N1cky

We elected to take all our health benefits through hubby's work, now he's been made redundant though, we need to switch onto my employer's scheme.

We have the option of switching to Anthem PPO, United HMO, or Kaiser HMO.

As a family we rarely visit the doctors (I know this can change in an emergency,) in the 7 years we've lived here, I've only ever been to the doctors once, outside the normal annual physical so I can get my birth control. Daughter goes once a year for her physical, so she can take part in summer camp, and hubby has never been to the doctors, but did have to go to ER with chest pains once a few years ago.

It seems to me, paying a flat fee per visit, with no annual deductible would work best for us, so a HMO. However, I seem to remember hearing these plans aren't the best

I guess I don't really understand the difference between PPO and HMO plans, and googling it didn't really help me.

Thoughts??

Sally Redux

With PPO you can go to anyone in network without a referral but the premiums and co-pays are higher.

HMO is more like the NHS, you go to your primary care physician in the first instance and then get a referral if needed.

Kaiser has its own network.

We have HMO and it's all right.

There was a recent thread on it but I can't immediately locate it.

N1cky

I think the Kaiser thing would work fine for us. I don't really care who I see, and I should imagine if I ever need a referral it would be a doctor recommended thing anyway.

How does it work if there isn't a Kaiser facility nearby? For instance, my daughter is going into the High Sierra's for a week in July. Would we be bankrupt if they just took her to the nearest hospital, if she fell...?

Sally Redux

I don't know for sure, but I think in an emergency you can just go anywhere.

Noorah101

I have United PPO. For my husband and I, it works well. Neither of us go to the doctor more than once or maybe twice a year. The $20 copay is easy to afford. Prescriptions are affordable at $10 or $20 per prescription (I take cholesterol meds regularly and get them through a mail-order plan...hubby has had to take some antibiotics here and there, nothing regular). Hubby and I each have primary care physicians, and I have a foot doctor specialist that I go to once a year, no referral needed.

On a couple of occasions, hubby has needed to go to the ER, and we only paid $100 out of pocket for each of those trips. Our home address is in Arizona...but he went to the ER once in Los Angeles and once in Lake Tahoe.

Many years ago, I had an HMO plan, but I honestly can't tell the difference between that one and my current PPO plan! They both seem to work the same way, for whatever we use we make of it.

Rene

N1cky

ok, thanks

Thanks Rene. I can't see any real difference, and that's why I keep thinking I am missing something. The pay period costs for the HMO and PPO are very similar, $3 difference. But with PPO there is an annual deduction of $2k per person and none with HMO, and then 10% of costs after plan deduction, as opposed to a fixed rate with a max out of pocket on the HMO. I would have imagined the HMO would be more expensive given these terms.

jibsymalone

Here it is. It was one of mine. The main thing I got from this is that if you have regular doctors you wish to use, or a specific health care provider, you will need to make sure they will be in network for the HMO option. All of our are, and the HMO is the plan I am going with.

Noorah101

But the PPO plan also requires you to use in-network doctors. So that seems the same as HMO, to me...?

Rene

N1cky

Great, thank you.

From reading things this morning, I'm coming to the conclusion (but maybe wrong) that the choice of doctors in-network on a PPO plan can be far greater, than the choice of in-network on a HMO plan.

jibsymalone

The PPO i was looking at had different percentages for in network as opposed to out of network (from what I can recall) and the difference was pretty large, so while there is some kind of coverage allowance for out of network, to avoid the chance of huge bills you pretty much had to stay in network.

The one difference that people seem to quote is having you primary physician act as "gatekeeper" for all other services (specialists and the like) with the need of referral from them. On a PPO you can go straight to any specialist and bypass your primary physician.

jibsymalone

I think this may depend on the plan itself also. I think, from the research I did, I would have to really try hard to find a doctor that wasn't in-network with my HMO!

Uncle_Bob

Yep both plans have the concept of in network and out of network.
It is my understanding that you can go to any emergency room, even without any insurance.
But you have absolutely no choices regarding in network or out of network surgeons or doctors. You get the person that is on duty in that ER while you are being treated. If that doctor is out of network then you pay

I had a nightmare once about being unconscious in the ER and evil out of network doctors were coming around the ward writing on my chart at the end of my bed. When i woke, recovered and got the bill I saw $1000's in charges from out of network doctors that had "seen" me in the ER.

cranston

We have a HMO this year and that's what my GP (PCP) said to me.

The Doctor pointed out that with a HMO, its up to him if I need referring. So example, I may say my back hurts can I see a specialist and he could say no and refuse to refer me (based on his medical opinion). I either have to accept that or pay out of pocket. With a PPO I could just phone the specialist and go for an office visit.

Yes, Out-of-network ER...I just don't want to even think about it...

S Folinsky

Kaiser is not bad. If one gets sick outside of Kaiser's service area, they will cover. We used to be with Kaiser. When youngest in University, the Kaiser physicians were available but were 50 miles away. They did pay for the one hospitalization at the local non-Kaiser facility. However, Kaiser and the hospital got into a fight over the amount to be paid. We got collection notices from the hospital AND a letter from Kaiser instructing us NOT to pay -- they would take care of it. By and by, the problem went away.

A few years back we switched over to Cigna and then to Anthem. For a few years we had HMO coverage and have now switched over PPO to give us the option of going out of network. The co-pay is higher for out-of-network. The trick with Anthem is finding your Primary Care Physician [PCP].

Our Anthem coverage has an eyeglass benefit which Kaiser did not.

cranston

In Texas Blue Cross now has 2 HMO Networks. HMO Blue TX is their traditional HMO plan and I think only available via corporate plans. This has a huge number of providers.

However, since Jan 2014, they have another HMO network for us who bought on the Govt Exchange. This network, Blue Advantage HMO, is much smaller then their other network.

One state, two HMO networks from the same company....