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View Full Version : Let's talk Healthcare benefits: HMO or PPO?


Duh Vuh Duh
03-27-07, 01:02 PM
I've had an HMO for the past couple of years, but recently went to a benefits presentation where they explained a bit of a PPO plan and it sounded pretty good.

I'll be re-enrolling in a benefits plan again in about a month or so and am trying to decide if I should switch plans. I rarely go to the doctor, I think the last time I really needed anything medically was when I broke my ankle playing hockey about 2 years ago.

So, I just wanted to see if the Otters had any advice, good/bad experiences, opinions, etc. on either of the two different plans.

Bushdog
03-27-07, 01:08 PM
PPO --> More flexibility at a higher price. Ask yourself if you are going to use your healthcare much and if, say, you want to go to specialists as you choose as opposed to having to wait for permission from a PCP.

Also compare things like deductible, etc...

I've had both and prefer PPO's.

4KRG
03-27-07, 01:09 PM
I had an Aetna PPO for years and then switched to Kaiser last year when the Aetna rates doubled.

I was pretty scared to switch to Kaiser with all the horror stories I had heard, but I guess it is just like anything else - YMMV.

I really like Kaiser. They seem to do a better job than any of the Aetna PPO doctors I had over the years. I have a wife and two kids, so we seek medical attention fairly often for the kids. One has Asthma and the other has had some strange issues as well.

I would say that you have to research the specific doctors and not just the plan.

FantasticVSDoom
03-27-07, 01:47 PM
It depends a lot on your health situation... Everyone says HMO's are bad, but if you are young and pretty healthy, they can be a good lower cost alternative. Look at your health needs and determine what fits your needs the best. Sometimes one may have lower prescription drugs for example, and that might be a better option for you than the one that gives free pap smears. I have really good insurance now that's a mix of both and works well for me, but in the past I have preferred PPOs for the freedom of not having to get referrals all the time.

Septemberbaby
03-27-07, 01:55 PM
Had HMO in the past... my kids were little so we were at the Dr. office once a month so, it worked out well for us.
We now have PPO for the last 3 yrs or so .. and so far so good. I do like the freedom of not having to get a referral every time we went to go to a specialist.

al_bundy
03-27-07, 01:56 PM
PPO is self insurance where the company pays the insurance company the actuall costs of care plus a management fee

in NYC the big one is Blue Cross/Blue Shield. Their PPO network generally has the best doctors here because their negotiated fees are high. But there are HMO type plans here that also have the top notch doctors in their network

melbatoast
03-27-07, 02:15 PM
PPO --> More flexibility at a higher price. Ask yourself if you are going to use your healthcare much and if, say, you want to go to specialists as you choose as opposed to having to wait for permission from a PCP.

Also compare things like deductible, etc...

I've had both and prefer PPO's.

Exactly.

I have a PPO now am prefer it just for the flexibility. Pricing sucks though.

Sdallnct
03-27-07, 02:33 PM
Keep in mind that PPO is generally a form of group that tries to take advantage of the cost savings of a HMO. Sort of a hybrid of the two.

Generally, if you go to the Dr. a lot or have small kids (which almost always go to the Dr. a lot) HMO has some benefit. If you rarely go to the Dr. don't have kids and are only worried about larger events, the Group/PPO may be the way to go.

I have gone with all three Group/PPO/HMO in the past. Now I'm on the 2nd year of a new system that is sort of a Group/PPO with a very, very high deductible but has it's own savings plan (that can be used for the deductibe/co-pays/etc) that rolls over each year if not used.

IMHO, the single most important thing about medical is NOT which plan, but that you learn about whatever plan you have. I have had excellent service with all but on one issue, and as it turned out it was a misunderstanding on my part. Whatever you get you should really review and read. Know what is covered and how. What is not covered. Choices, etc.

pyro383
03-28-07, 10:46 AM
how about a HSA or HRA, they should save you more money if you rarely go to the doctos.

RunBandoRun
03-28-07, 10:52 AM
Depends on your situation. As others have noted, if you are young and healthy, you could "gamble" with your health coverage a bit and choose the HMO. Also, if you have small children and are constantly at the doctor's, an HMO is a good choice because of the lower out-of-pocket costs.

I am in my forties with a couple of chronic health conditions which require me to be on medications forever, so I am better off with a PPO or traditional plan.

Your needs are dependent on your situation. Personally I hate HMOs. I would rather choose my own doctors. But that's because I see them at least three times a year. :lol:

PopcornTreeCt
03-28-07, 10:52 AM
I think HMOs are great. The cost is low and when you do have to go to the doctor you only pay co-pays. IMO, the other ones are ripoffs much like car insurance. You pay money out of every paycheck and STILL have to pay a deductible. And referrals consist of one phone call, I don't know why that would be a big deal. I have an EPO which is basically an HMO without need referrals or a primary care physician.

RunBandoRun
03-28-07, 10:56 AM
I think HMOs are great. The cost is low and when you do have to go to the doctor you only pay co-pays. IMO, the other ones are ripoffs much like car insurance. You pay money out of every paycheck and STILL have to pay a deductible. And referrals consist of one phone call, I don't know why that would be a big deal. I have an EPO which is basically an HMO without need referrals or a primary care physician.

HMOs ARE great ... for relatively healthy people who don't need to see specialists more than every now and then. But for people who have chronic medical conditions, they are not so great because their primary function is to save money, which is not always compatible with good medical care.

NotThatGuy
03-28-07, 10:58 AM
Up until a few years ago, I had only ever had PPO's (100% paid by employers, so it was a no brainer). I had an HMO for awhile since, it BLOOOOOOOOOOOOWS! Some may be better, but if you can afford it, go PPO.

-p

Deftones
03-28-07, 10:59 AM
I'll gladly pay a little more to be in a PPO. The ability to choose and keep my same doctor is worth it, in of itself.

Sdallnct
03-28-07, 11:03 AM
Depends on your situation. As others have noted, if you are young and healthy, you could "gamble" with your health coverage a bit and choose the HMO. Also, if you have small children and are constantly at the doctor's, an HMO is a good choice because of the lower out-of-pocket costs.

I am in my forties with a couple of chronic health conditions which require me to be on medications forever, so I am better off with a PPO or traditional plan.

Your needs are dependent on your situation. Personally I hate HMOs. I would rather choose my own doctors. But that's because I see them at least three times a year. :lol:

I'm not sure why it would be a "gamble" to have an HMO.

And while a HMO is a network of Dr's. don't dismiss that without during some research. When my wife and I first got married we had straight group. When our first child was born we were amazed at the out of pocket expenses, so we talked about switch on an HMO but were of course worried about having to switch doctors which we loved. Low and behold both my wifes Dr. our new borns Dr. and my Dr. were all on the HMO network. We switched to the HMO and literally saved thousands of $$ when we had our 2nd child under the HMO. Same Dr's, same hospital, same care.

Any when my son broke three fingers there was no child, hand specialist in our zip code. So they looked in several areas and we ended up going to a Dr. who worked on the local professional sports team. This guy was awesome. I LOVED the HMO, it was awesome. For us it was better service and cheaper.

Remember a PPO plan is similar. To gain the savings of the PPO plan you must use their "network" Dr's and such.

When we moved we decided to give this new plan a try. I believe it is a HRA plan. The first year we saved a little money overall, tho we did spend all the money in the account so we had a few things that were 100% paid out of pocket. But with the reduced premiums we did come out better overall. This year we have not had any issue's, so I'm kind of hoping we get to roll over some of that money to next year!

RunBandoRun
03-28-07, 11:14 AM
I'm not sure why it would be a "gamble" to have an HMO.


You gamble that you won't develop a raging carcinoma or have a catastrophic injury or something else in which your care will be "managed."

al_bundy
03-28-07, 11:20 AM
You gamble that you won't develop a raging carcinoma or have a catastrophic injury or something else in which your care will be "managed."

depends more on the insurance company and your plan more than anything else

not like PPO's will pay for anything just because you ask for it

leest3
03-28-07, 11:22 AM
I have Oxford. Does anyone know if that is an HMO or a PPO or something else?

das Monkey
03-28-07, 11:24 AM
I use a POS, which is essentially a combination of HMO and PPO. If I stay in-network, nearly everything is covered. I have no deductable and 100% coinsurance. If I leave the network (which is completely up to me), then I pay a hefty premium (a deductable and only 70% coinsurance). Really, the only drawback to POS is that it can be a pain in the ass to get referrals for specialists. But it's not <i>that</i> big a deal. If you have 8 kids or are a hypochondriac, this could get rough, but if you only see a specialist in rare cases where something really bad happens, then it's a great plan. My copays may be a tad higher than average, but I don't see the doctor or get drugs often, so I don't really care. Insurance should be about protecting you from the big things.

Example: I tore my ACL on a Wednesday night. Because I was POS, I had to see my PCP to confirm it on Thursday. He then referred me to a specialist, whom I saw on Friday. Under another plan, I could have seen a specialist a day earlier. That was the drawback. The advantage: outside of nominal copays for the office visits and PT, everything else is covered, which for the MRI and surgery is in the neighborhood of $20k-$30k. Even with a good 90/70 PPO, that's a lot of money.

Of course, all of this depends on how good your network is, and how comfortable you feel about your PCP. My PCP's a good doctor, and an excellent nearby hospital is in my network, so it's an easy choice for me.

das

Bushdog
03-28-07, 11:24 AM
depends more on the insurance company and your plan more than anything else

not like PPO's will pay for anything just because you ask for itThere's typically more flexibility though in you trying to make your own decisions as opposed to plan managers making those decisions.

But I agree, the company is likely more important than the type of plan.

al_bundy
03-28-07, 11:26 AM
I have Oxford. Does anyone know if that is an HMO or a PPO or something else?

my wife has worked in medicine for years and hates oxford because she says they don't have the good doctors

http://nymag.com/bestdoctors/

this is the list she uses

probably an HMO, but all the companies offer HMO, PPO and POS plans to the market and your employer buys whatever they want.

cdollaz
03-28-07, 11:39 AM
I gladly pay a little more for a PPO.

bhk
03-28-07, 11:43 AM
Any HMO will pay for standard treatments for known conditions. It might take the treating doctor to call the HMO physician to do so but they do pay for it. For experimental or non-FDA approved treatment though, it is hard to get the HMO to pay.
That's been my experience anyways.

leest3
03-28-07, 11:49 AM
my wife has worked in medicine for years and hates oxford because she says they don't have the good doctors

http://nymag.com/bestdoctors/

this is the list she uses

probably an HMO, but all the companies offer HMO, PPO and POS plans to the market and your employer buys whatever they want.
Yeah I don't like them much either. It's either oxford, or an insurance plan my employer offers themself. I hate the referrals things. One time I had a broken hand, and went to a doctor, I had to call my general physician and get a referral, meanwhile I had to wait, it was pretty obvious my hand was broken, why the need for a dam referral.

Sdallnct
03-28-07, 11:56 AM
You gamble that you won't develop a raging carcinoma or have a catastrophic injury or something else in which your care will be "managed."

See I actually had the opposite issue. My Group/PPO really gave me and my wife problems with the birth of our first child. About two weeks before delivery our Dr. made her check into the hospital due to her high blood pressure. When I called our group "consultant" they told me to immediantly check out of the hospital. I offered to have the Dr. talk to them and all and they basically didn't care. Per "their guidelines" there was no need for my wife to be in the hospital. After about a week our Dr. felt comfortable letting my wife go home. I had to fight for six months to get my group to pay for that week in the hospital. And with my deducible and co-insurance it wasn't like I was free and clear with no expenses. That year cost me several thousand dollars out of my pocket.

Despite what the titles imply, all health insurance plans have some sort of "managed" portion. None of them pay 100% for every single thing that could ever happen. As someone mentioned, it is more about the company then the plan.

Bushdog
03-28-07, 12:15 PM
I'm getting a new plan in May, no deductible or co-insurance for a PPO. YMMV.