I luckily don’t have any serious/chronic health issues - sleep apnea and somewhat high blood pressure so nothing urgent.
I thought I would just come to the dope and ask if anyone had some advice to share. Things you wish you knew before or “be sure tos.”
Thanks in advance.
What sort of health insurance did you have previously? An HMO? No health insurance at all?
I had an HMO previously.
So you’re already under the care of a PCP? You already get regular checkups and screenings? Because in my experience, the only difference between an HMO and a PPO is that you’re able to visit doctors and hospitals outside your insurer’s network. That can be helpful if, for example, you’re out of town and need to visit a doctor outside the network. But when you’re at home, presumably you can find in-network care.
This post is not going to be very helpful to you. I don’t have any experience being under a PPO, I have always avoided that option because I have heard such horror stories of long waits for treatments and equipment, and so on. I don’t offer those stories as evidence or even give them definite credence myself, but people love to share their experiences; I would bet that there are online forums of some kind, dedicated to each of the major PPOs in the US (assuming that’s where you are), and from which you can learn the tips and tricks of navigating the one that you now have. If I were doing that research, I would be paying most attention to the accounts from people in my own locality, because I suspect that such things can vary greatly within the same PPO, from one place to another.
Another difference I found between an HMO and a PPO is that my PPO doesn’t require referrals for specialists. My PCP might advise me to see a cardiologist and even give me a name if I ask him for one but when I had an HMO, the PCP had to give me a written referral for a certain number of visits to a cardiologist. The only specialist that didn’t need a referral was the gyn for a yearly visit - anything else, the ob/gyn needed a referral too.
Perhaps the other side of that coin is that the list of specialists available to you is probably shorter than it would have been in an HMO?
A couple of months ago it was open enrollment time for my employer provided benefits for this year. I thought about going for the PPO option rather than the HMO option for health insurance but doing so would have cost me almost $9,000 more for the year. I thought it might be nice to have the flexibility to see out-of-network doctors as I travel a lot for work and personal reasons but it would be cheaper just to pay directly for any out-of-network appointments.
Nope - I can see any specialist I want to, in network or out. But the list I had when I was in an HMO was much shorter than the list with the PPO is. I knew people in a different HMO years ago with no list - your primary care doctor worked at this center and that meant you saw this cardiologist , that dermatologist etc. No choice at all - all the doctors were employed by the HMO , the HMO owned the hospitals etc.
Oh, yes, I forgot there are different types of HMOs. The one I had when I was working was wide open on specialists, hospitals, etc. as long as the doctor and facility accepted that insurance. Most of them did, it was one of the big ones.
Huh.
I wonder if this varies by location/region. My experience with HMO’s had always been a nightmare of denials and barriers to care. While there are issues with PPO’s (just like all US health “care” insurance) I’ve found them easier (not easy, just easier) to work with.
I meant to ask @Roderick_Femm if he’s sure the horror stories are about PPOs in general (rather than one particular doctor or group of doctors) because in my experience, using a PPO just means that going to a doctor who participates in my network costs me only a copay while going to out of network providers involves a deductible and 80% of the “usual and customary charge” and so on. The doctors don’t work for the PPO and they generally are not connected to each other so you couldn’t really say that “the PPO” has a long wait or equipment - I’m going to have the same wait at my PCP no matter what insurance I have because he participates in both HMOs and PPOs.
No, and I wasn’t offering the horror stories as actual evidence of anything, just as the reason I had avoided PPOs when I was working. I also avoid Part C Medicare.
I have always had a PPO and it’s always seemed much easier for me. No referrals needed. No problem finding in network specialists. No deductible. Just a $15 copay. I’ve gone to the best rated specialists in my area and paid $15 to go. I would hate to have to go to a PCP every time I need to see a specialist. Waste of time and money.
You don’t actually need to visit the PCP to see a specialist. What’s needed is a referral and that may be provided without you needing to actually go into the office for the PCP.
Don’t need any of that. I’ve never heard of an advantage of a HMO over a PPO
The only one I’ve ever seen is price. Sometimes, not always.
Yes, in general HMO plans are cheaper than PPO plans. In my case, had I chosen the PPO option for the year, I’d have to pay several hundred dollars out of each paycheck, or almost $9,000 more for the year.
I believe with an HMO plan, the primary care physician gets a fixed payment per month per patient whether or not they ever see them. My understanding is that the PCP is expected to monitor the patient’s health conditions and advise them on what interventions may be appropriate.