Hi All, I need a serious explanation of the pros and cons of HMOs vs PPOs. A little background. I'm in an industry where I'm hired project to project. So I never get insurance from any of my employers. I'm also very healthy and have never needed anything once I got out of college. So I've been fine without any insurance. I also just hate running to the doctor for any little thing. I'm the type who will sweat it out and see how it is in the morning. My fiancee on the other hand is an alarmist. She'll want to go to the hospital if she sneezes. So what's the best plan for the both of us? Thanks
hmo is cheaper much cheaper, but it also depends on the state you live in. im in nj and for ushc for a family of 5 i pay 1100 per month. the ppo is a better ins because you can go to any dr without a referal. now some drs do not except hmo because the reimbursal rate sucks for them. sooo, if you ever had a major problem the dr you may want to see , may not except the hmo. either way the health ins prices suck and continue to raise every year. mine went up 46 percent in one year. its a disgrace. i want to add you should buy it if you dont have it. im very healthy but 3 yrs ago i got hit with melanoma, if i didnt have ins it would of cost me about 15 k for the surgery and dr visits. so its something to think about. good luck, J
IMHO neather are any good if the company you work for are self insured and dictates what the doctors can and cannot do.
PPO, you can pick your doctor, specialist, and don't have to bend over everytime you need a lab, etc. I am a doc, but I say this as a consumer. We had a practice policy that covered my family, and last year, we had an ill premature son, my wife had horrible delivery and bled for 2 months, and I perforated my intestine, had 3 surgeries, a colostomy x 4 months, and weeks in ICU. They paid most of it, 7 figures worth. They "didn't renew" the policy later, and I went out and bought much higher priced coverage with a PPO. Lots of pre-existing conditions now, but what choice do we have. FWIW
John, Thanks for the reply. I know I should get something as I'm not getting any younger. I don't quite understand when you mention that some doctors do not accept HMOs because the reimbursal rate sucks. My understanding was that with HMOs, you can only go to doctors that are already a part of the network. Is this not the case?
All depends on what you want. Answer these honestly. 1. Lowest cost premium - Yes HMO No - PPO 2. Greater choices for Doctors Yes - PPO - No HMO 3. Call you Dr. everytime before specialist Yes - HMO No PPO 4. Generally higher copays and deductibles Yes - PPO No - HMO 5. Lower cost hospital stay - Yes HMO - No - PPO 6. Annoying ass people who won't or can't answer your questions - EITHER 7. Emergency room visit without calling the Doctor for an ok? Yes PPO No HMO Personally, if cost is no object, PPO offers greater flexibility, at about a 20% or more additional premium. You also, I think, get a greater choice of doctors, and can go to specialists without pre-approval from your GP. If you're buying your own insurance, are young, healthy, don't need prescriptions and only see the doctor once a year, HMO is great. You're covered in a catastrophie scenario, and your monthly payments are lower. Use the doctor a lot, see a specialist or two, have a few monthly meds, wanna see a shrink, PPO is a better idea, lots less hassle when in need of something special, but you sure pay for it. BTW, I simply help to administer our plan for about 30 people. I am by no means an expert, but these are my observations. I am in the PPO at work, which I pay for. But I have a large family, my wife and I take several maintenance meds, and so a PPO makes sense. DM
correct, some drs do not accept hmo. i have a brother who is an oral surgeon, he does not take hmo. you can only go to drs that accept that ins.
If you're young and healthy and seldom need a dr, get the HMO. If you're not any of those things, get the PPO.
Dave, Thanks for the info. Is it easy to change from one plan to another? The reason I ask is that we are not planning on starting a family for a couple of years. I don't want to have to pay for maternity coverage if we aren't going to use it.
another interesting fact about hmo, hmo will only pay upto i think its 1 million for the life of the policy. so if your young and have health issues and start eating up the benefit, whats going to happen when your older. this happened to a friend of mine, diagnosed with brain cancer a few years ago, went through the entire benefit with surgerys and treatments, his family had to fight big time with ins co to continue to cover. health care is a total mess in this country !!!!!! and so many people dont have it due to the cost....
sfumato - sorry to hear about that. I had a similar issue years ago, but nothing to the extent you went through. However, due to the claims that were made, to renew or get "basic" insurance, well, the cheapest I could get at the time was $2300 a month. That's just rock bottom insurance. Later in college, I opted for the regular college plan for 149 a semester. Cheap. I've lived without insurance from time to time, but if you have a family and kids to take care of, I don't recommend it.
Usually there is an open enrollment period, maybe twice a year. At least here in PA with Blue Cross/Blue Shield's HMO. If you're taking employer coverage, it's only one a year at renewal time.
My fiancee is from overseas and she just can't understand why I don't have insurance. For them, it's a no brainer because it is taken care of mainly by the government. Now, when she sees the cost of health care here, she's shocked.
It is interesting that when your healthy you don't even think about what care you might need. I've had my eyes opened........... Just to add a little more info. There are HMOs that don't require a PCP (Primary care physician) referal to see a specialist. There are also some states that have HMO / PPO combos where you have Docs in the plan but you can go outside the plan and they only pay a %, like 80.
HMO PPO it doesn't matter. You get what you pay for. If you get a policy that doesn't cost much then you will have limited benefits. You need to look at what you want health insurance for. Some people get a health plan that pays for kids vaccines yearly physicals mammograms the ususal health maintance stuff. This stuff is not very expenssive so a lot of plans that don't cost much will offer them but if you get sick or need something expenssive they will deny deny deny. I had a guy com into my office last week with a lump in his breast. Breast cancer in ment is rare but does happen and The only way to prove if a lump is cancer is to biopsy it. His plan said that breast surgery on men was cosmetic and was't covered. I had to make several phone calls myself to get the biopsy paid for. The key is to read your contract very carefully to see what is covered and what isn't If you are self employed look into a medical savings account. They are like traditional insurance plans that pay for services without any BS. They have a deductable of $3000 to $5000. After that they pay. You also set up a checking account into which you contribute a certain amount each month. I think the total amount that you can put in is up to 80% of the deductable. This is your money. It is tax deducable. You use the checking account to pay for bills before the deductable is met. You choose how the money is used. If you are carefull with it you will build up cash. Since I have opened my account I have enough built up to fully pay the deductable for a couple of years. I cna use this money for any health related expense and the insurace will pay for services pretty much anywhere I want to go. Since the dectable is so high the premiums aren't bad. My plan for is about about $500 a month for my family and it includes the MSA contribution
