Hatrack River Forum: HMO vs. PPO: Any HMO horror stories?

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Posted by vwiggin (Member # 926) on :

My dad is changing jobs and he is switching from a PPO (healthnet) to an HMO (a small company called pacific something).

I'm a little concerned because my dad, who is 62, received two angioplasty this year. Although he is doing well, I'm sure there will be complications down the line.

Does anyone have any HMO horror stories to share? We really like my dad's current PPO plan. He can pick his own specialists and basically go to the doctors as often as he likes as long as we're willing to pay the deductible.

Are we going to have any problems with our HMO?

quote:

* HMO members must choose a primary care physician (PCP) from among the HMO member physicians. The PCP provides general medical care and must be consulted before you can see a specialist, who must also be part of the HMO. PPO members do not choose a primary care physician and can refer themselves to specialists.

* HMOs typically provide no coverage for care received from non-network physicians (with exceptions for emergency care while traveling, etc.). PPO members are not required to stay within the PPO network, but there is usually a strong financial incentive to do so. For example, the PPO may reimburse 90 percent of costs for care received within the network, but only 70 percent of costs for non-network care.

* HMOs typically do not set deductibles that must be met before insurance benefits begin (e.g., $5 or $10). Instead, HMO members often pay a nominal co-payment for care. In contrast, PPOs sometimes require members to meet a deductible (especially for hospitalization) and may have larger co-payments than HMOs.

Insurance.com

Posted by ludosti (Member # 1772) on :

If his current cardiologist and general practitioner (and any other specialists he sees) are on the list of approved doctors for the HMO, I think switching to the HMO shouldn't be too big a deal.

[ December 02, 2004, 01:52 PM: Message edited by: ludosti ]

Posted by jeniwren (Member # 2002) on :

I don't have any horror stories, but will say I like being on a PPO plan better, even though it means higher out of pocket expenses. I don't qualify for our HMO option anymore because there are no HMO PCP's for my insurance company in my area. But I can't say I miss it. When I was on the HMO plan I had exactly two choices for PCP: Planned Parenthood (PP) and a PP associated clinic here in town. I have big problems with PP's philosophies and would pretty much rather pay out of pocket for a Dr. who fit my moral beliefs than be forced to give PP my money.

Posted by vwiggin (Member # 926) on :

That's a good question ludosti. I don't think his current doctors are on the list but I've been told the new HMO he is joining has a pretty decent list of doctors.

Posted by Shan (Member # 4550) on :

Stick with the PPO, Beren, absolutely. I went to an HMO this past year, and the experience was horrendous. Pacificare was the name of the insurance company. I am going back to the PPO I was with for the last three before Pacificare and getting reasonable and good service, including the ability to choose my provider, my son's provider, etc.

Posted by vwiggin (Member # 926) on :

quote:
Pacificare was the name of the insurance company.

Thanks for the warning Shan. [Smile]

I'll send you an email for more details.

Posted by rivka (Member # 4859) on :

If Pacificare is the HMO in question, it is not a small company. OTOH, it ranks fairly low on HMO rating scales like this one.

Posted by Belle (Member # 2314) on :

I don't have any real horror stories, I just hated the paperwork and time involved in getting referrals from my primary care physician when I was in an HMO. Especially when I was going through treatment for endometriosis, and had to keep calling and getting referrals for all those visits to my gyn. Not long after a law was passed that made it possible for women to get healthcare from their ob/gyn without needing a referral, I think that was an Alabama law.

Anyway, now I'm on a plan that doesn't require any referrals and I like it so much better.

My only horror story from insurance came from a company telling me that when I switched to their plan, physical therapy for my son would be covered, and then when I switched, I found out the agent either outright lied or was completely incompetent because it wasn't covered.

Posted by vwiggin (Member # 926) on :

This is very helpful guys, thanks. I'll pass on the information to my dad and see if we can switch him to a different plan.

That's a great find Rivka. 37 out of 49 is a terrible ranking. Thanks for pointing it out. Ironically my dad's current provider, Healthnet, ranked 36. [Eek!]

Jeni and Belle, thanks for sharing your personal stories. I know healthcare-related issues are kind of personal, so I appreciate you talking openly about such a private subject. [Smile]

Posted by Shan (Member # 4550) on :

The horror stories coming your way via e-mail, Beren. Pour yourself a stiff drink . . .

[Big Grin]

Posted by vwiggin (Member # 926) on :

Wow. [Eek!]

How about a hug to go with that drink? [Razz]

Posted by Shan (Member # 4550) on :

That's nothing - I've heard worse.

But I'll take a hug from you any ole' time.

[Kiss]