HMO vs PPO ?

[Murf2]

Hey all Looks like we may have to go to a HMO in the ACA this year.

I've checked and both seem to have our doctors "in network" and cover our scripts about the same. We would realize approx $5K savings with the HMO, with much lower OOP max.

So, other than the limited network, what else should I look at?

I realize we would not be covered while away from home but are there any other catches I need to look out for.

On a side note, How do the HMO's save the provider money? Is it just the " out of network" savings?

The BCBS HMO seems to have most of the same providers in network as their discontinued PPO had. Maybe this is because we are a small rural market.

Any input would be welcome.

Murf

 

[Big_Hitter]

Way less flexibility with HMO. They usually have gatekeeper pcps which have to approve access for specialist care.

I've always gone with the PPO.

 

[ShokWaveRider]

We have a HMO this year, personally we found it no different from a PPO where we live as all the same doctors were on the plan. It was cheaper than a PPO too.

 

[skipro33]

You won't be able to self-refer to specialists. That will entail about 3 or 4 additional Dr. visits before you see the doc you need to see, as the PCP monkeys around and finally sends you to the specialist. Further delays as the HMO provider 'approves' the specialist referral. Same with lab work. Your PCP or the specialist you were approved to see wants an MRI for example. You wait again for the HMO provider to approve.

I know someone who can see their Dr. on a same-day phone call, even have surgery if it's required, follow-ups immediately, prescription handed out without having to go the the pharmacy and the cost is well under what the average Dr. visit costs. His name is Buttons and he's my dog. What a shame my pets have better and cheaper health care than I can get for myself.

 

[ShokWaveRider]

You won't be able to self-refer to specialists. That will entail about 3 or 4 additional Dr. visits before you see the doc you need to see, as the PCP monkeys around and finally sends you to the specialist. Further delays as the HMO provider 'approves' the specialist referral. Same with lab work. Your PCP or the specialist you were approved to see wants an MRI for example. You wait again for the HMO provider to approve.

I know someone who can see their Dr. on a same-day phone call, even have surgery if it's required, follow-ups immediately, prescription handed out without having to go the the pharmacy and the cost is well under what the average Dr. visit costs. His name is Buttons and he's my dog. What a shame my pets have better and cheaper health care than I can get for myself.

From Experience not hearsay, I never had the problem, Call the Docs Office asked for the Referral got it (Gastroenterologist in this example) No Visit needed, even if I had to go in it is a $2 copay problem!

Once you have the specialist in tow no further referrals are needed.

 

[skipro33]

From Experience not hearsay, I never had the problem, Call the Docs Office asked for the Referral got it (Gastroenterologist in this example) No Visit needed, even if I had to go in it is a $2 copay problem!

Once you have the specialist in tow no further referrals are needed.

My doc wanted to see me, $20 copay visit. Treat me with an antibiotic, $10 prescription copay. Followup 10 days later with another visit, $20 copay, referral to a specialist; 10 days wait for HMO approval. See specialist, $20 copay. Prescribe an MRI, wait for HMO approval, and $20 copay. Follow up appointment for MRI consult $20 copay. Try a different antibiotic, $10 prescription copay, another followup with the specialist, $20 copay and so on and so on until finally had outpatient surgery, followups, meds, etc.

All this for a cyst I should'a just lanced myself and treated with a disinfecting cream. Health care is a racket these days. Where's the old fashioned country doc any more who has common sense and knows how to practice medicine and not 'health care' HMO-style?

 

[ShokWaveRider]

My doc wanted to see me, $20 copay visit. Treat me with an antibiotic, $10 prescription copay. Followup 10 days later with another visit, $20 copay, referral to a specialist; 10 days wait for HMO approval. See specialist, $20 copay. Prescribe an MRI, wait for HMO approval, and $20 copay. Follow up appointment for MRI consult $20 copay. Try a different antibiotic, $10 prescription copay, another followup with the specialist, $20 copay and so on and so on until finally had outpatient surgery, followups, meds, etc.

All this for a cyst I should'a just lanced myself and treated with a disinfecting cream. Health care is a racket these days. Where's the old fashioned country doc any more who has common sense and knows how to practice medicine and not 'health care' HMO-style?

You need a new doctor...

 

[exnavynuke]

You need a new doctor...

I concur. Friend had a similar problem so he called up our telemedicine, got a referral, and was seen and treated outpatient the next day (probably would have been same day if he'd called in the morning). Everyone at my job pretty much switched over the the HDHP plan as the PPO was priced to be more expensive whether you used any medical services or not throughout the year, but hey, we got a "choice" lol.

 

[MRG]

DW had a HMO with little or no problem to get to specialist. That said we were in an urban area with an abundance of providers. YMMV

 

[DallasGuy]

I have a blood cancer called multiple myeloma and my oncologist told me that many times when you need expensive chemo or even a stem cell transplant (which I've had), it's more difficult to get that done through an HMO (because you have fewer choices and the reimbursements are lower for specialized treatments) and he told me not to get an HMO if I was faced with that decision. I'm sure some HMO's are better than others so just do your homework ahead of time to see what is covered. No one plans on getting a major illness like cancer...mine was found during a regular annual physical exam 4 years ago and was completely unexpected.

 

[template]

From Experience not hearsay, I never had the problem, Call the Docs Office asked for the Referral got it (Gastroenterologist in this example) No Visit needed...

Once you have the specialist in tow no further referrals are needed.

I have had a Blue Cross/Blue Shield HMO for the past several years with similar experience to yours, though I did not go through the government web site. The HMO experience has been very convenient.

YMMV with different medical groups. Choose your medical group wisely, grasshopper.

I will take original Medicare and a Blue Cross medigap insurance policy when I turn 65 soon.

 

[travelover]

............I know someone who can see their Dr. on a same-day phone call, even have surgery if it's required, follow-ups immediately, prescription handed out without having to go the the pharmacy and the cost is well under what the average Dr. visit costs. His name is Buttons and he's my dog. What a shame my pets have better and cheaper health care than I can get for myself.

It gets even better. When you are old and hurting and it is time to check out, the doc just gets out a needle.

 

[Texas Proud]

From Experience not hearsay, I never had the problem, Call the Docs Office asked for the Referral got it (Gastroenterologist in this example) No Visit needed, even if I had to go in it is a $2 copay problem!

Once you have the specialist in tow no further referrals are needed.

It is only a $2 problem for you.... for me, it is $45.... and I only get 2 at that price... I pay 100% after that, which is closer to $75 to $100....

 

[eytonxav]

Two years ago BCBSTX had good Dr and hospital choices, but all that changed for 2016 with very limited choices, so as far as I'm concerned, they both stink due to very narrow physician and hospital choices, aside from the deductibles and OOP costs. I imagine it will be no better and possibly worse choice wise in 2017.

 

[Bamaman]

A HMO may be okay for those with the sniffles. But if you have serious health issues, a HMO may not be for you.

We had Kaiser Permanente in Atlanta, and my wife had a serious GYN problem. She went to Kaiser time and time again to their in house OB-GYN's--over 5 years. Never did they agree to do any procedure or refer to another specialist that would get to the bottom of the problem.

I later had the choice to go to a conventional healthcare plan. One doctor visit and a procedure was scheduled. Bang, Bang--problem solved immediately.

This may be an isolated case. But my wife is a medical professional, and she worked the Kaiser Permanente system as good as it could be worked. And she couldn't get any action until we left their system.

We no longer would consider a HMO at our age unless there was no other option. PPO is a much better system--although we'd still rather have the old conventional healthcare insurance.

It makes us glad we're just old enough to be on Medicare with a supplement policy. We just hope politicians will leave Medicare alone and not think it's the new National Healthcare System.

 

[Another Reader]

Out here in the Bay Area, where Kaiser was born, it's been referred to as "the witch doctors" since at least the early 1960's. The HMO was a good way for the Kaiser family to obtain health care for their mostly blue collar workers when they started it. It was the expansion to UC and other employers that ruined a small medical plan and turned Kaiser into the juggernaut it is today.

I know of several cases where people were killed or medically compromised by Kaiser's incompetence or stubbornness. It will be a cold day in hell when I enter a Kaiser facility.

 

[bingybear]

I'm looking at 2 HMO plans. Both do not require referrals... how ever my family doc will do referrals anyway. $3k/year difference for the both of us. So which to take. The more expensive has my cardiologist, the least .. nope. I usually see him once a year and they read my pacemaker twice a year. So, is 3k extra worth it for one specialist?

Both HMO's do not require referrals or selection of a PCP. They do require being in network. My family doc will typically provide referrals without appointment. Within the day I sent a request about changing cardiologists due to insurance changes for next year provided her recommendations from the list of in network for next years plan. She will make the referral when I am ready.

Have a good PCP...

Some HMOs can be a bottle neck. Not all.

 

[Texas Proud]

I'm looking at 2 HMO plans. Both do not require referrals... how ever my family doc will do referrals anyway. $3k/year difference for the both of us. So which to take. The more expensive has my cardiologist, the least .. nope. I usually see him once a year and they read my pacemaker twice a year. So, is 3k extra worth it for one specialist?

Both HMO's do not require referrals or selection of a PCP. They do require being in network. My family doc will typically provide referrals without appointment. Within the day I sent a request about changing cardiologists due to insurance changes for next year provided her recommendations from the list of in network for next years plan. She will make the referral when I am ready.

Have a good PCP...

Some HMOs can be a bottle neck. Not all.

I would just ask your cardiologist what he would charge as a cash patient if you went to him.... I doubt it would be anywhere close to $3K....

So, take the HMO and pay out of pocket for the one or two visits with him...

 

[Another Reader]

I have an HMO policy from United Health Care serviced through Palo Alto Medical Foundation/Sutter Health. The difference is night and day in comparison to Kaiser. PAMF is not an HMO. It is a large assemblage of medical groups. The parent, Sutter Health, contracts with insurance companies that offer PPO and HMO policies.

I have not had a problem getting referrals to specialists or obtaining services and have had no problem getting them quickly.. Most of the doctors seem quite good. The one I thought was a disinterested lightweight was traded for another specialist in the group that was much more detailed and interested in solving the problem without any issues.

I had a procedure in the surgery center recently and the place was clean, the process was well organized, and the people were patient, detailed and efficient. Nothing like the Kaiser facilities I have seen over the years.

 

[NW-Bound]

I prefer PPO if I can get it. It is just not offered anymore.

This year, 2016, I had to go HMO for the first time. Seems to make no difference, as we need little healthcare. Next year, it is worse as we are down to only one insurer, and I just have to take what they provide.

 

[Murf2]

I don't understand some of the post. I have checked and all the specialists I saw while on a BCBS PPO are listed as providers on the BCBS HMO. Are you guys saying the will screw me around, even though they are providers?

 

[audreyh1]

ACA PPO plans are going away for us. HMO only, no HSA compatible plans either.

On or off exchange doesn't matter.

 

[FUEGO]

We went to Unitedhealthcare HMO (through ACA) this year after being on PPO w/ UHC for almost a decade through DW's employer plan. Nothing changed with our medical care other than the slight hassle of needing the primary care practice to set up a referral to a urologist (??) after the OBGYN noticed some funky test results at DW's routine annual exam (all is fine now thank goodness - false positive).

The only slight complication was that the OBGYN, while totally fine to use in addition to our designated primary care practice, couldn't do the referral to the specialist. So we had to call the PCP and get them in touch with the OB and the specialist (who already had the files and referral info from the OB) to set up the referral. One quick phone call to get the ball rolling and a second one to confirm the referral was in place (could have verified the referral online I found out later).

So a little bit more hoop jumping, but, hey, the insurance company and the medical industry is involved so what's a few more phone calls to get stuff sorted?

Otherwise, everything works like it always has. We pay the $20 or $40 copay and the 20% coinsurance once our $0 deductible is met (it's always met - isn't that pleasant?). Network appears pretty broad locally but sparse to non-existent nationwide (but emergency care is always covered as mandated by ACA). We traveled for several weeks this summer and skipped travel insurance.

 

[gardenfun]

Anthem Blue Cross here in CA will only offer EPO plans next year, at least for Bronze level. The rep told me the EPO plans were "kinda like HMO's" in that you HAVE to go to in-network providers, otherwise nothing is covered.

 

[exnavynuke]

I don't understand some of the post. I have checked and all the specialists I saw while on a BCBS PPO are listed as providers on the BCBS HMO. Are you guys saying the will screw me around, even though they are providers?

Neither I nor anyone I know have had any issues on our BCBSGA HMO. This includes a friend/coworker who went to get seen for arm pain and "firmness" and ended up seeing a PCP, 4 different cancer specialists, had 2 biopsies, and 1 surgery so far.

One nice thing is most of the hospitals around here (all maybe?) require all their doctors/anesthesiologists etc to be in the same networks.