their patients. So my experience could be skewed.

 

 

yes, and everyone has their opinions about HMO's. My husband even has an opinion, yet he's never belonged to one...swears that they are the Debbil...yet I belong and our kids belong. Go figure.

[Rusty Syringes 478]

OPP

 

You down with that?

[TheNewGirl 1,514]

OPP

 

You down with that?

 

You know me!

[Rusty Syringes 478]

You know me!

 

[Baby Jesus 0]

yes, and everyone has their opinions about HMO's. My husband even has an opinion, yet he's never belonged to one...swears that they are the Debbil...yet I belong and our kids belong. Go figure.

Hmmmm..........is this what's behind the topic?

 

Am I safe to assume that DH thinks they're the debbil because they deny care where a PPO wouldn't?

 

Please elaborate, specifically if possible.

[TheNewGirl 1,514]

Hmmmm..........is this what's behind the topic?

 

Am I safe to assume that DH thinks they're the debbil because they deny care where a PPO wouldn't?

 

Please elaborate, specifically if possible.

 

 

Elaborate on what? He doesn't like HMO's, but he's never belonged to one...I don't know about denying care by an HMO, I have never been denied care by mine...anything from regular check ups, referrals to specialists, mental health, etc.

 

I went to the ER not long ago, and it cost me $75. He went to the ER, and we got a bill for over $500. I would prefer to pay more every month, and not get HUGE bills in the mail later on.

[itsbigmoni 1]

Don't they work in opposite ways? Like, don't HMO's have a cap to how much they'll cover? They'll pay everything up to $15,000 or something and then after that its on you right? I know with PPO's you have to meet your deductible (can be as low as 1k or as high as 5k) and after that, they'll pay for everything.

 

I've never had any problems before so i opted for a PPO since it was a bit cheaper for me. This year, i got focked over and over. I met my 5k deductible and now they pay for everything.

 

I like PPO better because you don't need referrals. If i need a non-emergency appointment, it usually takes about a week to get one. Then they fill out the referral, go back and forth, and they make the appointment for you which is like a month away. With a PPO you just call the place and make your own appointment and usually don't have to wait as long.

 

The only thing i don't like about my PPO is only the negotiated rate counts towards the deductible, not what you actually pay. When i i got an MRI, my cost was about a thousand but since the negotiated rate between my insurance and the facility was $450 for an MRI, only $450 of it counted towards my deductible. I think, part of it is my fault though. Most Dr.'s will only charge you the negotiated rate, but when i was going through the process, i didn't know jack sh1t about my plan so i was confused. I'm sure i could've paid only 450.

 

I've had an HMO in the past and the only major problem i had with it was the referral stuff. Also, i think i got slightly less quality care. When i hurt my knee snowboarding back in 03, the dr. didn't suggest an MRI and i was too naive and believed whatever he said. My knee still wasn't right. I tore my ACL earlier this year and my dr. said she saw to meniscus tears, one recent (i tore my meniscus and acl at the same time) and one tear that looks a few years old that healed itself.

[TommyGavin 790]

I Got a finger mashed in a door

 

Serves you right Dog - werent you taught No means No ??

 

 

(I've had it on fingernails and big toe - freakin painful)

[joneo 558]

Easy. Go get the flu and then give it to your husband, which in turn kills him. Collect on his life insurance and come look me up.

[TommyGavin 790]

Easy. Go get the flu and then give it to your husband, which in turn kills him. Collect on his life insurance and come look me up.

you need the inheritence for a new thumb?

 

sweet hook up.

[Johnny Ringo 0]

Ok, I sell benefits for a living, so here's a quick course on HMO vs PPO.

 

Which is the "better" option depends on your situation. Generally, the big difference, as noted several times, is the physician choice that a PPO gives you, through larger networks and an out of network option. Usually, more doctors will be in a PPO network than in an HMO network. HMO coverage varies by geography, with larger carriers in big cities usually having HUGE networks. If you live in a rural area or you are looking at an HMO with a smaller carrier, you might want to go PPO. Bottom line is there's a big difference in the potential number of doctors when you look at an Aetna HMO in Houston versus an ABC Health Company HMO in Akron.

 

The biggest ADVANTAGE of an HMO plan is that your out of pocket costs will almost always be lower in an HMO. In a PPO, you will have a deductible and then co-insurance to pay if you go have surgery or have a baby, etc. In an HMO, many times there is no deductible or a small deductible, and usually there's copays instead of percentage coinsurance if you end up in the hospital, as TNG said. The idea that care is "better" in a PPO is not accurate...many of the same doctors that take a PPO plan also take an HMO and once you see your doc, he's not going to treat you differently because you happen to be in one plan or the other.

 

The biggest mistake I see is that people look at the wrong things when they compare health plans. You should pay attention to PREMIUM, DEDUCTIBLES, and certainly OUT OF POCKET MAXIMUMS. Premium per month is key, obviously. Deductibles are key, especially in a PPO plan. There's a HUGE difference between a PPO with a $250 or $500 single deductible, versus a PPO with a $1500 or $2000 deductible. Keep in mind that for anything other than regular office visits and prescriptions, you have to meet that entire deductible before the coinsurance even kicks in. Out of Pocket Max is probably one of the most important things to look at in a health plan, and is probably the most overlooked by the typical employee. This is basically the "worst case scenario" that says the out of pocket max is the MAX out of pocket you could pay in any one year. Once you meet the out of pocket max, everything is covered at 100%. So an out of pocket maximum for a Family of $3000 is a far cry from an out of pocket max of $8,000 or $10,000. If you get in a car accident or something, can you afford the worst case scenario?

 

That being said, probably 2 things that people pay TOO much attention to are COPAYS and COINSURANCE LEVEL (for a PPO plan). People look at an HMO Value plan versus a HMO High plan and see that copays are $15/primary care office visit and $25 for a specialist in the High plan but $25 for primary and $35 for specialists in the Value plan. Pick the High plan, right? Not necessarily. If the High plan will cost you $30 more per month out of your check, is it really worth it? Do the math. $30 times 12 months = $360 more in premium. You're saving $10 in copays every time you go to the Dr. Unless you plan on making more than 36 doctors visits between you and your family, I would save the premium and go with the Value plan. COINSURANCE on the PPO plans is likewise a little overrated. Let's say you have a PPO Value plan that's an 70/30 plan versus a PPO High plan that's an 80/20 plan. In other words, once you hit your deductible, the plan will cover 70% and you'll pay the other 30% (until you hit the out of pocket max) OR the plan will cover 80% and you cover 20% (up to the out of pocket max). Think about it, if you end up in the hospital, you'll likely end up with a HUGE bill...$15k, $20k, $25k, who knows. On a $20,000 total bill, 20% coinsurance is $4000 and 30% would be $6000. Well, if your coinsurance max is less than $4000, does it really matter? If the difference in premium is small, then maybe it does...if it's a lot more per month out of your paycheck, probably not.

 

Also, pay attention to the prescription costs on the plans. There is usually a three tier system, Generic, Brand Name and Non-Formulary. So if you see 10/35/50 next to prescriptions it's $10 for a generic, $35 for a brand name and $50 for a non-formulary drug. Likewise, 20/45/70 would mean $20 for generic, etc.etc... If you or your kids take a lot of prescriptions, pay attention. Also, take advantage of MAIL ORDER prescriptions. If you see Prescription costs of $15/$35/$50, you'll probably see Mail Order option of $30/70/100. The key is that you get 3 MONTHS of the drug for basically a 2 month copay. If you take something EVERY SINGLE month, take advantage of this.

 

Here's a quick example of some things you might see in comparing "typical" plans:

 

Plan 1: HMO Low, $0 Deductible, $2500 Out of Pocket Max, $25 office copay, $35 specialist, $100 ER copay, Prescriptions $25/45/70.......$129 per paycheck premium cost.

 

Plan 2: HMO High, $0 Deductible, $1500 OOP Max, $20/office, $25/specialist, $75 ER, Prescrip: $15/30/50....$155 per check premium cost.

 

Plan 3: PPO Low, $1000 Deductible, 70%/30% plan, $2000 Coinsurance Max, $3000 OOP Max, $25 office, $30 specialist, ER = Deductible + Coinsurance....Prescriptions $20/40/70....$110 per paycheck

 

Plan 4: PPO High, $500 Deductible, 80%/20% plan, $1500 coinsurance Max, $2000 OOP Max, $20/office, $25/specialist, ER = Deduct + Coinsurance...Prescrip: $15/35/50...$140 per paycheck

 

Again, look at the key differences in the plan, but always BALANCE THAT OUT with the difference in premium that it will cost you per check or per month to "buy up" to the other plan.

 

Also, a KEY difference between an HMO and a PPO is that office visit copays, ER copays, lab work copays etc all accumulate TOWARDS your Out of Pocket Max in an HMO but not in a PPO. In a PPO, your Out of Pocket max is always your deductible plus your coinsurance max...period. So as an example, if you have an HMO with 0 deductible and a $1500 out of pocket max versus a PPO with a $500 deductible and $1500 coinsurance max (so a $2000 total OOP Max). If you get hospitalized late in the year, and you'd already spent $300 on office visits and labwork earlier in the year, your true "worst case scenario" for the HMO would be $1200. On the PPO side, if you haven't met that $500 deductible (office visits dont apply), you're potentially on the hook for the whole $2000.

 

On the whole referral thing, it's something to consider, but keep in mind how often you really see specialists. I'm a 34 yo male so you cant DRAG me to the doctor, so I just dont care. If you see specialists on a regular basis, you might like the choice a PPO will give you. However, if that same doctor is on both the PPO AND HMO network, is it really that big of a deal to get a referral from your family doc?? Everyone will answer this differently, but with the internet, referrals these days are usually VERY easy to obtain. Again, the key is whether your dermatologist, Orthopedic surgeon, etc takes the HMO or if they ONLY take the PPO. Before you sign up for ANY plan, you should go to their website and use a search feature to see if your doctors are on the plan...most carriers use the internet instead of the old provider books these days. When in doubt, just call your doctor's office and ask them.

 

As an aside, you may check and see if your employer offers a POS (Point of Service) option. This is a hybrid plan that is built on an HMO network and typically has low out of pocket costs and copays like an HMO, but also has an out-of-network option and no referrals required more like a PPO. A POS plan can often be a nice mix of the two...again, pay attention to premium, deductible, out of pocket max, and prescription costs.

 

Finally, whatever plan you choose, if your company offers a medical FSA (flexible spending account) PLEASE take advantage of it if you know you're going to have medical costs in that year. If you have a PPO with a $1000 deductible and you know you'll have knee surgery in June, put that $1000 into the FSA. You'll save Federal, State and FICA taxes on it, so likely at LEAST 30% savings...so effectively you'll turn that $1000 deductible into a $700 deductible. That's worth sending in a fax or two...even better if your plan has an FSA debit card. Even if you might not hit the deductible or aren't sure, if you spend $50/month on prescription drugs and have 2 kids that will go to the doctor at least 2-3 times per year, that's probably $700 or so in just prescriptions and copays...not to mention dental, vision, over the counter meds, etc. It always kills me to see people not taking advantage of an FSA.

 

By the way, if anyone is considering one of the newer "High Deductible Health Plan with a Health Savings Account" options that a lot of companies are starting to offer, let me know and I can post a follow up message. That kind of plan can be great for the right person, or it can be HORRIBLE for the wrong person.

 

Ok, I'm tired now...I hope someone finds this post somewhat helpful.

[Chiefs04 0]

Wow....an excellent breakdown of this subject Johnny Ringo!

 

 

 

 

 

 

And this is very true....

 

The idea that care is "better" in a PPO is not accurate...many of the same doctors that take a PPO plan also take an HMO and once you see your doc, he's not going to treat you differently because you happen to be in one plan or the other.

[Baby Jesus 0]

Ok, I sell benefits for a living, so here's a quick course on HMO vs PPO.

 

Which is the "better" option depends on your situation. Generally, the big difference, as noted several times, is the physician choice that a PPO gives you, through larger networks and an out of network option.

Although Johnny Ringo is right on all accounts, you can stop reading here.

 

Go with the HMO unless you have a damn good reason to go with the PPO. Most companies nowadays (that I've seen) don't even have an HMO option.

 

I think it goes back to a decade ago when the consumers and advocacy groups were biotching a storm up about how bad HMOs were. The insurance companies answer was to create a different type of plan that focks consumers over even more.