Choosing your health insurance benefit

renerian, BSN, RN · Feb 18, 2003

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

hoolahan, ASN, RN · Feb 18, 2003

(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!)

RN auditor · Feb 18, 2003

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.

Gomer · Feb 18, 2003

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.

hoolahan, ASN, RN · Feb 18, 2003

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.

christinemj · Feb 18, 2003

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!

NicuGal, MSN, RN · Feb 19, 2003

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.

hoolahan, ASN, RN · Feb 19, 2003

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!)

emily_mom · Feb 19, 2003

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

NurseGirlKaren · Feb 19, 2003

Go for the HMO. I've always been happy with the ones I've been involved with.

Home Health Columnist / Guide · Feb 19, 2003

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.