Choosing your health insurance benefit

  1. Hi all, I finally found a new job. I am very excited, I will be working as a case manager for an insurance company.

    Anyway, I have narrowed down the choices for my health insurance to two: The PPO vs the HMO

    I have never ever selected the HMO option before b/c I never wanted to deal w the hassle of referrals. BUT, the HMO is FREE to me & my family. The PPO w vision and dental inculded will be a grand total of 68.50 deduction from each paycheck, which is still not bad considering my husband is currently having 98.00 per paycheck.

    So, for those of you who have HMO's, is it that awful to get referrals? My kids see the dermatologist regularly, and I have never had to worry about dragging along the paperwork.

    All my docs are on the plan, except the hospital I prefer is not on the PPO or the HMO, but also not on hubby's, so all surgery would have to be at the yucky hospital, or I guess I could go out of my county??

    Otherwise the plans are very similar, in fact, the HMO covers 100% whereas the PPO covers only 70% of many procedures. The drug co-pay is slightly higher for my BP med, but still way cheaper than a bi-weekly payroll deduction. And cheaper still if I use the mail in option, which is a three month supply for the same amount as the pharmacy.

    So, for those of you who have HMO plans, is it do-able or is it the worst hassle and not worth saving the 68.50? Our budget is kinda limited right now, so if I could save some money this way, I really want to try it, but by nature I am NOT a gambler, and the last thing I want to gamble on is my family's health.

    Help me to choose!! Thanks! :kiss
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  2. 12 Comments

  3. by   renerian
    Hoolahan I have been part of an HMO (different ones ) for about 6 years or so. I have been very happy and got referrals fairly easy. The only time I was irked was when I needed a hysterectomy and I had lots of problems getting them to finally approve it and then they wanted me to do it outpatient if you can believe that one. I ended up having complications and stayed two nights which they paid for.

    Free is mighty hard to pass up. . I wonder what others experience has been.

    Congrats on the new job. You will no doubt be missed in home health.

    renerian
  4. by   hoolahan
    (I'll still be doing some time in HH, on w/e's. Can't pass up that $36/hr AND I really really want to pay off these credit cards!)
  5. by   RN auditor
    I absolutely love my HMO. The two times I have had things denied (such as a provider) I was able to appeal the case and have the decision overturned. I have not had to wait a long time for decisions to be made and as long as there are plenty of providers in your area it may be the best for you. The coverage is great! I would definitely give it strong consideration.
  6. by   Gomer
    Hoolahan, check out the maximum life-time payout before you decide. Some HMO's, PPO's, and POS's have a $1Million maximum life-time payout limit. Some have no limit. I would look at that first and what MD's are on each plan second. Then decide.
  7. by   hoolahan
    Interesting Gomer, the PPO has a max payout of $1 mil for out-of-network providers, but for in-network, there is no max for either.
  8. by   christinemj
    We have used an HMO for a couple years. We've had no problems with referrals. My hubby sees a cardiologist and he gets referral for a specified date range (usually 6 months). All of the "referral paperwok" is handled by the referring MD and he just gets a copy in the mail. After 6 months, he has to get a new referral from his primary care provider...but, this has never caused a problem, and I actually think it's beneficial because all med. info gets back to the ONE (primary) doc... this provides for good continuity of care and a sort of checks and balance system.

    He also went through a procedure that needed prior approval. That was a"simple" process also as it was coordinated through the docs and the hospitals and the HMO. "We" really didn't have to do anything except to ensure the doc/hosp followed through..and then to wait for the letter that said the HMO WOULD cover it.

    Of course... it all depends on YOUR HMO. But we've enjoyed the relationship with ours.

    BTW - IMHO the 70% vs 100% copay differencece is even more important the the 68/.50 per month. One broken leg and you've already blown the bank in co-pays!

    Good Luck and good health!
  9. by   NicuGal
    I was in an HMO and had a terrible time with referrals. Just keep in mind that there is a "gatekeeper" that watches that money and they don't like to let it loose. Personally, I would go with the PPO, even if it costs. We were offered and HMO again this year and the majority of the hospital turned it down. I like the fact that I can pick my doc, and if I think I need a derm appointment I can just make it myself, not rely on someone else to decide that for me. JMHO.
  10. by   hoolahan
    But I wil be working for the company who runs the HMO. (That is one of the things I will have to learn, they have many many different plans) so I am sort of hoping I can just walk over to the precert nurse and pull her hair if she denies anything (LOL!)
  11. by   emily_mom
    We have had an HMO for years, and are happy with it as far as referrals go. Our plan is pricey and only pays 70%, so we have over $2000 in hospital bills from one time. But, referrals are done for a year and have no problem getting them.

    Congrats on the new job!

    Kristy
  12. by   NurseGirlKaren
    Go for the HMO. I've always been happy with the ones I've been involved with.
  13. by   NRSKarenRN
    Will you be keeping you PCP or changing provider? How well is your doctors office organized. I would ask them how difficult getting a referral is and time frame.

    If you still want to use your preferred hospital, what is out of network coverage liek on your plan.

    Since we have 10 different doctors between myself, kids and hubby, PPO was easier for me to maintain and I have better lifetime maximum with this plan.

    Another thing to consider: What is the HMO formulary like? Are many of the meds you take on it or will you need to change to generic or other drug in class---that was a problem for my husband who found he needed brand necessary as generic BP med ineffective for him and HMO didn't cover some of his.

    Good luck in your decision.
  14. by   judy ann
    My only comment is this. Having worked insurance claims, and gotten the referrals and pre authorizations from the MD offices, if you want a GED wanna-be directing your health care, go HMO. With PPO, you have a lot more leeway and control of your own care.

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