Question:
I have BCBS HMO and have a chance to be a PPO? Which one?
I have had BCBS HMO for 3 years and I have the option of selecting a PPO if I want. Does anyone have any thoughts? I am BCBS of Fl HMO and my surgeon is Dr. Paul Wizman. Thanks ahead of time for an answer. Tara — Tara J. (posted on June 2, 2003)
June 1, 2003
I had BCBS of FL, HMO for years but when I started my WLS journey, I also
had an opportunity to switch to a PPO. I was told it was slightly better
because you don't need to get a referral from your PCP every time you need
to go to a doctor. I switched. I guess what counts is knowing what
exclusions the employer may have written in the policy.
— Kim W.
June 1, 2003
If you plan on having a lot of medical bills, I would go with the
HMO..because they usually pay at 100%....you'll just have to check to see
if your doctors/hospitals/surgeons are in network for you...otherwise
you'll probaly have NO out of network benefits...PPO's are better in some
ways because you can choose whoever you want as a doctor etc...but you'll
have more costs that way. See if you can get a list of everything they
cover compared to the HMO list and make your decision that way...but after
you've checked on a few things.
— Heather D.
June 1, 2003
One PPO beats an HMO anyday - even sitting down lol
— [Deactivated Member]
June 1, 2003
I think it would depend on the particular provider's HMO and PPO plans. I
have had an HMO for about 8 years and it's served me quite well. I've
never had a problem getting my PCP to make referrals for specialists, I've
got a great prescription plan, low co-pays and my hospitalizations are
covered 100%. I was in the hospital 7 times in 2001 and 2002 for non-WLS
problems and all I had to pay was TV & telephone charges. No
deductibles to worry about, no out-of-pocket maximums. HMO's are the plan
for me...JR
— John Rushton
June 2, 2003
I had the HMO which had an exclusion for Obesity surgery and changed to the
PPO. If your HMO plan covers Gastric Bypass keep it. It certainly is
cheaper! I had no choice but to change mine and I'm quite glad I did. My
surgery is 7/11 and I had no problems getting approval at all. I met the
criteria and was approved over the phone!
— Shelly R.
June 2, 2003
Hi Tarra,
I have BC/BS of Fl Health Options (HMO) and I was denied with 2 hours. I
appealed their decision and told them that they were ridicous to have
denied my surgery. The next day after my appeal review I was APPROVED!
It doesn't really matter what insurance company you have. You need to met
the medically necessary guildlines. You may have to go to a lot of
"bull-crap" to prove it but don't give up.
Good Luck
Jeanette
— Jeanette D.
June 2, 2003
Tara,
We switched to PPO this year and love it. As long as my doc is in network
I don't have to pay any more than with a HMO (with a lot less hassle).
Click on insurers above and then Florida and look at the differences
between the types of insurance. It seems like most of the BCBS PPO are
approved after first letter. That was just after a first glance. Also ask
your doc if they come under whatever plan you are looking at. The comfort
of not having to wait for my PCP for a referral is huge to me. Good Luck.
— [Deactivated Member]
June 2, 2003
We had BCBS HMO for 6 years and just switched to PPO and it seems to be a
little better, my Doctor said it was a better insurance too. I'm crossing
my fingers for PS!
— Sandy M.
June 2, 2003
I have BCBSFL Health Options.. I was denied on first request and approved
on first appeal.. probably would have been approved first if my PCP's
letter of medical necessity had not been buried in the middle of my medical
records and no one found it til I spoke to someone in the appeal office. As
someone below said, although it's a hassle to get referrals with HMO's, the
PPO usually has a higher copay than the HMO. With either, the main thing is
that you can prove medical necessity. If you can, you'll get approved.
Good luck !!
— Bonnie
June 2, 2003
Tara, I believe BCBS PPO is better. In my case I pay more because mine is a
Federal Plan~overall though, it's better because the "control" is
in your hands...you can pick and choose your own healthcare providers and
specialists.
Hadiyah~~~LAP RNY 265/159/115-126
— yourdivaness
June 2, 2003
Hello Tara,
I also just changed from a HMO to a PPO. I live in MA but my employees main
office is in PA so all our benifits come out of there. I have Highmark
BC/BS of PA PPO. As of the first of this year we changed from the HMO to
the PPO. I have to pay more for it and my co-pays went from $15.00 to
$25.00 for office visits and I have a deductable of $800.00 for the year on
a family plan. Now each plan is differant and it all depends on what the
employer signs up for. I was approved for WLS in four weeks. It was very
easy. No problems at all. From what I have been told by the doctor and
others that have BC/BS HMO, it is easier to be approved with the PPO then
the HMO. I didn't have any problems with the PPO and I don't know of anyone
that did have problems but I do know of a few people that had problems with
the HMO. SO with all the being said, it is going to have to be a personal
choice that you make. I would look into seeing what the deductables are and
if that aren't that high, it might be worth going with the PPO. I love the
PPO. I don't have to ask my primary doctor for referals. There is no more
begging to see other doctors. My daughter had a bed wetting problem and her
primary I had under that HMO would let me go to see specialist. He kept
telling me she would just out grow it. But being a mother and having a gut
feeling there was something else going on I just wanted to go and have it
check. But the doctor wouldn't okay the referal. When we changed to the
PPO. I was able to go to the specialist without my primary doctor's okay
and come to find out there was a problem and she had to have surgery to fix
it and she is all better now. No more bed wetting!!! So I am a big
supporter for the PPO if you can afford the co-pays and the deductable. I
know for my family it's been a little hard. I have had to work extra hours
to cover the cost of the insurance but it has been well worth it!!!
Good luck with whatever road you decide to take!!!!
— LMBeaton
June 3, 2003
Tara - I have Empire BC/BS PPO (NY) and I love it. There's nothing wrong
with HMOs, but I chose the PPO so that I would have more flexibility and
more choices. I understood that it would cost more than a traditional HMO,
but like I said you're paying for the flexibility of both types of plans -
paying little or nothing for in-network, and 70/30 or 80/20 for out of
network. And either way, you don't need referrals. For me, it seemed like a
win-win-win situation.
— [Deactivated Member]
June 3, 2003
I think as long as you have a PPO, you'll be pleased. It might involve
paying a little bit more, but overall, it's the best thing to do~it really
depends with the state you are in and what is outlined in your plan
(benefits package). Not sure if I mentioned that earlier.
— yourdivaness
June 3, 2003
I would stick with the HMO, I have BCBS Of GA PPO my friend BCBS of GA HMO.
Her copays are lower(mine 20 hers 10), for prescriptions I have to pay
full price and then get reimbursed 80% she only pays a copay for any meds.
I'm responsible for the other 20% of all my bills , she's not . For her
surgery she had to pay a small copay $100 to the hospital I had to pay my
$500 deductible and 20% of the bill. Also I had a pre-existing condition
with PPO and had to wait a year she got her insurance and in 3 months
applied for surgery got approved in 3 days took me 10 .
— Kimmie C.
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