HMO or PPO?
 

Hi all!

I did a little searching in the forums but did not get the answers I was really looking for.

It looks like I may be switching companies in the very near future. Right now my medical insurance is through the Union and is more a medical fund, with one big pot everyone pays into. It is a PPO setup so no need for referrals etc. I have never had to pick plans before because of this, My new employer offers two options, a PPO and a HMO. Both are through Cigna it appears. The PPO has a lower monthly premium (only by about $20) but a higher out of pocket maximum ($3700/$7400 vs $2400/$4800). We are looking to hopefully start trying for another baby in the near future so, due to this the HMO seems like it would be the better option? I gather HMO's are far more limiting and this is what has me concerned. I am about to start checking to see if our present doctors accept this HMO plan, if so I will probably go this route. Does anyone have any insight as to the for or against for each?

I hate that this is all so complicated and confusing here!

Re: HMO or PPO?
 

I would never (never say never) do an HMO. I want the option to be able to choose to go where I want when I want. Our neighbors have Group Health (although the husband calls it Group Death) and they've had numerous problems.

Re: HMO or PPO?
 

This is the reason I am questioning going with the HMO option. I like choice too! All completely new to me though!

Re: HMO or PPO?
 

I suppose with an HMO you have the luxury of paying just a co-pay to see the doctor, right? Or have things changed there?

We also have Cigna, but our only option was the PPO. Even though our deductible is fairly high ($2500) we do have an HSA attached and my husband's employer contributes to that (as does my husband) so that doctor appointments, prescriptions, etc come out of that fund.

Re: HMO or PPO?
 

It appears that the co-pays are the same on each plan for in-network outpatient Services (Primary Care Provider), Specialist Office Visit, Preventative Care, Urgent Care and ER?

Our co-insurance is 10% difference in favor of the HMO

Re: HMO or PPO?
 

What about out-of-network? Is the PPO nationwide for in-network? What if you are out of your area on the HMO?

Re: HMO or PPO?
 

Have a look around the local area you're in and see how many healthcare providers are in network for Cigna.

I have an HMO with United Healthcare, but almost every doctor's office and hospital in our local area is in the United Healthcare network, so not an issue, I have literally hundreds of doctors offices to choose from. So in that sense it made sense for us, as the co-pays were less and the premiums were a little less expensive.

If we go on holiday somewhere (not likely this year, we're not made of money) I'd spend a lot of the time worrying that if something did happen, we'd be using an out-of-network provider and paying through the neck as a result.

Re: HMO or PPO?
 

I am assuming so, as my employer is based (HQ) in a different state to me? I will make a call and verify I guess. There is a list of providers online I will check also.

As for the HMO, no coverage amounts are listed there, so I am presuming I am on my own if I cannot find anyone in network while out of town?

Re: HMO or PPO?
 

It appears to be the same here, a lot of our existing doctors are in-network. I also have the concerns if i were to travel anywhere.

What I would give for a single payer system!! No need for all this BS!!

Re: HMO or PPO?
 

Hush now, that's socialism. :frown:

Re: HMO or PPO?
 

It's also Medicare but some people chose a HMO through "Medicare Advantage" because they prefer being billed by private insurance companies than the government.

Re: HMO or PPO?
 

Depends on the plan and location.

If you don't have much choice for doctors and hospitals, it might not be as good, but if you're in a city, it probably won't make much difference.

Sure, you'll need a referral for stuff, but if your doctor isn't a arse, it won't be a problem.

If I need a referral I can just ring my doctor and they'll fax one to who I want to see and the insurance company so there's no actual visit/co-pay.

It's not been any different to the old PPO.

Also apart from co-pay, no up front costs.

Edit: To add, for us, there's a option on network, the cheap one is limited to local vicinity for in-network. There's a option for state/region wide network or nationwide/international network.

Re: HMO or PPO?
 

PPO: gives more choice but one can spend a lot of time dealing with claims etc. I found the hassle factor to be quite a burden.

HMO: much easier but less choice. However, that doesn't mean no-choice. The better HMO's have very large networks and can be reasonably accommodating with your preferences.

We have the choice of plans and have remained with the HMO option. We're pretty satisfied, at least with our provider/network.

Of course, neither system is perfect and you'll find horror stories from HMO members as well as PPO members.

Re: HMO or PPO?
 

We didn't find that to be the case with our options. Same hospitals, same doctors.

Only difference was with PPO, you could go straight off and then had to deal with claims whilst with the HMO, you had to ring your PCP first to get a referral.

Re: HMO or PPO?
 

Ok, it looks like the HMO might be the better option. The co-insurance is 10% less, so if something major were to happen my exposure is limited, plus the out-of-pocket is a lot less. All our current physicians are all in network, so no issues there. As far as being out of town / travelling and something happens I was told as long as I contact my primary care physician within 24 hrs it will also be covered even though out of network.

Does this sound right?
This is coming from their (prospective employer) HR department.

Re: HMO or PPO?
 

HMO is OK I think. People love to brag and show off about their specialists (as I keep saying), but nothing I've heard has convinced me they're actually getting better treatment. You just have to go through a primary care physician to access one. In my view, means they're less likely to be a charlatan.

Re: HMO or PPO?
 

This does sound right. I have always had HMO plans and I love them. Like others have said I think it may depend a bit on your area - our HMO's have always allowed us to access a few different extremely large networks. One was UCSD and now we are with Kaiser and they are huge in Southern California.

I had a baby on our HMO and the care was brilliant with very little out of pocket to me (We have a 0 deductable HMO so only pay co-pays). My out of pocket cost for the whole pregnancy, post natal care and delivery was only $400.

If we travel and something happens I just need to notify my PCP within 24 hours.

Re: HMO or PPO?
 

On my PPO i love being able to pull up a list of local specialists, choose which one i want and to go directly to the specialist if i so wish. Get treated ASAP and get back to work, minimal time off work sick.

Contrast that with having to make an appointment to see my PCP, wait for appointment. Request a referral, wait 5-10 days for approval to be approved and then eventually go to the specialist. An additional amount of time spent off work sick while waiting for a procedure.

I'm not saying it is better treatment from medical viewpoint but it is a better treatment in terms of time frame. Getting me well and back to work in less time. But maybe being off work is not a concern for some, maybe even desirable?

I do not understand how you arrive at a specialists office is related to how "charlatan" they are likely to be.

Initially I had an HMO and got a referral to an ENT specialist. When later on a PPO i choose to use that very same ENT specialist. Same with a dermatologist.

Don't take this as bragging or showing off, I'm making a choice on what is best for myself and my family. And if people are asking about the difference between an HMO and PPO this type of response is totally relevant.

Re: HMO or PPO?
 

Fair enough :confused:

Re: HMO or PPO?
 

I am on an HMO plan and I can usually get a referral faxed over the same day.

I'd be pretty upset if I was off work for 2 weeks waiting for paperwork. But that has never been the case.

Re: HMO or PPO?
 

This covers even out of network?

How are you supposed to let the PCP know within 24 hours if, say, this happens on a Saturday evening?

Re: HMO or PPO?
 

Yeah, i am the same. If i want to see a specialist i just email my doctor's office. Only done this twice, never been refused and been seen the same day.

The main problem is not with the specialists, but actually getting an appt with the primary care physician. It takes a while if you want to see your assigned doctor, rather than who is available.

Bu tI heard that is the same for most primary care places, even with PPOs

Re: HMO or PPO?
 

Seriously, get to know more than one.

My PCP's office has two Docs. I know both and am happy to see either. The pediatricians office has nine Docs but with 3 kids and 10 years, I'm met all of them! No problem getting in to see one that I know and feel comfortable with.

Re: HMO or PPO?
 

That's not my experience at all.

I find who I want, I ring my PCP, he faxes referral to doc/insurance and jobs done.

I've never actually had to go see him for a referral.

So again, it's all got to do with your own insurance plan.

A PPO can be just as crap if they are limited on in-network.

All about the details, rather than which is a better system or not.

Re: HMO or PPO?
 

why confused?

Re: HMO or PPO?
 

Well lucky for you, you big show off, bragging about your HMO PCP. Shame on you :D

Re: HMO or PPO?
 

Didn't really understand why you were directing a tirade at me - surely each person will just offer their own thoughts/experience.

Re: HMO or PPO?
 

I know, how dare I not want to go see my doctor :lol:

Re: HMO or PPO?
 

The only thing I can add is something my insurance agent told me, this applies in Texas and may apply in Florida.

Basically the states that haven't had a strong managed care (HMO) culture Pre-ACA are not as up-to-speed as some other states. So, somewhere like California or Massachusettes, will have better networks with more participating physicians and hospitals than somewhere like Texas which, up to now, has been resistant to HMOs in general. Hopefully this will change but, since the ACA is so new, the networks are very thin.

Re: HMO or PPO?
 

Ah ok! Thank you!

Re: HMO or PPO?
 

Do you have doctors that you like and wish to keep? Or are you okay with changing doctors if they aren't on your new plan?

1) If you are already established with your doctors, and don't wish to change, then I would call each one of them and ask if they accept the Cigna HMO that you are considering signing up for. Don't go by the provider directory exclusively --- they are not always up to date.

2) If you aren't attached to any specific doctors then I would look at the logistics of the HMO provider network. Are the in-network hospitals, labs, etc, reasonably close to your home? Since you are thinking about having a baby, is there an OBGYN convenient to where you (and spouse) live and work. Call them and get a feel for them. Are they taking new patients? Do they have a long wait time for new patients?

Do research on stuff like that and you should be okay.

Re: HMO or PPO?
 

I did check the Cigna site, and every doctor we use is said to have coverage. I will get the OH to call around tomorrow to make sure. Thanks again!

Re: HMO or PPO?
 

Sorry, just reread and saw that you were looking into whether the doctors are in network. I would still check out the labs, hospitals, and other facilities.

I think the HMO is the way to go financially but there are things that can come up later that can cause problems or at least inconvenience.

Re: HMO or PPO?
 

Yeah, for peace of mind if nothing else. Anecdotally, I was talking over the weekend with a friend whose mother lives in Florida (not sure exactly where) and they picked an HMO specifically because her oncologist was in-network --- he was listed on the website as in-network. In this case it was Blue Cross. When she called to give the doctor's office the new insurance they were informed that he was no longer on that plan because of some sort of "realignment" within the practice. :blink: Anyhoo, they quickly changed plans and everything worked out okay but it was a PITA.