HMO or PPO
Thursday, December 17, 2009 at 6:00AM It's open enrollment time at my place of employment and I have a decision to make.
HMO or PPO.
Here's the thing, my company has been paying for me to be on a 10$ copay HMO with Blue Cross of California. It's a pretty sweet deal since I don't have to pay the monthly premiums and ever since we put my kids on my wife's insurance it is even sweeter. I was paying almost $800 a month for them to be on it.
Anyhow, my work has changed the deal and are now going to be paying the premiums for the 40$ copay HMO. That means outside of now playing $40 for a visit, I have a $250 deductible for medication, $3000 copay for hospital visits, and a higher cap on out of pocket.
I need your advice. There are bunch of PPO plans I can get into also which is tempting. To be able to see an Endo without needing an approval every time would be a dream come true. Or being able to see a podiatrist without the same hold up is completely unreal to me.
Plus if I switched to a PPO I would be able to really pick and choose which Endo I go with. And you all know the troubles i've had with mine.
So I am flat out looking for advice. What do most diabetics do? HMO or PPO? Please comment and let me know why you think I should go with either one. If you need more info about the PPO's offered let me know and I will look it all up.
Reader Comments (11)
We spend the extra money and do the PPO thing. The freedom to see whatever specialists we need is worth it and in our case, the deductible is lower than the HMO option.
Honestly, it is a very hard decision to make.
We changed from a PPO to an HMO this past year. And this year I am going back to the PPO. We don't have kids yet, so the expense is a lot less for just my husband and I. But the peace of mind and ability to not have to wait for approval with a PPO make it all worth it. Our HMO was Kaiser, our PPO is Aetna. I haven't had issues with Aetna in the past. The cost is up there, but like I said... my peace of mind is worth it. Well, my husband said that. I guess because he has to deal with the emotional effects of the HMO ;) We compared out of pocket, copays, deductibles and premiums. The cost difference was less than $1,000 for the year by my crude calculations (because our % OOP for DME with our PPO would be less than with the HMO).
I've always had PPOs myself. My original endo was on my parents' PPO, and through the years it always seemed like HMOs have more hoops to jump through. (Like the time Aetna decided Humalog was 'off formulary' and wouldn't give me more than a bottle every 2 months...then complained I was 'using too much'. Srsly?!)
Most doctors' offices in my area are no longer taking HMO plans, so there's another reason. But the PPO is more expensive in terms of copays, etc.
Good luck! I *hate* open enrollment!
I'm a big fan of the PPO, and will stay on one as long as we can afford it. Don't get good service from your Enoc...you can change. Need a retina specialist...your choice. Your nomal GP is booked solid for 2 weeks and you have strep throat...you can seek care elsewhere. Case in point: I had my annual eye exam yesterday with a top retina practice. Thankfully I don't need all of their skills just yet (one small hemorrage....laser not recommended yet), but it's nice to get to know them first. I switched to them after my Opthamologist criticized me for eating oatmeal for breakfast, and tried to sell me supplements. Nice to just be able to walk away from that without anyone's permission or referral.
I'm a big fan of the PPO, and will stay on one as long as we can afford it. Don't get good service from your Enoc...you can change. Need a retina specialist...your choice. Your nomal GP is booked solid for 2 weeks and you have strep throat...you can seek care elsewhere. Case in point: I had my annual eye exam yesterday with a top retina practice. Thankfully I don't need all of their skills just yet (one small hemorrage....laser not recommended yet), but it's nice to get to know them first. I switched to them after my Opthamologist criticized me for eating oatmeal for breakfast, and tried to sell me supplements. Nice to just be able to walk away from that without anyone's permission or referral.
I've had some bad experiences with crazy bills with PPO, so I try to stick with HMO-- I worked at universities for my past and current jobs, so good doctors were never hard to find, and they were always in network.
Good luck, George! This is a tough decision. I actually went from HMO to PPO and back to HMO at my last job because the PPO side was just too much to deal with.
I'd opt for the PPO. That has been my current insurance, and I'd elect to keep it as long as possible. Started on a PPO, and I was grandfathered and allowed to stay with it in August when our new cycle began, even though new employees aren't able to get it anymore and we're told that Anthem BCBS will likely phase it out completely in the next year. They're shifting away from the PPO in favor of a high-deduct HSA, which they claim is "so much better and affordable" for everyone. Not the case. Maybe that's true for "healthy" people without a chronic condition, but not I. We went on my wife's insurance with a new job once she started, and have a PPO - which costs a little more in premiums, but is worth it as far as the freedoms. Caps are common with most plans these days, and they're hard to avoid. If you have the option of getting a Flex Account also, that could help - we have one with about $2500 available for the year, which allows us to put the copays, deductible, premium payments on it if we choose. Just have to plan for it when budgeting for the year. Worth it, in my opinion.
Helping you out without knowing anything about the PPO or HMO is a bit like flying blind. The PPO, or "Preferred Provider Organization" plan will limit you to doctors in the plan, so the first place to start is by finding out if your doctors are already in the PPO; if they are, great. Next, you should consider the HMO ("Health Maintenance Organization") but you should check out the list of physicians on their websites, and also the drug formularies for both the HMO and PPO; the co-pays and out-of-pocket expenses on HMOs are generally less than they would be with a PPO, but you'll be more limited in terms of what is covered with such a plan. Although co-pays are rising with both, keep in mind that the average cost increase nationwide this year is about 20%, so yours don't seem to be much different in terms of the costs that are being passed along. Ultimately, you need to answer the questions 1) are my drugs covered, and what will my out-of-pocket expenses for those be and 2) which doctors can I see, and what will my costs be for those? Once you answer those, also determine if you can enroll in a flexible spending account to cover those expenses.
Always PPO, G. Since I first had the option. It's worth the extra premium money. The copays and deductibles are usually lower, don't typically apply to pharmacy items, and you get the option of seeing any doctor in-network anytime. Really good deal.
I would suggest sitting down and figuring out how much out of pocket you'd spend on each plan - then make a decision based upon what you can afford AND the convenience and pros/cons of each choice.
Let me know if I can help, I'm excellent at figuring stuff like this out.
Also - does your company have an FSA or HSA? If they do, and you don't take advantage already, you may find those options beneficial in terms of putting away pre-tax the out of pocket money you'll need for a year.
We're on a PPO and love it. I suggest you go with it too, especially with all of the endo troubles. You really need a good one. We just have an FSA that covers the deductible and extra cost for copays. You might want to look into that too. It's helped the higher out of pocket costs for us. Hope you're feeling better. Good luck with whatever you choose.
I've never had any other coverage for myself than a PPO. I think every single doctor I see is a specialist (I don't even have a pcp!) so I can't begin to imagine the hassle of needing a referral. I think if you can afford the premiums, go for the PPO. I'm my opinion they give you much more flexibility with your coverage. Good luck deciding!