Medical Insurance: PPO vs. HMO. Which is better?

[monarchsfan16]

I thought the referral requirement was done away with with the ACA? My doctor's office did tell me though that their specialists (big medical practice with primary care and specialists all under one roof) still require a doctor's order, despite insurance no longer requiring a referral.

I've had an HMO for years. It's been great. We've all needed to see specialists and they've covered some very major stuff with no hassle. But not all plans are created equal.

 

[sonnyjane]

I thought the referral requirement was done away with with the ACA? My doctor's office did tell me though that their specialists (big medical practice with primary care and specialists all under one roof) still require a doctor's order, despite insurance no longer requiring a referral.

Ehhh, I don't think so? At least not according to this: http://www.sharecare.com/health/hea...-a-policy-in-the-health-insurance-marketplace

 

[Lisa loves Pooh]

It's that time of year where I need to switch my medical plan to one available under the Affordable Care Act. I most likely will qualify for a subsidy, but through my insurance, the only plans available under the subsidies are the HMO ones. What's the difference really? What can I expect if I do go under an HMO plan? Any suggestions would be greatly appreciated.

With my PPO, referrals are not required.
I am fairly certain that HMOs require referrals.

I prefer to see a specialist when I know I need one without the red tape of an office visit with my PCP. Example: I broke my ankle in the spring and went to urgent care. I had to follow up with an Ortho for the permanent cast. No referral needed. Today--I finally made a chiropractic appt as I am overdue for a visit. They made sure I had PPO first because if it wasn't, I would have needed a referral.

I can go to pretty much any specialist without a specific "doctor's order aka referral". It is freeing.

None of my doctors on past HMO plans would do a referral without seeing me. As evidenced here, YMMV.

 

[Lisa loves Pooh]

HMO's by definition require referrals though.

Yep

OP would be well served to disregard all the posts about whether specialist referrals are needed. It really varies by plan so the specifics of the plans under his/her consideration are the realities to be concerned with.

You would do well to be aware of the law. Perhaps some doctors have work around a--but unless it is POS (point of service) HMO--a referral is required before a patient can see a specialist.
http://www.sharecare.com/health/hea...-a-policy-in-the-health-insurance-marketplace

This link says it as well--exceptions are emergency services and preventative gynecogical care.
http://healthcoverageguide.org/part...ions/#Health+Maintenance+Organizations+(HMOs)

In any case, when OP shops, this would be disclosed.

 

[Disneyland1084]

Thank you for all the responses.

 

[Lintasare]

You certainly would need a referral from the primary for a first-time visit to a specialist. However, follow-up visits to a specialist don't typically require another referral.

No all HMOs require referrals to see a specialist. I know mine doesn't and I know a couple others on this thread have said they don't need referrals either.

 

[Lintasare]

HMO's by definition require referrals though.

As others have pointed out it depends on the HMO and the benefits offered. I have an HMO and don't need a referral to see a specialist. I just have to pick an HMO contracted provider.

I can certainly get a referral from my PCP if I don't know who to go to. I picked my own dermatologist and my mom recommended my current GYN as she had worked in a hospital with him. However I did get a referral to a podiatrist from my PCP though and while his bedside manner could use some tweaking, he is an excellent doctor.

 

[CPT Tripss]

HMO's by definition require referrals though.

Not in NJ -

some plans have open access features in which members may obtain a wide range of specialist services within the HMO network without the necessity of a referral.

In recent years, HMOs have offered Point Of Service (POS) benefit plans. A POS plan allows a member to obtain healthcare services from network providers, or receive reimbursement, subject to the terms of the contract, from the HMO for medically necessary healthcare services obtained from providers outside the HMO network.

http://www.state.nj.us/dobi/division_insurance/managedcare/hmos.htm

Is NJ unique in this regard?

 

[CPT Tripss]

Yep



You would do well to be aware of the law. Perhaps some doctors have work around a--but unless it is POS (point of service) HMO--a referral is required before a patient can see a specialist.
http://www.sharecare.com/health/hea...-a-policy-in-the-health-insurance-marketplace

This link says it as well--exceptions are emergency services and preventative gynecogical care.
http://healthcoverageguide.org/part...ions/#Health+Maintenance+Organizations+(HMOs)

In any case, when OP shops, this would be disclosed.

What law?

 

[Handbag Lady]

I love my HMO. I get to go to Cedars-Sinai Hospital, prices are good, service is great. I've had the same doctor for over 10 years and for some things, I need a referral, others, I don't.

I wouldn't want to have a PPO and pay more. I don't need flexibility and there are enough specialists in my group, I can pick and choose. For example, I just didn't work well with the assigned dietician. I just asked for another one in her same practice.

 

[Happy Snowman]

I thought the referral requirement was done away with with the ACA? My doctor's office did tell me though that their specialists (big medical practice with primary care and specialists all under one roof) still require a doctor's order, despite insurance no longer requiring a referral.

I've had an HMO for years. It's been great. We've all needed to see specialists and they've covered some very major stuff with no hassle. But not all plans are created equal.

Maybe you are thinking about not needing a referral for Ob/Gyn care? That went away with the ACA.

There are HMO health insurance plans that generally have no out-of-network coverage, usually a pretty small network just in your area, that operate otherwise like a PPO, but you pay 100% out of pocket if you go out of network. Then there are HMO's that are a medical system, have their own doctors, clinics, hospitals. Those require referrals to specialists and you can only use their doctors/facilities. They are somewhat different. The ladder is what most people are talking about when they say they require the referrals, the former is what most people that don't need referrals have. The HMO system is flawed and why it's mostly gone away in most areas. The HMO health plans are dying as well, but you can still find some around. They are EXPENSIVE for companies to offer and after next year, I wouldn't expect to see many left.

 

[Lisa loves Pooh]

What law?

The ACA law the person I quoted was referencing.

 

[Lisa loves Pooh]

Not in NJ -

http://www.state.nj.us/dobi/division_insurance/managedcare/hmos.htm

Is NJ unique in this regard?

POS HMO is a separate distinction. It isn't an HMO. It is a POS HMO. Telling the OP that not all HMOs require a referral is misleading because they do. To avoid that, you need to specifically get a POS HMO which comes with its own caveats per the links provided.

 

[OurBigTrip]

HMO's by definition require referrals though.

Incorrect.

It may work that way in Minnesota, but it's not that way everywhere.

 

[Happy Snowman]

Incorrect.

It may work that way in Minnesota, but it's not that way everywhere.

Correct everywhere...if you are talking about a true HMO, which you are not...in any state

 

[OurBigTrip]

Correct everywhere...if you are talking about a true HMO, which you are not...in any state

Wrong again.

First, HMOs do not by definition require referrals.

An organization that provides comprehensive health care to voluntarily enrolled individuals and families in a particular geographic area by member physicians with limited referral to outside specialists and that is financed by fixed periodic payments determined in advance —called also health maintenance organization

http://www.merriam-webster.com/dictionary/hmo

Second, BCBS recognizes that not all HMOs require referrals for specialists.

But what if you need to see a specialist? For most, but not all, HMO plans you’ll need a referral from your primary care physician before you can see any other health care professional (except in an emergency). If your plan requires a referral and you don’t get one first, your insurance won’t cover the cost of your care.

http://www.bcbsm.com/index/health-i...hmo/how-do-referrals-work-in-my-hmo-plan.html

Other than most (not all) HMOs requiring referrals for specialist care, the biggest difference is that unless it's coordinated in advance, there will be NO payment if an out of network doctor is utilized.

 

[Lisa loves Pooh]

Wrong again.

First, HMOs do not by definition require referrals.



http://www.merriam-webster.com/dictionary/hmo

Second, BCBS recognizes that not all HMOs require referrals for specialists.



http://www.bcbsm.com/index/health-i...hmo/how-do-referrals-work-in-my-hmo-plan.html

Other than most (not all) HMOs requiring referrals for specialist care, the biggest difference is that unless it's coordinated in advance, there will be NO payment if an out of network doctor is utilized.

Dollars to donuts that the "not all" are the POS HMO plans...

They may not call it that, but without the ability to actually view plan langauge to see if the language meets the definition of a PSO HMO, that is hard to say.

Bottom line, someone needs to view individual plans to know for sure what they are getting and commonly, unless a POS HMO--no specialist without a referral.

I did notice that dermatologists always require a referral without any qualifier of most but not all plans. Also the language is confusing on this page that indicates that if the doctor doesn't have any of these titles, then a referral is required.

http://www.bcbsm.com/index/health-i...bout-primary-care-physicians-specialists.html

ETA: also, OP lives in Nevada. Which seems to have that POS plan that folks are talking about where referrals aren't necessary. http://www.healthplanofnevada.com/body.cfm?id=25

 

[Happy Snowman]

Wrong again.

First, HMOs do not by definition require referrals.



http://www.merriam-webster.com/dictionary/hmo

Second, BCBS recognizes that not all HMOs require referrals for specialists.



http://www.bcbsm.com/index/health-i...hmo/how-do-referrals-work-in-my-hmo-plan.html

Other than most (not all) HMOs requiring referrals for specialist care, the biggest difference is that unless it's coordinated in advance, there will be NO payment if an out of network doctor is utilized.

See, wrong again, the BCBS quote is talking about a POS HMO health insurance plan, not a Health Maintenance Organization.

 

[OurBigTrip]

See, wrong again, the BCBS quote is talking about a POS HMO health insurance plan, not a Health Maintenance Organization.

And you know that how? Nowhere on that page does it mention POS or point-of-service.

Face it, you're wrong. Not all HMOs require referrals for specialists.

 

[Happy Snowman]

And you know that how? Nowhere on that page does it mention POS or point-of-service.

Face it, you're wrong. Not all HMOs require referrals for specialists.

That is the point you are missing--a POS HMO is a health insurance plan, like a PPO. It has a small network and generally do not require referrals but also rarely have out of network coverage except for emergencies. It is NOT an HMO.

A Health Maintenance Organization, HMO, is a health system, like Kaiser, which you are a member of the HMO, your declare a primary care physician, that person coordinates all of your care--meaning they REFER you to specialists. Without that referral you can't see that specialist unless you want to pay 100% out of pocket. Your "insurance plan" is the same name as the HMO--Kaiser is your "insurance plan" and you go to a Kaiser Clinic. If you go to say the U of CA clinic, you will be paying out of pocket.

Face it, you are just wrong---or talking about two different things, which you do not understand the difference....the BC/BS quote is not talking about a POS HMO because it is just what their plan is called. BC/BS is not an HMO.