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

[OurBigTrip]

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.

So, you know more about BCBS plans than BCBS does? Because the link I posted is listed under "HMO" on the main page, and PPO is a separate page. Why would they list PPO information on the HMO page?

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.

Absolutely untrue - but I guess that since you think you know more about BCBS than BCBS does, it isn't surprising that you would be wrong about this too.

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.

BCBS offers HMOs in many, many states. BCBS isn't talking about an HMO, even though they say they are talking about an HMO?

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But you're right - I shouldn't believe my lyin' eyes!

 

[Happy Snowman]

clarification--BCBS isn't MENTIONING the POS HMO because it is a health insurance PLAN and those that understand the distinction, don't need to have POS there.

Again, there is a distinction that you are missing and I don't know how to get you to understand that...how many BCBS clinics have you ever seen anywhere???

 

[OurBigTrip]

clarification--BCBS isn't MENTIONING the POS HMO because it is a health insurance PLAN and those that understand the distinction, don't need to have POS there.

Again, there is a distinction that you are missing and I don't know how to get you to understand that...how many BCBS clinics have you ever seen anywhere???

I can only assume that you haven't actually read the link, at as it specifically says "HMO" and explains what an HMO is.

You seem to believe that to be an HMO, all doctors must be employees of an HMO company, and that all clinics must be owned by the same company, like Kaiser does. But that is incorrect. Doctors and clinics don't have to be employees of the organization, they can be contracted by the organization, which is what happens with the BCBS HMO plans, Aetna HMO plans, etc. Even Kaiser contracts with non-Kaiser doctors and hospitals to provide care to their subscribers.

You're insisting on sticking with a decades-old definition that is no longer valid. You're free to do so, of course, but the health care industry doesn't, and hasn't for years.

 

[Lisa loves Pooh]

So, you know more about BCBS plans than BCBS does? Because the link I posted is listed under "HMO" on the main page, and PPO is a separate page. Why would they list PPO information on the HMO page?



Absolutely untrue - but I guess that since you think you know more about BCBS than BCBS does, it isn't surprising that you would be wrong about this too.



BCBS offers HMOs in many, many states. BCBS isn't talking about an HMO, even though they say they are talking about an HMO?



But you're right - I shouldn't believe my lyin' eyes!

I would be curious of the language of the "HMO that does not require referrals" is similar for the language describing a POS HMO.

I don't pretend to know more than BCBS---but national insurance definitions indicate that those HMOs that remove the referral requirements are point of service plans.

The generic website doesn't indicate this distinction as it is a marketing tool to get you to look at their plans.

What does a literal HMO plan that allows no referrals actually say regarding choice of specialists. I am curious.

Additionally--your argument over plans available in the State of Michigan does not really mean much to the OP whose state has the POS plans being discussed.

 

[Lisa loves Pooh]

I can only assume that you haven't actually read the link, at as it specifically says "HMO" and explains what an HMO is.

You seem to believe that to be an HMO, all doctors must be employees of an HMO company, and that all clinics must be owned by the same company, like Kaiser does. But that is incorrect. Doctors and clinics don't have to be employees of the organization, they can be contracted by the organization, which is what happens with the BCBS HMO plans, Aetna HMO plans, etc. Even Kaiser contracts with non-Kaiser doctors and hospitals to provide care to their subscribers.

You're insisting on sticking with a decades-old definition that is no longer valid. You're free to do so, of course, but the health care industry doesn't, and hasn't for years.

POS is a type of HMO.

The link you provided is vague to the details. If you are a resident of Michigan, could you please provide the language of your insurance policy options where a referral is not required for the HMO?


Here is what I find so far for BCBS Michigan--it is the Medicaid plans...but note, HMO-POS distinctions.

http://www.bcbs.com/healthcare-news...expand-ma-offerings-for-michigan-seniors.html

 

[bcla]

I can only assume that you haven't actually read the link, at as it specifically says "HMO" and explains what an HMO is.

You seem to believe that to be an HMO, all doctors must be employees of an HMO company, and that all clinics must be owned by the same company, like Kaiser does. But that is incorrect. Doctors and clinics don't have to be employees of the organization, they can be contracted by the organization, which is what happens with the BCBS HMO plans, Aetna HMO plans, etc. Even Kaiser contracts with non-Kaiser doctors and hospitals to provide care to their subscribers.

You're insisting on sticking with a decades-old definition that is no longer valid. You're free to do so, of course, but the health care industry doesn't, and hasn't for years.

Technically Kaiser Permanente doesn't employ the doctors that serve Kaiser patients. They're considered "captive group", where smaller medical groups actually contract with Kaiser as exclusive users of their services. They work in Kaiser buildings, but technically they're not working for Kaiser.

However, I get what you're trying to say. "HMO" doesn't necessarily mean a complete managed care system like Kaiser or Humana. Even the big insurance companies have HMO plans where they contract with physician groups, and the physician groups are free to provide services to other patients not in HMO plans. The primary-care providers generally get a flat rate per patient regardless of the number of visits. There are some regional HMO companies that contract with medical groups. Several Blue Cross/Blue Shield providers have a "Network HMO" model where they have a network of available HMO

Here's a pretty good rundown of five different types of HMOs, which are staff, group/captive group, network, IPA (independent practice association), direct contract:

http://www.healthlinks.net/archive/will4.html

 

[georgina]

everything here turns into an argument! I like our HMO, it used to require referrals but they dropped that several years ago. Some things, like MRIs require an authorization number which takes a few days to get, but there is an extensive list of doctors, specialists and hospitals in the region that accept our insurance. I have had a couple of major surgeries where I only had to pay for the phone in my hospital room. We paid nothing for the birth of our children. All of the kids' vaccinations were covered in full, and my yearly MRIs also. All the kids went to a dermatologist without referrals. The copay for doctor visits and prescriptions is reasonable. The only downside is that it is regional, so no coverage except for emergencies when traveling. When DH retires we will have different insurance, and I am fearful of all the extra costs we will have to pay. I have friends who have to pay a certain amount out of pocket before their benefits kick in, and then their insurance only pays a portion of their expenses. We are spoiled with the 100% coverage.

For the OP, there are so many variations in HMOs that you obviously need to read what specific plans you are considering.

 

[Happy Snowman]

everything here turns into an argument! I like our HMO, it used to require referrals but they dropped that several years ago. Some things, like MRIs require an authorization number which takes a few days to get, but there is an extensive list of doctors, specialists and hospitals in the region that accept our insurance. I have had a couple of major surgeries where I only had to pay for the phone in my hospital room. We paid nothing for the birth of our children. All of the kids' vaccinations were covered in full, and my yearly MRIs also. All the kids went to a dermatologist without referrals. The copay for doctor visits and prescriptions is reasonable. The only downside is that it is regional, so no coverage except for emergencies when traveling. When DH retires we will have different insurance, and I am fearful of all the extra costs we will have to pay. I have friends who have to pay a certain amount out of pocket before their benefits kick in, and then their insurance only pays a portion of their expenses. We are spoiled with the 100% coverage.

For the OP, there are so many variations in HMOs that you obviously need to read what specific plans you are considering.

You will probably pay less out of pocket for a PPO plan or HD plan. HMO premiums are generally very high. Your employer may be footing a large portion of your premiums so you don't see how much it really costs but chances are you are paying up to twice as much (or more) than you would pay with a PPO or a tax qualified high deductible plan...

 

[aprilgail2]

I was just on the phone last night with my mothers insurance agent- she lost her insurance that she had for years last year with the "if you like your health insurance you can NOT keep it" deal- but each year we go over the policy she has to see if it is still working for her or not. She has a PPO policy and I was looking for a policy that included hearing aid benefit. The agent told me that a bunch of HMO's include that benefit (actually they only cover 750.00 of the 5,000 hearing aid) and are cheaper than the PPO's but they have many many less choices in Dr's and you can't pick a Dr you like, they have limited choices. She said that if you can afford it to stay away from an HMO.

 

[Happy Snowman]

I was just on the phone last night with my mothers insurance agent- she lost her insurance that she had for years last year with the "if you like your health insurance you can NOT keep it" deal- but each year we go over the policy she has to see if it is still working for her or not. She has a PPO policy and I was looking for a policy that included hearing aid benefit. The agent told me that a bunch of HMO's include that benefit (actually they only cover 750.00 of the 5,000 hearing aid) and are cheaper than the PPO's but they have many many less choices in Dr's and you can't pick a Dr you like, they have limited choices. She said that if you can afford it to stay away from an HMO.

Insurance companies drop and change plans all the time. This has nothing to do with the ACA at all. Most plans cover little to no benefit for hearing aids, they never really have. I've seen more plans offer SOME coverage for HA's since the ACA was adopted. $5000 is WAY more than she needs to spend on ONE hearing aid. If she has a $750 benefit per ear, which is how most plans are written, Phonak is selling it's top of the line HA at Costco for around $1800/pair. If she doesn't need that much power, there are lower priced options. The Costco hearing centers are staffed with AuD's and HA techs just like your ENT's office. HA's are just flat out expensive unfortunately. They are like glasses, just not covered under your health insurance plan usually.

 

[aprilgail2]

Insurance companies drop and change plans all the time. This has nothing to do with the ACA at all. Most plans cover little to no benefit for hearing aids, they never really have. I've seen more plans offer SOME coverage for HA's since the ACA was adopted. $5000 is WAY more than she needs to spend on ONE hearing aid. If she has a $750 benefit per ear, which is how most plans are written, Phonak is selling it's top of the line HA at Costco for around $1800/pair. If she doesn't need that much power, there are lower priced options. The Costco hearing centers are staffed with AuD's and HA techs just like your ENT's office. HA's are just flat out expensive unfortunately. They are like glasses, just not covered under your health insurance plan usually.

When they dropped her plan they said it was due to the ACA. We priced hearing aids at her ENT but I may have to join Costco and see about the 1800 (she needs 2). Funny thing is the insurance agent was telling me that her insurance plan just added a small eyeglass benefit for next year which shocked me (of course we just bought her new glasses LAST WEEK!!) they also added in 2 dental teeth cleanings a year (which doesn't help either since she has dentures)

 

[Happy Snowman]

When they dropped her plan they said it was due to the ACA. We priced hearing aids at her ENT but I may have to join Costco and see about the 1800 (she needs 2). Funny thing is the insurance agent was telling me that her insurance plan just added a small eyeglass benefit for next year which shocked me (of course we just bought her new glasses LAST WEEK!!) they also added in 2 dental teeth cleanings a year (which doesn't help either since she has dentures)

How old is she?

Of course they are going to blame the ACA, but it could actually be the reason if her old plan did not provide the basics required by the ACA, but it's a good thing because it's usually annual physicals and preventive care that wasn't covered at 100% that needs to be included. Either way, it's not something new for individual plans to be discontinued for many reasons.

 

[aprilgail2]

How old is she?

Of course they are going to blame the ACA, but it could actually be the reason if her old plan did not provide the basics required by the ACA, but it's a good thing because it's usually annual physicals and preventive care that wasn't covered at 100% that needs to be included. Either way, it's not something new for individual plans to be discontinued for many reasons.

86- and it was something about not covering breast pump or birth control or something to do with having a baby ( I can't recall which cause I was so pissed off at the time)...but it DID cover prosthesis which is what she needs- new plans do not cover that---so she can have a baby now at 86 but can't get the breast prosthesis she needs. So screwed up.... her old plan was great, covered way more than the new ones.

 

[Happy Snowman]

86- and it was something about not covering breast pump or birth control or something to do with having a baby ( I can't recall which cause I was so pissed off at the time)...but it DID cover prosthesis which is what she needs- new plans do not cover that---so she can have a baby now at 86 but can't get the breast prosthesis she needs. So screwed up.... her old plan was great, covered way more than the new ones.

Why doesn't she have a Medicare Supplement plan? Yes, all plans have to cover women's health, which includes prosthesis. Most traditional insurance plans do not cover people over 65 (private plans).

 

[aprilgail2]

Why doesn't she have a Medicare Supplement plan? Yes, all plans have to cover women's health, which includes prosthesis. Most traditional insurance plans do not cover people over 65 (private plans).

. She has empire medi blue - when you could start picking your own plan over just basic Medicare that is what we did- basically it's 70.00 a month extra to get a much better plan than just Medicare.

 

[Happy Snowman]

. She has empire medi blue - when you could start picking your own plan over just basic Medicare that is what we did- basically it's 70.00 a month extra to get a much better plan than just Medicare.

She has a Medical Advantage plan then and those are not subject to the ACA, although many of them are including some of the ACA basics like 100% covered preventive care. Her age plus being on Medicare is probably why she isn't getting a prosthesis. Medical Advantage plans are Medicare Part C. They cover Part A and B and D if you select a plan that has that. Totally separate rules covering these plans and the ACA based plans.

 

[OurBigTrip]

However, I get what you're trying to say. "HMO" doesn't necessarily mean a complete managed care system like Kaiser or Humana. Even the big insurance companies have HMO plans where they contract with physician groups, and the physician groups are free to provide services to other patients not in HMO plans. The primary-care providers generally get a flat rate per patient regardless of the number of visits. There are some regional HMO companies that contract with medical groups. Several Blue Cross/Blue Shield providers have a "Network HMO" model where they have a network of available HMO

Exactly! The outdated notion that if there isn't a clinic called "BCBS", then it really isn't an HMO is, well, completely outdated.

 

[Happy Snowman]

Exactly! The outdated notion that if there isn't a clinic called "BCBS", then it really isn't an HMO is, well, completely outdated.

again...the distinction between a POS HMO and a Health Maintenance Organization that you just don't get...

 

[georgina]

You will probably pay less out of pocket for a PPO plan or HD plan. HMO premiums are generally very high. Your employer may be footing a large portion of your premiums so you don't see how much it really costs but chances are you are paying up to twice as much (or more) than you would pay with a PPO or a tax qualified high deductible plan...

Really? How much less than $332 a month would we pay for family coverage? We have a copay for Dr visits and prescriptions but everything else is covered 100%, I can't imagine a PPO would be less out of pocket. My self-employed friend who buys her family plan with a high deductible pays around $1300 a month.

 

[OurBigTrip]

again...the distinction between a POS HMO and a Health Maintenance Organization that you just don't get...

Again...the fact that you can't acknowledge that BCBS KNOWS what they sell, and they are selling HMO plans, as does Aetna and many other companies. Funny that you think you know more about BCBS than BCBS does.