PPO vs. HMO?

kaykaye · 11-25-2008, 07:15 AM

I was just wondering what the difference between a PPO and an HMO are. Right now I have an HMO, but I'm looking to switch to DH's work insurance (a PPO) because as I understand it, if there are more than 25 employees covered, they're required to cover infertility treatments (this is in Illinois). But I don't know what his plan is like versus mine. They're both with the same company (Health Alliance). I'm super clueless about insurance stuff!

BekTens · 11-25-2008, 09:32 AM

I'm no expert, but from what I understand, HMO's are generally cheaper, but they're much more strict about what they cover. I have an HMO, and fertility treatments was 100% out of the question.

The nice thing is the ow co-pays - $15 for visits, $20 brand name drug, $5 generic drugs

PPO's cover more, but they're more expensive. I don't know how much the premiums differ, but as far as co-pays, my parents have a PPO. They pay $30 for a visit, $40 for brand name drugs and $15 for generic drugs.

Of course, every plan is completely different, but from what I understand, you pay more money out of pocket for PPO but you have much better coverage.

*~SugarPlums~* · 11-25-2008, 11:49 AM

Could you have dh get a copy of his plan so you can compare?

Dh worked for a company in Illinois and he had HMO. That plan covered fertility up to 3 ivf cycles. I never had a problem with them not paying anything. During my pregnancy with the twins all I paid was 1 10.00 co-pay during my first prenatal visit, then 30.00 for training we had to take for the breathing monitors we took the twins home on. They were in the nicu for over a month.

Then he got another job, same state, ppo. I am grateful that I get to go to whatever Dr I choose but no in fertility coverage what so ever, not even clomid, not even diagnostics test. He worked for a union and there was over a 1000 employees, so I am not sure about the details of that law.

We are getting a new insurance in January, another ppo. Again, grateful to be able to keep/choose my Dr's but it seems to have a lot more restrictions to me than my old HMO.

For instance, because I am high risk for a number of reasons, I have to have multiple ultrasounds, I am scheduled 3 this year and we only have a little over a month left. My ppo now is covering them, but the one that goes into effect in january on allows 1 ultrasound per pregnancy. I will have to be fighting them a lot.

RunnerDuck · 11-25-2008, 12:21 PM

You can't just say HMO vs PPO - you have to look at the list of benefits.

I used to think HMOs were across the board bad... but with DHs old company we had a choice of PPO with no infertility or HMO with full infertility except for IVF. I don't know why they didn't cover IVF...

I was for the most part really happy with the HMO - but it was Kaiser Permanente which seems to be well known for having their act together. The one thing in the end I didn't like about it is how heavy handed they are when it comes to pushing multifetal reduction on women who concieve higher order multiples through the infertility clinic - one problem with an HMO is if you try to get a second opinion within the network you may be just asking a different person who has the same goals/policies/etc in mind. But up until those last few horrible months, I was really happy with the HMO and miss a lot of aspects about it. (Though there were some aspects I hated - like there being a big call center you'd call for advice/appts rather than actually knowing your doctor's phone number)

You would need to talk to someone in HR to get a full breakdown of benefits and what they really mean.

kaykaye · 11-26-2008, 07:58 PM

Thanks, everyone! DH has a meeting next week to find out what the benefits are and such, so I guess I'll find out when he does. (Hopefully he'll bring home lots of papers, because I know he won't remember half of what he hears!)

PookASaurus · 12-11-2008, 01:17 AM

Be careful switching to a PPO in Illinois - check into the infertility coverage on the PPO first. Not only does the company have to have 25+ employees but it also has to be headquartered in Illinois and not be self insured. If the company doesn’t meet just one of those requirements, the mandate doesn’t apply and the plan doesn’t have to cover infertility... Unless there is an established HMO network.
Example - I live in IL. DH works for a large company that is not self insured (our insurance company is a major one). However, because DH’s company is headquartered in California and we have a PPO (only offered a PPO)... We have nothing. Not a single thing, diagnostic or otherwise, regarding infertility is covered.

Just a heads up to double check

mscysters2 · 10-12-2009, 07:39 AM

SugarPlums, you can get your new insurance to cover all the u/s you need, you just need to your ob's office to code it w/ the correct high risk codes along with possibly having your ob's financial administer talk with your ins. company about it.

angel1823 · 11-16-2009, 01:55 AM

With my company's options the basic differences between the HMO and PPO are that the HMO is cheaper (premium wise and copay wise) but there is coverage ONLY for in-network doctors, hospitals, etc. With the PPO the insurance is a little more money out of each paycheck but I can rest assured if I'm out of state and get sick I can go to a doctor there and know I'll have coverage even if it's not 100%. I believe out-of-network doctors are paid on a coinsurance basis, such as 80%. So if the doctor bills $1000 the insurance will pay $800 and I'll pay $200, which stinks, but it's better than with an HMO which would pay $0 towards that $1000.

I switched jobs in 2008 and that's my current company's plan. Under my former company's plan the HMO required referrals to any specialists. So basically if I wanted to see a chiropractor, a podiatrist, a dermatologist, or an endocrinologist, I had to call my primary care/family doctor and get a referral. Sometimes they wouldn't give me the referral and would ask me to come see my primary doctor first to see if she could deal with the problem (such as for skin problems). The following year I switched to a PPO because I wanted the freedom to go to whatever doctor I wanted. The premiums and copays were both higher but it was worth it to me to be able to see a dermatologist if I wanted.

Really you should get both plan documents and compare. It may be hard to make a decision as both may have pros and cons but think about what your needs are and decide based on that. Good luck!