Going from PPO to HMO

[vettechick99]

I have UHC PPO through the state of GA. It's time for open enrollment and I was thinking of switching to HMO. The monthly premium is actually cheaper, and so are the deductibles. It seems as though it covers most everything 100%, including maternity care. Surgeries are only 80%, but so is my PPO (down from 90% last year).

I'm wondering what the catch is since it seems like a better deal for my family. I have looked up my doctors and they are all in the HMO network. So what am I missing?

 

[dumboiu]

So what am I missing?

In most cases, the flexibility to be able to go to a specialist without needing a referral, for one thing.

 

[manning]

The primary care doctor is the gate keeper. You have to have his/her permission to see specialists. And I think the insurance company too.

 

[vettechick99]

I kinda thought you always needed a referral so I've always asked for one. Are there any other big differences? Thanks!

 

[bicker]

I equate going from PPO to HMO to going from a stand-alone single-family home to a condominium or HOA; essentially, you're trading off some control in return for paying less, or having certain things covered in a certain way that wouldn't otherwise be covered or covered in the same way.

 

[smiley]

My family has belonged to Kaiser Permanente, an HMO for more than 25 years. We have never had any problems with them. Not all HMO's are equal so you should probably do your homework regarding the HMO you are considering.

It is true you do have to have a referral from your general practiioner to be seen by a specialist. Sometimes that can be a pain, especially when you know you need the specialist. You are allowed to choose your primary care doctor. The first time I went to see the gynecologist they set my appointment up with a nurse practitioner. Subsequent visits to my OBGYN were with an actual doctor, one I chose myself.

Immunizations and lab testing are readily available and if you go at the right time there are no lines.

Some of the criticisms I have heard are that the doctors get bonuses based on how much money they save the corporation. My doctor has referred me every time I have asked to be seen by a specialist. I have always received the care I believe I needed.

As you can see, an HMO worked out for my family and I. However, as I stated earlier, do your homework and you should be fine.

Good Luck.

 

[mikehn]

If you are a healthy family, then the tradeoff is a good one. So what if you need a referral to a specialist once or twice a year?

 

[Pigeon]

I would try to get opinions from people who have the HMO in which you are interested. Some are great and some are dreadful.

 

[Pakey]

I can only state, from my experience, that I would never choose an HMO over a PPO. 3 years ago, I found a lump in my breast. My doctor called several hospitals to get the quickest biopsy he could; an HMO would have meant waiting for an appointment at a participating hospital.

My family has always been healthy and never used our insurance but in the blink of an eye, that can all change. I had advanced stage breast cancer. I was able to get the best surgeon (in another city) and the best oncologist. My company offers both an HMO and PPO and neither of these specialists were on the HMO list of participating doctors.

Our of 200+ employees at my company, only 17 of us have elected to pay more to get the PPO so I realize I'm in the minority in my opinion. However, with such a serious illness, I am glad that I had control over the choices.

 

[golfgal]

I would try to get opinions from people who have the HMO in which you are interested. Some are great and some are dreadful.

What she said!!

The big difference with an HMO is that dr's are paid to keep costs down-to me that just doesn't make good medical sense when they order an x-ray vs an MRI because the x-ray costs less, but it also won't show as much.

 

[3boymthr]

What she said!!

The big difference with an HMO is that dr's are paid to keep costs down-to me that just doesn't make good medical sense when they order an x-ray vs an MRI because the x-ray costs less, but it also won't show as much.

Not necessarily true - especially now-a-days. It depends upon the % of drs who are capitated. Capitated drs. make more the less they send you for services and if they have to send you for services they make more if they send you for a less expensive service. Originally with HMOs 90% of Drs were on capitated arrangements. Now a days it is primarily "In-Center" HMOs like Kaiser or Mental Health providers who are capitated probably less than 25% of providers nationwide. On average for our employers' health plans the range is more like 5-10% of drs. are on a capitated arrangement.

To OP - double check the prescription drug formulary. Some HMOs have a more restrictive formulary than PPOs. By that I mean the prescription that you now pay as a brand drug may be come a select brand drug with a higher co-pay or they may have a step therapy program - this is becoming especially common with drugs like prilosec. (Can you tell I do this for a living??).

Other things to look for does the PPO plan offer chiropractic care - how about the HMO are there differences in limits.

In addition, many HMOs are adding Inpatient and outpatient co-payments which can be more end up being more costly than a global deductible, e.g., pay $500/admit with no annual maximum on number of hospital co-pays (so four hospital admissions in or out patient would cost $2,000) vs a global deductible of $1,000 for all services. Some HMO plans are also putting in a tertiary vs community hospital co-pay which means the hospital closest to you could end up costing you twice what the one halfway down the street costs.

ETA - we went from PPO to HMO about 7 years ago. I worked for an insurance company that offered us the world in plans for cheap money. I became a SAHM while the youngest were babies/toddlers. DH's co only offered an HMO - at first I was very concerned but really it was pretty painless, especially since all our drs were on the plan - nothing really changed for us but the name of the company on the card. Now that they are back in school I'm back at work but we still have the HMO and I wouldn't change.

 

[Rupert B Puppenstein]

You couldn't pay me to drop the PPO option. Especially because of the ability to choose whatever doctor you want, not being committed to one and being able to visit specialists whenever you want/need to. My view is that insurance is all about worst case scenario, and the PPO has exceeded my expectations. I was able to see a Neurologist without any issues that was outside of the network whereas with an HMO that wouldn't be an option. I would print out the sheet for the HMO and compare it with all the details of the PPO. You may be surprised how much a difference there is with coverage. I pay over $100 a paycheck just for myself ($200 a month) and it works for me. Also, another thing that could lower your insurance costs is not including your husband on your plan if his job has a plan available. Keeping it separate saves a ton of money usually as most companies/insurance companies penalize you for having someone on your insurance plan that works and has access to their own plan. Good Luck! It is a confusing time of year!

 

[DianeV]

We have an HMO called Health Alliance Plan and really like it. Many of the better doctors and hospitals participate anyway and they have always covered my kids physicals including their immunizations. We recently got higher copays but that was due to my husbands work. Have never had a problem with a specialist when we want to see one which hasnt been often.

We are able to pick an ob/gyn ourself and dermatologist too..which are some of the major routine specialists

 

[georgina]

You really need to check out the specific HMO you are interested in. Our HMO dropped the needing referrals to specialists years ago; I can see any specialist in the plan by calling and making an appt. There are A LOT of doctors in ours, and many hospitals. My family doctor was able to get me medication that was not on the approved list by explaining that it was the best one for my condition. I have had a couple of serious medical issues over the years and have been very happy with the way they were handled.

 

[sue1013]

I know with our PPO we can go to any hospital with the HMO only those in their network. This really makes a difference if your family has reason to go to a specialized hospital such as cancer, heart etc. I've had family members not get the best treatment because their HMO would not cover a better hospital.

 

[vettechick99]

It's United HealthCare HMO. All of our current doctors are covered under the plan, including the local hospitals. Thanks for all your advice!

 

[cruisnfamily]

In my experience the HMOs are really much better coverage at a cheaper price. Really loved it when I had one! The only caveat. You must follow their rules. With a ppo if you don't follow the rules or use the right doctor you'll get your bill paid at a lower rate. With HMOs you could find yourself out of luck with 0 payment if you didn't follow the rules.

So, bottom line, if you can follow their rules, it's great coverage!