Question:
CAN ANYONE TEL ME THEIR FEELING ABOUT A PPO VS. HMO

i have bcbs of fla. health options, (HMO), and have the opportunity to switch to PPO for a little more money. i am in the process of getting approved and want the best care possible after surgery. what do yall reccomend?    — Tica G. (posted on January 9, 2002)


January 9, 2002
I think with HMO's, your choices can be very limited because of the narrow scope of their network. I have an HMO and I believe there is one general surgeon in my plan who performs WLS and he is not a member of any bariatric surgeon's association. I hear he's actually good, but he's WAY backed up. If you go with a PPO, you are not as constrained. That is how I understand it. Hope that helps.
   — Carolynn J.

January 9, 2002
I have a co-worker that has our company's PPO. She went to the BTC in Belvidere and had open RNY, she ended up paying around $9,000 out of pocket. I have our company's HMO and am going to Chicago's Northwestern University Wellness Institute, and will probably be having Lap RNY. My only out of pocket costs will be a few $5.00 co-pays. Before you say "Oh, my God!" she had a PCP that recomended against WLS, my PCP introduced the idea to me. She had a BMI of right around 40, mine is 46. She had no co-morbidities and I have a seriously screwed-up back. Take these factors into consideration, I think the biggest reason to go with the PPO would be if you had a great Doctor and they were out of the HMO you were offered. I have BCBS and I have been told many times by many people there that I will be approved with no problem what-so-ever. Probably because they know that they will have to shell out even more on my back surgeries that I will need if I don't get my weight off, heck they will probably make their money back in a few years from me not filling 8 prescriptions every month!
   — Andrew R.

January 9, 2002
I have Cigna PPO, and had no problems getting approved, and I've had no problems getting them to pay their part of the surgery costs. I really love the flexibility they offer, and am especially happy that I can go to any specialist I want without a referral from a PCP, and I also love the fact that I can change PCPs without any hassle.
   — blank first name B.

January 9, 2002
I had United Healthcare PPO. There were waiting to approve me before the doc got all the paper work to them! They were awesome. Cost to me for my surgery? $15.00
   — Lisa U.

January 9, 2002
I have BCBS PPO and my deductible for the yr is $250 and out of pocket max is $750 for a total of $1000 a yr. I had already met my deductible so when I went for my surgery at BTC at Belvidere, after the discount I was only responsible for about $600 and they take payments for your balance. It does depend on the plan you have for a PPO and what the percentages are, the deductibles and out of pocket max,but PPOs are less restrictive for where you can go.
   — Judy K.

January 9, 2002
The major difference between PPO and HMO is the amount of control you want over your own health care. With an HMO, they essentially choose the doctors you will see, the medicines you can take, the tests that are "warrented", the surgeries that are needed, the hospital time you are allowed regardless of complications, and so on. With a PPO, YOU choose, YOU decide if you want generic or not, or if one medicine is what you need, you can get it without having to wait three or more months for your HMO to decide if you REALLY need that medicine since it costs 10cents more per pill than this other one that almost does the same thing... and so on... get the picture?? Take the PPO... you won't regret it.
   — Sharon H.

January 9, 2002
The biggest difference between an HMO and a PPO is that with an HMO, if you don't stay 'in network', they don't pay, unless they refer you out of network. You also usually need a referral from your PCP to see a specialist. PPOs allow you to see anyone in or out of network. Now they pay a bigger percentage if you use in network providers than for out of network. The really tough part about making those kind of decisions is that you have to really look at the options you are being offered. You have to know what it is you want/need from your health insurance. Will your PCP refer you to a specialist if you need it or will they decide they can treat anything that's wrong with you whether they really have the knowledge required? Are you willing to pay the higher amounts required from a PPO? You nearly always have a deductible to meet and then the insurance pays a percentage of the costs. This is nearly always more than a typical HMO co-pay. Only you know what your insurance needs are and only you can make the decision about what kind of plan to choose.
   — garw

January 9, 2002
Hi, I work for a major health insurance company and I think I can answer you question briefly and accurately. An HMO will pay more (usually around 100%) but you are limited as to your choice of providers. If you see a doctor that is not on your plan your insurance company pays the big goose egg. ($0) PPO plans are more flexible in that you have more choices as to providers you want to see. If you see a participating provider a PPO pays a little more (usually 80% after your deductible if any. If you see a non participating provider it will be subject to a higher deducible and you plan will pay less (generally 60% or thereabouts.) In my opinion there is no better or worse as it relies much on personal preference. Good luck no matter what!!!!!!! :)
   — Christina M.

January 9, 2002
PS... I have an HMO with my company. I got a referral from my participating Primary Care Physician to a participating surgeon. The plan paid 100% for the surgery. I have only paid one $10 copay for my initial consultation. I couldnt be happier with the way it turned out. Hope that helps a little... again best of luck to you!
   — Christina M.

March 19, 2003
Hi Tica...sorry, I just checked this site and hope it's not too late to advise. Switch, if it's not too late. I HATE HMO's. I've tried them twice and got out quickly. The list of participating drs is excellent and you will get partial for those who don't participate. I haven't had any trouble keeping in the list. Good luck.
   — Stella E.

March 20, 2003
I have an HMO and I couldn't be happier, I pay nothing out of pocket, they have been fantastic about getting all my referrals in a timely matter, I have never waited more than 48 hours for anything to be aproved. I think the key is not only the "right" HMO but having a really good PCP is the biggest factor in my humble opinion. Even though the choices are limited my HMO has contracted a REALLY good surgeon, I couldn't be happier.
   — Sarah S.




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