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HMO vs. PPO??

Jem04Jem04
in Success after IF

I currently have an HMO, and since IF treatments were 100% OOP for me, it didn't really matter in 2008. 

Now I need to sign up for 2009 benefits - and I think I may stick with my HMO (Blue Cross Blue Shield).

Any good/bad thoughts on this?  I am concerned because I am pg with twins so I might have more complications/bedrest/NICU than others.

I also need to decide how much to put aside in the flex spending acct for medical expenses...

Thanks in advance!

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Re: HMO vs. PPO??

  • hannah&benhannah&ben

    We chose an HMO when my husband changed jobs earlier this year. Obviously coverage is different for every plan whether HMO or PPO but the big difference we saw was that:

    with HMO the % of coverage was much higher for all services (100% after copay for almost everything) the trade off being you have to go to in-network providers. Copays are a bit higher with the HMO too - but not a ton ($20 hmo vs. $10 ppo for office visits and a $50 - $25 - $10 hmo RX tier vs. $40 - $20 - $10 ppo) However there is no non-formulary list which is a bonus.

    with the PPO the % of coverage was lower (like 80% covered you pay 20% - which can be lots when you think of NICU time, surgeries, etc).  The bonus being that you don't have to go to in-network providers - you can go wherever you want. And like I said above - copays are a bit lower - but they had a larger list of non-formulary drugs that were $100 - including some of the meds my son will take for the rest of his life)

    HTH,

    Hannah

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  • Kem93006Kem93006

    I get asked this question a lot.  (I'm in HR)  The main differences are with an HMO you need to get a referral from your PCP before seeing a specialist (except for the obgyn) and with a PPO you can go out of network, with an HMO you have to use doctors that participate with the carrier.  Which means if you have a doctor that you really like but does take the insurance carrier you have (Blue Cross BLue SHield) than you will be charged co-insurance, typically around 20%.  I highly recommend staying with the HMO because of the money you save.  However if you see alot of specialists (as we all do) and you hate getting a referral first from your PCP, I would go with the PPO.

    I hope that all makes sense.

    ~Kate

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  • Jem04Jem04
    Thanks Hannah! 
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  • hannah&benhannah&ben

    No problem - and FWIW we do not have to have referrals for anything as long as we are seeing someone in-network. But I don't think that is the standard.

    Hannah

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  • jsusannjsusann
    We had the same decision to make right before we started injectibles for our IF treatment. I wanted to be sure I got the most $$ coverage. We had a PPO previously and had our choice btw. PPO or HMO but different providers. We decided on the HMO b/c it covered all costs and the PPO covered 80%. I had to jump through some hoops for the IF coverage and for my last ultrasound b/c it was a specialist and you need referrals. But it wasn't that big of a deal. My insurance co. was easy to work with. I'm glad we went with the HMO b/c I haven't had to pay a thing so far and we did 1 IUI and 1 successful IVF cycle.
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