Question:
PPO v HMO...

I feel like an idiot, but can anyone explain what the difference is between a PPO and an HMO? I have PPO...I was wondering if a PPO would be easier to go out of network??    — Amy S. (posted on July 18, 2002)

July 18, 2002
Hi Amy...don't feel like an idiot...Insurance is a complicated business--otherwise they wouldn't be giving us so much grief!! ;) Anyway...PPO usually gives you more flexibility as to which doctor you chose. If you stay in the network you usually only have to pay a copay...if you go completely out of the network (you see, they contract w/the drs/hosps to establish a negotiated rate so they/you get a discount) you usually have to pay a percentage, 20-30%. If you have an HMO...check to find out if you dr. is already listed...check your exclusion to see if it matches the PPO exclusion (if one exists...and make sure it doesn't say something like "excludes treatment for obesity surgery/services/etc...except when medically necessary for morbid obesity). IF you dr. is listed for both plans (which is usually the case), the HMO will probably be cheaper if the dr. is in network----however...if the dr. is not in the network, HMO probably will not cover it. If you have questions about it, call your customer service # and ask them. Be vague and beat around the bush until you understand what will best benefit your situation! Best of luck to ya'!!
   — Lynda L.

July 18, 2002
Let me clarify regarding the exclusion: if your exclusion says "excludes treatment for obesity blah-blah-blah....except when medically necessary for morbid obesity"...then you have to prove medical necessity of the surgery. If both plans are the same, then the pro of the PPO would be choice of drs; the con is perhaps a copay. If both plans are the same, the pro of HMO would be no copay, the con possibly be limited choice of drs.
   — Lynda L.

July 18, 2002
Hi Amy! Donna actually summed it up for you and Lynda was on the money with regard to flexibility. As a Federal employee, I had always had HMO UNTIL I made the decision for WLS and the surgeon I chose. I knew after looking at the Explanation of Benefits during Open Enrollment what I'd be in for. Now I'm inclined to believe that between PPO and POS you *sometimes* have a better chance of going out of network if that is what you prefer. I like the freedom of MY choosing who I want for whatever I'm interested in. Basically because I'm *choicey* like that. Going out of network oftentimes may cost you more (unless you are well-prepared financially), but IF you are happy with the professional you've chosen, and have done your homework, then it may well be worth it!!~~Best wishes in your decision~~Hadiyah
   — yourdivaness

July 18, 2002
Hello! Most PPO companie's it is easier (in my expirence) to get the surgery approved, etc. On an off note, I've found that certain companies (ie: Pacific Care) at least in the plan my worl had, would only cover WLS under the HMO. I'd call them and ask all the questions you could think of :)
   — Heather H.