HMO vs PPO

[TigerGirl1226]

DH started his new job today and we were given the option choose between a HMO and PPO. The HMO is more per month, but less for hospitalization and there is no deductible. The PPO is a little bit less per month, but more for services and hospital stays.

DD goes to speech therapy once a week. I have orthopedic issues with my feet. DH is on meds for blood pressure, cholesterol and blood sugar.

I'm just wondering if we should put out more per month knowing that right now it saves us in the long run with our current issues.

We've always had a PPO. Is there a downside to HMOs? I appreciate any input.

[frugalfranny]

Be sure to find out which doctors they use...........that could be a real issue! Are you allowed to keep your current dr's or do you have to change to theirs?

Finding new dr's is the pits!! IMO!

If you will have a co-pay once a week for the speech therapy.......do the math......may work out to go with the cheaper fee for service. Also......the RX......if it isn't a generic drug........what do you pay with each? If it IS generic........what do you pay?

I would request their booklet from each to see what was covered and NOT COVERED! Most will send them .....but it takes awhile so you will have to get on it if you have a time line to pick.

[TigerGirl1226]

Ok, a little more info.

• Prescription coverage is the same regardless of PPO or HMO
• DD's pediatrican, DH's priamary doc, and my OBGYN are all on both plans

[frugalfranny]

Ok, a little more info.

• Prescription coverage is the same regardless of PPO or HMO
• DD's pediatrican, DH's priamary doc, and my OBGYN are all on both plans

That is great news.

Then you are back to doing the math for the co-pays. Will paying a little more each month but a lesser co-pay each time make up for the difference?

And---just in case---I would still request each of the booklets.

[2ndGenGranola]

I hate our PPO. "Bad" regular insurance was better than this. I just had to have a sonogram and we had to pay 1/2 of it. Our "bad" insurance paid the whole bill when I was having pg related sonograms. The sure take our $$$ every month but they don't pay for much.

[imagine]

HMO are not liked where I live. It might be that many of the doctors are not on them.

I always thought that HMO stood for Health Management Organization and that they kept thier cost done my managing the cases. That the docs had to have more approval to do things or the HMO wouldn't pay. The few people I know who have an HMO say often things like "Well the doc wanted to do that but our HMO wouldn't agree". Make me wonder what would happen if they thought that you DD had enough therapy or didn't need it.

Again, I only see HMOs though the bias against them that is apparent in my community so it might not be an accurate or fair interpretation.

[craftypam]

I know a person who has an HMO and has terribly high chlorestrol; and the meds she needs to take are out of the ordinary and they won't cover them. I also have heard where I live that people don't like HMO's. I also think insurances are getting away from paying more and more; meaning higher and higher deductibles.

[ladykemma2]

i love my aetna HMO, but remember, you have to play by their rules. pre approvals, etc.

[mek42]

What kemma said. Check to see what each plan requires for specialist appointments. Do you need a primary care doctor as a gatekeeper? Meaning, even if you know the primary care doctor won't be able to help, will you need to go there first to get in the system to see a specialist?

Good luck!

[lisaflex]

PPO

dont like anything about hmo's

[Neeley]

Love my PPO. Since October I have been hospitalized twice for a total of 21 days. My charges totaled $200,000. All I had to pay was $500. I've also had a PICC line twice and a combined total of 30 days (and counting) of at home IV antibiotics. A seven day supply for my antibiotics is a little over $4000, of which I pay nothing.

I do not need a referral to see any of my specialists, don't need pre-certs for tests and I get to choose any doctor I please. I had an HMO many years ago and it was a nightmare. I cannot find one thing I like about an HMO and will never have one again.

[TigerGirl1226]

Thanks everyone!

This a lot of think about. If we went with the HMO, DH doesn't have a problem going to his primary care doc for specialist recs. I on the other hand can't stand our primary doc so I would need to find a new one if they have to be our hub for all other treatment.

[BudgetLoving]

PPO

dont like anything about hmo's

Ditto! I've always had a PPO because it gives me more options. I agree with the above comments to make sure to get the booklets and research your coverage!

[IntlMom]

had an HMO once. hated it. H A T E D it.... every single thing about it!! The pre-approvals themselves are enough to keep me from an HMO forever. Never mind that I want to see the doctor I WANT, WHEN I WANT and not have to ask permission like with the HMO plan we had.

My PPO might not be perfect, but it's my choice....hands down!!

[ladykemma2]

i love my aetna HMO, but remember, you have to play by their rules. pre approvals, etc.

I have aetna HMO with kelsey seybold as the provider.
ok, the way to play by their rules is

CALL THE NUMBER ON THE BACK OF THE CARD. be sweet as pie, and the kelsey seybold nurse managing your case will preapprove what you need right there on the phone. OR she will direct you to see the primary care doctor who will give the pre-approval.

example: i see my kelsey seybold dermatologist once a year for a skin check. I call the number on the back of the card, she pre-approves it, it's in their computer, and then i know the bill will be paid. i then make an appintment with the dermatologist.

ditto for ob/gyn

when i couldn't smell last year, i had to see the primary care first, then was pre-approved to a neurologist, and then an ear nose and throat, and the MRI lab.

you have to go to the emergency room. back to the rule. call the kelsey seybold number on the back of the card. Ask the nurse WHICH EMERGENCY ROOM WOULD YOU LIKE ME TO GO TO? they will direct you to the nearest, go to (hospital downtown) , or go to the urgent care clinic (gives address). now it's in the computer and the bill will be paid.

i have to see the super-specialist endocrinologist once a year for PCOS. i pay cash becuase she is not a provider.

it's easy to play by the rules. if you buck the system they will not pay.