Switching from PPO to HMO

[utrecht]

This year I spent my max OOP way back in May due to several serious disc issues in my back and neck. Ive had surgery on one disc, Ive had 3 separate steroid injections and have another scheduled in 2 weeks. Multiple MRIs, 17 physical therapy appts., etc. I still have more than my share of pain. I still have burning in my left arm, numbness and tingling in my right thigh and numbness in my left big toe.

All of that to ask this:

In Feb I will lose my employer health insurance and will have to switch to an HMO which is the only thing available at even close to a decent price in Florida. I will be seeing doctors for a long long time. Ive never switched plans or insurance companies in the middle of treatment before. Even though I have several doctors who have all of my records, will I still have to see a primary doctor on the new HMO to get a recommendation to see a specialist on this new HMO plan? Or can it be done thru my records?

I assume this pre-existing condition wont cause me any problems when getting my new insurance?

 

[MichaelB]

Even though I have several doctors who have all of my records, will I still have to see a primary doctor on the new HMO to get a recommendation to see a specialist on this new HMO plan? Or can it be done thru my records?

Yes. You will need a pre-approval for every visit. Also, the specialist needs to be in the HMO network.

I assume this pre-existing condition wont cause me any problems when getting my new insurance?

It won't bar you from getting new coverage, and your current condition will be covered in the new policy, if that's what you mean by problem. See here https://www.healthcare.gov/health-care-law-protections/pre-existing-conditions/

 

[utrecht]

What do you mean "pre approval for every visit"? I had an HMO years ago, I went to a primary doctor who referred me to a specialist (some joint problem years ago) and from that point on I just saw the specialist for that problem. I dont have to see the primary first for every followup with the specialist when its the same issue do I?

 

[MichaelB]

I suspect it most likely depends on the plan you choose. Open enrollment begins in another 3 weeks but BCBS Fl has already posted their policies and prices for 2016.

 

[ziggy29]

What do you mean "pre approval for every visit"? I had an HMO years ago, I went to a primary doctor who referred me to a specialist (some joint problem years ago) and from that point on I just saw the specialist for that problem. I dont have to see the primary first for every followup with the specialist when its the same issue do I?

I don't think it means for every *visit*, but every time you develop a new condition you have to use your PCP as the "gatekeeper" to the specialist in just about all HMOs I'm aware of. You don't need to keep seeing the PCP before every appointment with a specialist if there are multiple appointments for the same condition that led the PCP to refer you to the specialist.

 

[eytonxav]

I wonder how accommodating PCPs will be referral wise when they have an HMO looking over their shoulder. My DD will be in a similar situation since BCBSTX will drop her PPO plan next year.

 

[utrecht]

I wonder how accommodating PCPs will be referral wise when they have an HMO looking over their shoulder. My DD will be in a similar situation since BCBSTX will drop her PPO plan next year.

What do you mean by that? The primary doctor knows what they are signing up for when they join an HMO. Why would they have a problem making a referral to a specialist? Aren't they really coming out better being in an HMO? I will have to go to a primary doctor who will make money off of me just to make his referral when I would never go to him in the first place if I had a herniated disc, or allergies, or a strange lump that Im worried about.

 

[AllDone]

What do you mean by that? The primary doctor knows what they are signing up for when they join an HMO. Why would they have a problem making a referral to a specialist? Aren't they really coming out better being in an HMO? I will have to go to a primary doctor who will make money off of me just to make his referral when I would never go to him in the first place if I had a herniated disc, or allergies, or a strange lump that Im worried about.

The PCP doesn't "make money off" you for every visit. He or she is paid a set amount per month by the HMO whether or not you use any services. There is no additional amount per visit. If specialist care is required, your PCP authorizes a referral to a specialist for a course of treatment -- not each individual visit -- although there may be additional referrals for procedures, referrals to additional specialists, or referrals for prolonged care by the specialist. In all likelihood, these referrals will be handled automatically without any required intervention on your part. The PCP pays for the specialist care out of the monthly HMO payment.

If you don't need many services, then your PCP does "come out better", but if you need a bone marrow transplant, then your PCP pays for it and gets killed. HMOs transfer risk from the insurance company to the primary care group.

 

[Sunset]

We went with HMO this year, I call it Hopeless Medical Option.

Besides your PCP being reluctant to refer you, all specialists have to be in the group.

Plus look at the co-pays they are steep.

 

[utrecht]

We went with HMO this year, I call it Hopeless Medical Option.

Besides your PCP being reluctant to refer you, all specialists have to be in the group.

Plus look at the co-pays they are steep.

Its either an HMO for around $600 per month or a PPO for about $1100. Do the co-pays go towards the max OOP?

The particular plan Im looking at has no co-pays. It has a $6300 deductible and $6300 max OOP which I will surely hit next yr again.

The neurosurgeon I'm seeing now is also in this new plan.

 

[eytonxav]

What do you mean by that?

My concern is that the PCP may have financial incentive to disallow referrals or make the process very difficult.

The PCP doesn't "make money off" you for every visit. He or she is paid a set amount per month by the HMO whether or not you use any services. There is no additional amount per visit. If specialist care is required, your PCP authorizes a referral to a specialist for a course of treatment -- not each individual visit -- although there may be additional referrals for procedures, referrals to additional specialists, or referrals for prolonged care by the specialist. In all likelihood, these referrals will be handled automatically without any required intervention on your part. The PCP pays for the specialist care out of the monthly HMO payment.

If you don't need many services, then your PCP does "come out better", but if you need a bone marrow transplant, then your PCP pays for it and gets killed. HMOs transfer risk from the insurance company to the primary care group.

 

[MichaelB]

My concern is that the PCP may have financial incentive to disallow referrals or make the process very difficult.

A reasonable concern, given the recent history of some insurers. I'm not sure there is an easy way to find out if that is a problem, other than look for feedback from current policyholders. Kaiser in California seems to have a very good rep despite being an HMO, so there are notable exceptions.

 

[Texas Proud]

We just went through our PCP for the need of a specialist....

Got the form from BCBS and it had docs name etc... and IIRC something about units.... I asked the specialist's office and they said that we were approved for 10 visits to the specialist.... if we need more, we go back to the PCP (as far as I know).... but maybe the specialist can say they need to do more work and get approval without a PCP...

We will not find out as the problem we thought DW had was not a problem....

 

[Bamaman]

It sounds as if you specifically need to be referred to a real Pain Management Clinic. I'm talking about one that's run by an anesthesiologist that's had a fellowship in pain management. (DW has been going to them for 15 years.) They don't usually give steroid injections unless it's under fluroscope and under anesthesia. Series of 3 injections 1 month apart are the only way they really work. And they must be willing to dispense controlled substances under very strict rules so you can function in society without becoming a junkie. My wife would be an invalid without a carefully balanced number of medicines.

Our experience with Kaiser Permanente HMO (Atlanta) was mixed. They were very good to handle "the sniffles", however my wife's conditions required a bunch of specialists not on their staff. The salaried gatekeeper M.D.'s jobs were to keep you inside the HMO physician group--and they received pay incentives if they met certain budgetary goals and high patient ratings. When patients' phyiscal conditions get serious, their in house staff just did not have the quality of a superstar specialist M.D. in private practice.

Looking back, Kaiser's doctors and their in house OB-GYN overlooked a problem that tortured my wife year after year. After we switched to conventional healthcare coverage, the new OB-GYN immediately spotted the problem and took care of it in a 30 minute outpatient surgery. Her lifestyle improved immediately when her healthcare wasn't "budgeted."

If someone has really serious medical problems, they're going to receive far superior treatment outside of a HMO. You should explore all options.

 

[utrecht]

I have been referred to a pain management specialist who has started with the injections under the fluoroscope like you mentioned. I had one set last week in my lumbar area and I have another scheduled next eek in my neck. My lumbar feels better at least for now. Hopefully the next one on my neck stops the burning in my forearm.

I'm hoping for the best with the switch to the HM because all of the doctors Ive been going to are also in the HMO I'm looking at. Hopefully there wont be too much of an issue going forward since they will already have all of my records on file.

Ive had a bad back for 25 years but Ive always kept it under control with stretching, walking and medium to light exercise. I retired in Jan. Hurt my back in Feb and Ive been in debilitating pain my entire 9 month retirement so far. Im at the point where I really dont see the point in getting up in the morning....just to go thru the day sitting around watching TV in pain because I cant do just about anything else. Certainly not any of the active things I love to do.

I bought a Taylor guitar 2 weeks ago and decided to sign up for some lessons to get back into playing. The next day I had to cancel the lessons. The pain in my leg went thru the roof 20 mins later due to the slightly bent over position you are in when you play. No point in taking lessons if I cant practice very much. I thought playing guitar would be at least one thing I could do since I dont have to move around much.

 

[donheff]

. The PCP pays for the specialist care out of the monthly HMO payment.

If you don't need many services, then your PCP does "come out better", but if you need a bone marrow transplant, then your PCP pays for it and gets killed. HMOs transfer risk from the insurance company to the primary care group.

Wait. Can someone else knowledgeable about HMOs confirm this? So, if a PCP sees signs of a brain tumor and refers me to an oncologist, the PCP has to eat that specialist's costs? The PCP owns the entire budget for health care, not the HMO overall? So do some HMO PCPs become fabulously wealthy because they learn to game the system? That doesn't pass the smell test for me. Something is wrong with that picture.

 

[Gotadimple]

Wait. Can someone else knowledgeable about HMOs confirm this? So, if a PCP sees signs of a brain tumor and refers me to an oncologist, the PCP has to eat that specialist's costs? The PCP owns the entire budget for health care, not the HMO overall? So do some HMO PCPs become fabulously wealthy because they learn to game the system? That doesn't pass the smell test for me. Something is wrong with that picture.

No, that's not correct.

The PCP and the group he/she practices in receive a monthly payment from the carrier to cover the cost of care for a patient, and that care is specifically identified to the type of services a PCP performs.

The group also may receive a bonus payment from the carrier for demonstrating that they are (1) providing all the needed services based on protocols (i.e,. How many women of child-bearing age are signed up with your group? And of those, how many had Pap Smears?) AND (2) on the quality of care (it takes x visits to resolve y condition - your practice, however, is using x+3 visits to resolve y condition over the entire range of patients in your practice who had the same condition).

So it is not in their interest to withhold access to care to "line their own pocket."

The carrier still pays separately for covered specialist services (and they negotiate for what they pay for). However, in a large multi-specialty practice where they have both PCPs and Specialists, the practice may do some accounting where a part of the monthly stipend is allocated to the specialist (but the PCP is on salary, so it should matter). That's their issue, not the issue of the insurance carrier. However, it becomes a carrier issue when they do not measure up on quality of care results.

Hope that's clear,
Rita