Question:
WHATS THE DIFFERENCE AETNA PPO & HMO

OK WAS AT MY PCP OFFICE TODAY, THE NURSE TOLD ME THAT AETNA PPO HAS LESS REQUREIMENTS TO GET APPROVED THAN AETNA HMO! ANY ONE KNOW THE DIFFERENCE? ANYONE KNOW AETNA'S REAL REQUIRMENTS? I HAVE LOOKED AT THERE WEB SIGHT, IT DOESNT TELL THE DIFFERNCE! I HAVE PPO!    — CYNDI B. (posted on September 23, 2002)

September 23, 2002
i have aetna POS which is where i can use it as a ppo or an hmo. i used it as an hmo and went through my pcp and was approved in 48 hours. i called aetna first and asked them if it was a covered benefit, and what their requirements were. they wanted my diet history, including a md supervised diet, weights for the past 2 years and a list of co-morbiditys. i would start by calling aetna and find out what your plan wants from you as many plans are different. good luck :-) jen
   — JENNIFER A.

September 23, 2002
The primary difference between PPO and HMO is that with the PPO you have a CHOICE of using doctors that are IN the Aetna PPO Network or going to doctors that are OUT of network. With the HMO Plans, you must first see your Primary Care Provider (PCP) and your PCP must refer you for any specialized care (surgeon, orthopedic specialist, urologist, etc.) With a PPO Plan, you pretty much control your medical needs, with an HMO plan, they are controlled for you. The HMO generally has lower co-pays than the PPO, but you must be referred for services, if you self refer or go outside of the HMO Network, then you pretty much have no coverage for charges incurred. With the PPO, like I say, there are two levels of provider...IN NETWORK, which means that the doctors NEGOTIATE with the insurance companies to accept a fraction of the billed charges as payment in full. For instance, my hospital was an IN NETWORK Provider, of the $25,000 hospital bill, they "wrote off" $15,000, since they are a contracted provider, I'm not responsible for that $15,000, I'm only responsible for 10% of the NEGOTIATED RATE, in this case, it's 10% of $10,000. Providers that are OUT OF NETWORK are not contracted, so they would want payment in full of the billed amount. Insurance carriers will usually reimburse a percentage of the USUAL AND CUSTOMARY rate and that generally that they take an average of what other doctors in a geographic are charge for certain procedures. Let's say that your doctor charges $8,000 for surgery. When the go to process the claim, they may find that for that particular procedure, doctors in your area charge, on the average, $6,000. That means that the insurance company will pay a percentage of the $6,000 - not the $8,000. COnfusing, isn't it? Also remember that PPO's have Maximum Out of Pocket expenses - this means that once you've met these Out of Pocket amounts, your insurance will begin paying charges at 100%. Feel free to email me with questions, this is what I do for a living, benefits administration. You can email me at [email protected] ~ Rosario
   — Rosario T.