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Medicare HMO vs PPO
Old 11-04-2013, 04:02 PM   #1
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Medicare HMO vs PPO

My husband just came home from a medicare seminar. They were pushing the HMO, saying it is cheaper monthly and they pay the same as PPO as long as your dr. is in network.

I find that a little hard to believe unless they are trying to get everyone onto an HMO pgm. then change what they pay when majority of people have HMO. Just like "If you like your health insurance, you can keep it."

Anyone here have ins companies that are trying to push HMO too? Do you believe you can get same coverage as a PPO? It just seems hard to believe you can get the same coverage for less money.
I just made an app't to go next week just to listen.
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Old 11-04-2013, 04:23 PM   #2
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Aetna just cancelled my wifes MA plan which was an HMO,you might want to look into
medicare supplement F High Deductible if you can find a good price in your state,you of course will also need a Part D drug plan. I am real happy they cancelled the MA plan.
Yes they push HMO's. My HD plan cost about 60 a month with 2100 deductible for part A, 147 for part B,regular plan F about 160/month. Before the HD plan even kicks in,medicare pays out 80%. All depends on your medical condition,pay me now or pay me later. Also be warned once you go into a MA and after the first year you cant get out without medical underwriting, in other words no guaranteed issuance unless you move out of the plan area or they cancel.
Old Mike
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Old 11-04-2013, 04:48 PM   #3
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I learned the hard way. After leaving my employer to become self employed, just kept the HMO plan. It was ok while I lived in that area, and the insurance saw me through a major expensive cancer operation. After that, I could not get other insurance because of a pre- existing condition, so remained tied to the HMO.
We then retired and began a snowbird life, (Florida), where DW had a serious stroke (full recovery, thanks... 20 years ago) and the Illinois doctor refused to authorize a Florida operation, because he did not "see" her... and despite the urgent correspondence from the Florida Specialist. It was touch and go for 24 hours, and the operation ($100K+) only took place because of my agreement to pay. Finally received okay, just before the operation, after threat of lawsuit.
It was a very difficult time, and took years off my life.

I'd guess this would not happen again, though I don't know why not. I'll defer to others with more current knowledge, but there is no way that I would EVER tie my healthcare down to a certain doctor or a local hospital or clinic.

After this event, we lived on the edge for the three years before we were eligible for medicare.
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Old 11-04-2013, 07:44 PM   #4
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Quote:
and the Illinois doctor refused to authorize a Florida operation, because he did not "see" her...
Wow...that so hard to believe a Dr. would be that stubborn.

I talked to the medicare ins carrier this past summer because I'm getting close to that age too. Since we'll be going to Fla. every Feb. I asked him the exact question you're talking about. He said if it is an emergency the insurance would cover it. That sure sounds like an emergency to me.

I'll bring the same topic up next week when I go to the seminar.
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Old 11-04-2013, 07:58 PM   #5
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We used our company's HMO plan for a few (younger) years. Mainly it was just a more restricted network of providers that we had to (fairly automatically) stay within, along with possibly more restricted care. In return, it was cheaper and we didn't have to worry about insurance forms or if our doctor might send us out of network. We had to coordinate everything through our primary care provider. The PCP then sent us to any specialists. I'm sure they probably had guidelines as to what the HMO was willing to pay for, though we never felt we received substandard care.
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Old 11-04-2013, 08:11 PM   #6
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We had a family member need a specialized surgery. Our Kaiser HMO doctor suggested we have it done through Kaiser. I asked if they had any experts in that area. They said they had a surgeon who did maybe three a year. We waited to have it done until we were on a PPO plan and went to specialist who has done close to a thousand of the same kind of surgery - one of the best surgeons in the country if not the world for what we needed.

My relatives seem happy with their Kaiser plan. The Kaiser hospitals by us you could die in the ER waiting room without being seen. Sometimes there would be thirty or more people in the waiting room. I was there once all night and we were never seen. I left in the morning and just made an appointment with our regular doctor. To add insult to injury, before I left they tried to insist I sign a form that I was refusing treatment. I asked if I stayed could I get treated within 24 hours of more sitting in the waiting room? The answer was they couldn't say. Could I get treated in 48 hours? Still the same answer.

We switched to a PPO and the first time I had to go to the ER for something I was the only one there. There was no one ahead of me! It was just a whole different vibe from commodity / cattle car to personalized health care. Maybe other HMOs are better or other Kaiser plans are better, but personally I would be scared to go back to Kaiser. I feel someday it really could be a matter of life and death. I'd rather pay the money for the PPO and get to choose my hospital and doctors.
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Old 11-05-2013, 09:00 AM   #7
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I had mostly good experiences with Kaiser when I was in California. Yes, you had to use Kaiser facilities and yes, sometimes it took a few weeks to get a routine appointment, but I did like the lack of an insurance bureaucracy (I lost Kaiser coverage in 2003; maybe it's changed since then but I don't know). And I liked that if a Kaiser doctor said a procedure or a prescription was medically necessary, it was covered -- no additional layer of insurance bureaucracy or claim forms. And when my wife needed maxillofacial surgery (probably about a $15K procedure including all aftercare), something many plans don't cover, the Kaiser surgeon decided it was medically necessary and all we paid was a $10 copay.

Just the same, I don't think I'd ever pick an HMO over a PPO again. Yes, they can be a little cheaper but the network can be much more limited, and you often have to go through a GP before you can be referred to a specialist.
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Old 11-05-2013, 09:42 AM   #8
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Just a few more words on the HMO... experience from years ago, so perhaps changes since then.

In my previous post, about the HMO doctor not approviing DW's operation without seeing her... It goes a little deeper. Apparently in his contract with the HMO, he would receive a "bonus" for keeping per-patient expenses below a certain level. After our ordeal was over, I went to the Patient Advocate for the hospital, and learned more about how the "contracts" worked. Scary.

As it stood, at the time, we were almost required to have the operation performed in the Illinois HMO hospital, rather than in Florida. This would have required a medivac flight, which, with attendant doctor and nurse would have cost more than $35,000 at the time. (Just in case of future possibility.. we joined "Angel Flight" after the ordeal).

...............................................
After the operation, because we were even more 'unuinsurable', we had to keep the HMO... even tough we had already moved from the area. To offset this, we were allowed, by a neighbor to claim residence in his home, in the area of the HMO... a situation which was uncomfortable, but based on the incident, didn't trouble my concscience. Still, WHEW! , a great weight lifted when we became eligible for medicare.
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Old 11-05-2013, 11:42 AM   #9
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Oh boy! My pre-ACA individual plan that we have had for many years is PPO. I am not going to change to HMO now, no matter what savings might result.

When I needed medical care this year, I was able to get seen by specialists that I chose within 1-2 days of contacting them. That's worth some extra money.
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Old 11-05-2013, 04:14 PM   #10
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I have classic Medicare and the best type f Medigap plan. Still, there are long waits for the popular surgeons for joint replacement surgery- 6 months for the guy I chose. Of course I chose him mostly because he does my operation all day at least a couple days/week. I should think a big HMO like Kaiser or Group Health here in Seattle would have similarly very busy surgeons. People who operate frequently on a limited set of issues should get faster, better, and less likely to have call-backs/re-dos due to screw-ups or random events. Of course this is theory, not necessarily reality. I have a friend who did mostly carpel tunnel release. He rarely had difficulty.

Before I scheduled my upcoming surgery I read a paper that followed one Fellow in a joint replacement program, I think at Stanford, as he was taught and then performed 3 sets of 100 anterior minimally invasive Total Hip Replacements. Very careful records were kept of complications, duration of surgeries, and total x-ray fluoroscopic time. He got better and faster over each period of 100 operations, and the biggest improvement was between the initial group and the second. And of course these surgeries were not coming once a month or so. Once he began they came hot and heavy till the study was completed. I wonder if we shouldn't all be enrolled in the same program, and big regional centers handle the very specialized studies and surgeries. Here is Seattle, all big trauma eventually finds its way to Harbor View Hospital, from all over Western Washington. My parents lived a few blocks from big city University affiliated general hospital, When I went to visit them the copters were flying over all day and night. Every large metro could have specialized centers, not only for emergencies, but also for breast surgery, non-emergency bowel surgery, etc.

Before I go up my nerve to have hip replacement I talked to as many people as I could. A surprising umber of people have had this surgery. Most, but not all, of those who are not happy had it done at smaller places, closer to home, by surgeons who could not have been as experienced as large medical center surgeons unless they had just retired from Houston or LA or some such. There is a palace in Santa Monica called the Hip and Pelvis Surgery Center. They don't even do knees!

Ha
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Old 11-09-2013, 01:10 PM   #11
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Here is something else that is going on United Healthcare dropping lots
of MA plan docs around the country.
Aetna decided to drop the wifes whole plan.
Seems to be making many people not real happy.

Old Mike
UnitedHealthcare drops 10-15 percent of its doctors in Medicare advantage plans | NJ.com
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Old 11-09-2013, 06:45 PM   #12
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Originally Posted by ziggy29 View Post
I had mostly good experiences with Kaiser when I was in California. Yes, you had to use Kaiser facilities and yes, sometimes it took a few weeks to get a routine appointment, but I did like the lack of an insurance bureaucracy (I lost Kaiser coverage in 2003; maybe it's changed since then but I don't know). And I liked that if a Kaiser doctor said a procedure or a prescription was medically necessary, it was covered -- no additional layer of insurance bureaucracy or claim forms. And when my wife needed maxillofacial surgery (probably about a $15K procedure including all aftercare), something many plans don't cover, the Kaiser surgeon decided it was medically necessary and all we paid was a $10 copay.

Just the same, I don't think I'd ever pick an HMO over a PPO again. Yes, they can be a little cheaper but the network can be much more limited, and you often have to go through a GP before you can be referred to a specialist.
+1

I am doing the whole ACA healthcare thingy now. I am a Kaiser HMO booster but now it is not an option because of where I live. I was considering an HMO because of this past experience. In this thread I realize that my HMO days are behind me. Imoldernu's experience definitely got my attention. One decision down, one thousand to go.
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