HMO & PPO - Whats the difference?

[Marc Vaughan]

Hi,

SOA have in their kindness accepted me under their wing, hence I'll finally be getting medical cover via. them ... only thing is they have two schemes available a Blue Cross PPO and two HMO schemes (one Blue Cross and one Kaiser California) ....

I have no idea what the terms HMO and PPO mean let alone which is best - if anyone has a half-grasp on such things please feel free to post and let me know.

Marc 'missing the good old fashioned British National Health service' Vaughan

[knolysis]

Anymore, it can be difficult the to tell the difference between a PPO and an HMO.

In general, an HMO is more focused on controlling expenses and thus imposes a few restrictions on your healthcare choices compared to a PPO. Under an HMO you are usually required to select a Primary Care physician. You are required to have this physician refer you to a specialist if you need more specialized treatment (thus, if your doctor thinks you are hypochondriac, he can refuse to refer you for further treatment and therefore control costs for the HMO).

In practice, I much prefer Blue Cross's PPO (I live in Florida and have BC's PPO coverage now). Just about everybody in Florida takes it and you don't need a Primary Care physician. If you decide you want your first trip to the doctor to be a neurosurgeon, go for it!

I had an HMO when I first moved to Florida and I couldn't find any doctor close to me to be my Primary Care physician. I have always had that problem with HMOs and thus try to avoid them when I can.

[OldGiants]

HMO is a Health Maintenance Organization. A PPO is a Preferred Providor Organization. The key difference is that in an HMO, you pick a primary care physician and you must go to him for every need, including referrrals to specialists.

With a PPO, you can go to any doctor on the 'Preferred' list at your choosing.

In general, the HMO costs less, both per month and per visit. But your access to specialists is controlled by the Primary Care doc. If he won't refer you, you bear all the cost.

In general, if you are a healthy male and don't have a doctor whom you prefer, (that is, don't need an OBGYN) choose the HMO option and pick a Primary Care doc who is near your office and home. Most HMOs have gotten to where you can switch primary care physicians every month, if you need to, so that locking into a PC doc you don't like for an entire year is no longer a concern. However, you'll need to check into that if its a concern for you.

Best of health to you.

[Eaglesfan27]

I agree with everything that is said, but I'll also add that some HMO's actually cover a higher percentage of the expenses for procedures and have other benefits such as a higher lifetime maximum benefit. It really depends upon the individual company, but in our case, the HMO was the better option. In other cases, the PPO is better.

[lordscarlet]

In addition to what everyone else said, typically you have to pay a higher premium ($20 as opposed to $10) for PPO.

[flere-imsaho]

I can confirm what everyone else has said. Although ironically I do the PPO option since I wanted to stick with my "primary" doctor, who is very, very good, and he doesn't work with any HMO plans.

[oliegirl]

I refuse to be on an HMO. I was on one once, my son was about 15 months old and had a seizure...the EMT's that came said they didn't need to transport him, but that we needed to get him to the hospital asap. I called my ins company to report it and they wanted me to be put on hold for "up to" 10 minutes while they researched it and decided if they'd authorize it. I told them I had to get him to the hospital and I'd call back later. The lady I was talking to said I could do that but I was taking a chance on them not covering anything because I didn't go through the pre-authorization process. They covered everything, but I was so mad at the whole situation that I changed plans and will never be on another HMO again.

Plus, the whole idea that if I need to go to a dermatologist for something, I need to go to a PCP first to get approval/referral is just ludicrous to me.

[SnDvls]

Mark,

Is the insurance just for you or are family members on it as well? If you are single is a marriage or kids on the way that would/could be added? These might factor in your decision too.

[Subby]

PPO crushes HMO in healthcare deathmatch.

[flere-imsaho]

As long as you do your homework on deductibles and lifetime maximum coverages the main difference between the two (to be very simplistic) is that you're paying more with a PPO for the convenience of not jumping through so many HMO hoops.

[Marc Vaughan]

Mark,

Is the insurance just for you or are family members on it as well? If you are single is a marriage or kids on the way that would/could be added? These might factor in your decision too.

Its for my entire family (myself, my wife and 3 kids - Haley 13, Jake 8, Keegan 4).

[BigDPW]

Marc - I hadn't realized you moved across the pond until this post. That is pretty cool. Hope you are enjoying it here in the states. I must have missed why you are joining us yanks here in the US but welcome!

[Mizzou B-ball fan]

Blue Cross has one of the best PPO's available. Given that you are covering your children as well, I'd highly recommend getting the PPO. There are some risks in HMO that, no matter how extreme or rare they might seem, are not worth taking when it comes to your own children. My wife is a doctor and we have a child. She wouldn't even consider the thought of getting a HMO, even with a company as good as Blue Cross. Most of the doctors that we know make sure to get Blue Cross PPO. That obviously speaks volumes given their profession.

You might have to pay a bit more here or there in the form of a extra $5 for an office visit or something like that, but the PPO is MUCH safer when something catastrophic occurs. For me personally as a father, a few dollars here or there is not worth the risk.

[SteveMax58]

PPO crushes HMO in healthcare deathmatch.

This kinda really sums it up. No doubt, in a strict rules deathmatch, PPO wins.

I live in Florida as well and have had BC HMO & PPO, although our company recently switched to cover other people in other states, etc. In my anecdotal findings, I didint really have a big problem finding enough decent docs to choose from for a Primary Care physician, and it was a little cheaper for each visit.

[gstelmack]

My one experience with an HMO was having major health issues (heart palpitations, felt like I had the flu, really bad), walked into the HMO, saw some old nutcase, he took blood and urine samples and told me he'd get back to me in 2 weeks.

I have never walked in to an HMO since, and never, ever will again. If you are healthy and need some minimal routine care, they are great, but as soon as you get sick their primary goal is to control costs.

PPOs may cost more, but you are much better off if you have any chronic health issues or if someone gets sick. I love the BCBS PPO plan, at least the one here in North Carolina.

[Eaglesfan27]

Blue Cross has one of the best PPO's available. Given that you are covering your children as well, I'd highly recommend getting the PPO. There are some risks in HMO that, no matter how extreme or rare they might seem, are not worth taking when it comes to your own children. My wife is a doctor and we have a child. She wouldn't even consider the thought of getting a HMO, even with a company as good as Blue Cross. Most of the doctors that we know make sure to get Blue Cross PPO. That obviously speaks volumes given their profession.

You might have to pay a bit more here or there in the form of a extra $5 for an office visit or something like that, but the PPO is MUCH safer when something catastrophic occurs. For me personally as a father, a few dollars here or there is not worth the risk.

Yet myself, and most of the doctors I know choose Humana's HMO over the PPO that is offered here and I've been absolutely thrilled with their coverage as I've had a bunch of tests recently to figure out what is up with my headaches (still no answer on that.) It really depends upon the situation and the state. I'd just reiterate that you should look at every factor, Marc.

[lynchjm24]

Kaiser is not a normal HMO. They provide much of the service themselves in their own facilities, that is why their rates are so low. They are big in California and in the Mid-Atlantic region.

[lynchjm24]

Blue Cross has one of the best PPO's available. Given that you are covering your children as well, I'd highly recommend getting the PPO. There are some risks in HMO that, no matter how extreme or rare they might seem, are not worth taking when it comes to your own children. My wife is a doctor and we have a child. She wouldn't even consider the thought of getting a HMO, even with a company as good as Blue Cross. Most of the doctors that we know make sure to get Blue Cross PPO. That obviously speaks volumes given their profession.

You might have to pay a bit more here or there in the form of a extra $5 for an office visit or something like that, but the PPO is MUCH safer when something catastrophic occurs. For me personally as a father, a few dollars here or there is not worth the risk.


Be careful what you read here because much of what is in this thread is untrue and uninformed.

First of all there are many types of HMO's. There are true HMOs and there are plans that only look like HMO's but are really traditional PPO type plans that have no out of network benefit. Sometimes you will see them refered to as EPOs or EPPs depending on the carrier but many plans called HMO are the same things as a PPO or POS they just lack the out of network coverage.

Secondly 'Blue Cross' means many different things in many different places. There is no one 'Blue Cross' there are many different franchises doing business under the banner of Blue Cross or Blue Shield all over the country. For example, Blue Cross of California and Blue Shield of California are different companies. Blue Cross/Blue Shield of Maryland has nothing to do with Empire Blue Cross/Blue Shield (which is the NYC BC/BS) or Excellus BC/BS (which is some parts of Upstate NY) or BC/BS of Northeast NY which is the Buffalo area.

Some BC/BS are for profit, others aren't. Some are trying to become for-profit (like Horizon BC/BS of NJ). Some are owned by other companies now like Wellpoint. Some band together and share their discounts freely - the Blue Cross Consortium, others don't and charge access fees in claim costs to utilize their network and process the claims. For example if you are a Horizon BC/BS member and you utilize the BC/BS of Texas network, BC/BS of Texas may tack on an additional amount to your claim - doesn't matter to the member, it's the plan sponsor who picks up that charge.

In general the Blues are known for large networks and in many places local dominance. They typically aren't as interested in wellness initiatives or cost control as the major for-profit carriers (Aetna/CIGNA/United/etc).

In general when choosing the plan I would consider this:

A. Network - you probably don't have providers you are married to yet because you haven't been here long, but the bigger the network the better, you can research online on most carriers websites
Is the HMO an open access HMO? In this case I doubt it since it's Kaiser, but many are and you don't need PCP referrals to see a specialist. Edit: actually since you live in Florida you might not even have Kaiser as an option, I have never seen a Florida Kaiser plan (doesn't mean they don't exist, I would imagine if it does though that the network is very poor).

B. Payroll contributions (in general people overpay and take plans that are overly rich, most likely in a high/low option the difference in benefits is not as great as the difference in employee contribution)

C. Out of pocket limits. Don't pay extra to have a $15 copay instead of a $25 copay, almost never worth it. Don't pay for out of network benefits if you generally stay in network.

People are convinced that PPO's are better. This goes back to the 90s when HMOs were a very different beast then they are today. Every company is going to have plans that have advantages/disadvantages. I saw something today from Amerihealth that was called a PPO but was just an HMO that had an out of network benefit. It all comes down to state insurance filings and marketing. Many times it isn't even the insurance company that is naming the options, it's the company itself in order to maintain the same terminology they have used in the past with other carriers or to simplify a complex set of options.

[SnDvls]

Its for my entire family (myself, my wife and 3 kids - Haley 13, Jake 8, Keegan 4).

Then it depends on how "healthy" your kids are. Do they always get a cold/flu in the winter? Constant ear infections that need Urgent Care, but not an emergency room visit? If those are the cases I'd go with a PPO (I have Blue Cross/Blue Shield of Arizona so it might be a bit different where you are) I like that I can pretty much choose where to go quickly if needed in these small cases with my 2-year old.

Hope some of the info here helped you sort through the medical mess that we all have to deal with here.

[Marc Vaughan]

Then it depends on how "healthy" your kids are. Do they always get a cold/flu in the winter? Constant ear infections that need Urgent Care, but not an emergency room visit? If those are the cases I'd go with a PPO (I have Blue Cross/Blue Shield of Arizona so it might be a bit different where you are) I like that I can pretty much choose where to go quickly if needed in these small cases with my 2-year old.

Hope some of the info here helped you sort through the medical mess that we all have to deal with here.

They're normally fairly healthy.

Thanks to everyone who posted and gave advice - its been very helpfuly and reassuring, choosing something like this is quite stressful for someone who's come into it somewhat ignorantly and the information given here has definitely helped.