February 2013 Moms
Sophia1913
member
Options
HMO or PPO?
Sophia1913
member
Hi ladies,
So I am in the process of changing my insurance at work. Does anyone know if an HMO or a PPO would be better? Of course I am looking for the best plan that will cover the maximum cost for my delivery as well as a plan that will be good for once LO arrives. TIA.
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Re: HMO or PPO?
My job offers Aetna, Blue Shield, Heath Net, Kaiser and United HealthCare.
It still depends a lot on which plans your employer has with each company. In Oregon, I've had Blue Shield (hated their claims/service, but they gave us really good coverage for our last birth - total out of pocket bill was somewhere around $600, I believe), Health Net (alright, but very expensive for the plan we had), and Kaiser. Kaiser - the HMO - is absolutely fantastic (in Oregon) as far as quality of care goes, great for preventative and office visits, but they tend to have higher out of pocket maximums than the Blue Shield PPO plan I'd had several years back - I can't say whether that is because the BS plan just had better coverage, or if it is just a "sign of the times" with increasing med costs.
The things I think you should pay the most attention to are how much each of them charge for your labor and delivery (is it a $300/day copay or is it 20% coinsurance... is it subject to your deductible.. how much is your deductible... what is the total family out of pocket maximum, in the event that baby has to be in the NICU for any reason, etc). With the PPOs you will have more options for choosing your doctors, with HMOs you will have everything centralized in one or two buildings, cutting down on the number of offices and pharmacies you need to visit. Find out which hospitals the insurance covers and decide if you're comfortable delivering at them, etc.
My own preference leans toward HMOs for the convenience and the quality care I've had with both Kaiser and Group Health (in WA) - but depending on where you live and what kind of coverage they're offering at your company, each of our personal opinions could be really unhelpful.
Right ovary removed 09.04.2012 via vertical laparotomy
Essure implant placed on remaining tube 06.13.2013; successful followup scan 09.30.2013
WOW, thanks! This was actually really helpful. I was sitting here reading some of these brochures and still trying to make sense of exactly what is offered and covered. Thanks again!
I am going to play devils advocate. While HMO's can generally afford better coverage I hate having to get referrals.
Due to this i always go with a PPO as I can quickly change doctors without an approval, go straight to specialists without a referral and find a larger network of doctors. Also as I travel for my job I like knowing I have insurance coverage across the US due to the larger provider network.
Also with PPO I have found less hassles with emergency care as in we can go to any hospital we are close to.
I think it's a personal decision and if you don't mind having to make two appointments for one issue (ie first with primary care to get the referral to specialist) and don't mind specifying specific doctors understanding it generally takes 30 days to change said doctor if you need to then go for the better coverage. IMO, the PITA aspect of the HMO is worth paying more for the PPO.
Again just playing devils advocate and it truly is a very personal decision based on the care that you need/want.
06/12 - BFP!!!!
Beta #1 15dpo - 256
Beta #2 18dpo - 1097
6wk U/S on 07/02 ~ TWINS!!!
EDD 02/21/13
09/10/12 Found out it's two Boys!!!! Sam and Jake
Jacob and Samuel born 1/29/13 at 36 weeks.
My parents have United and love it. I used to have Blue Shield and loved them (had to switch cause of employer dropping the contract with them). I have heard mixed things about Kaiser. Kaiser locks you into your physician, so for my grandfather who had Kaiser, it meant he was going to a dcotor who practiced very far away from his house (which was really inconvenient). Sometimes, you can get better (and easier to read) overviews on each providers website.
it depends on if you like the hospital/OBs/pediatricians covered by your HMO.
I switched from an amazing HMO plan to the PPO version when I got pregnant because I wanted to be in control of my own healthcare and I didn't want to go to the hospital that my HMO covered. so I like PPO, but it will cost me a little bit more(for me it's a matter of $36 more for the delivery, so really not that big of a deal). Also keep in mind that any thing ELSE that happens between now and the delivery might cost you more on the PPO plan, for instance my PPO has a global matarnal health cost meaning I pay a small fee at the end of the maternal health and everything that has to do with the pregnancy is covered under one fee, but anything ELSE (ie, I needed to get some warts frozen) will cost you more as well.
so it's all about what the most important thing is to you. do you want more control or do you want to spend less money? I'm a bit of a control freak, so having control over my own care is more important to me than the small amount more that it will cost me, but that may not be as important to you.
To clarify this, Kaiser doesn't lock you into a physician - I can and have changed my own, DH's, and our kids' physicians a few times with them - it's not even mildly difficult to change your actual doctors, it literally takes about 5min via phone call - the restriction is that you can only see Kaiser doctors at Kaiser locations unless you need an outside referral for specialty services. If Kaiser facilities are far from you, this is a serious disadvantage for their coverage.
Right ovary removed 09.04.2012 via vertical laparotomy
Essure implant placed on remaining tube 06.13.2013; successful followup scan 09.30.2013
Ditto all of this! My work offers either an HMO (Group Health) or PPO (Premera). At last year's benefits fair I talked to reps from both to fully understand the options. With the plans my work offers I would have paid somewhere between $350 (my deductible) and my OOP max ($2850) on the PPO plan. With the HMO I calculated that I'd spend a max of $300 (assuming copays at every appt) because in patient is covered 100%. At 30 weeks I've only had two appts that required a copay + one prescription, and thus far I've paid $50. The rest of my appts should be routine, so that may be it. We'll see! The thing I like about it is that for maternity care I had several options, one of which was CNMs. I've been VERY happy with my experience there. The first PCP I had was also FABULOUS (and completed her residency earlier this year). I haven't met my new doc yet, but GH has a thriving family medicine program and gets hundreds of applications for only a few positions every year (even though family medicine is declining around the nation), so I'm optimistic that she'll be good to. And if she's not, I'll just pick another one! It's super easy to do online.
I also asked around at work and almost all of the women my age had GH and really loved it. I think that if I had more complicated health issues, I might switch back to a PPO. And I might do so anyway after we're done having kids.
Though if we lived closer to work, I think I'd stay with GH because I like the facilities by my office. I haven't been to the clinics closer to home yet, so we'll see if I like those.
To counterpoint, I have UHC HMO and my plan does not require a referral and I have never had an issue getting them to approve full coverage for an OON provider. I can also go to any hospital in an emergency and it is treated as in network.
Ultimately, it is impossible to make generalized statements about insuance plans since coverage really is plan specific.