HMO vs PPO

by Guest » Tue Mar 03, 2009 05:04 am
Guest

Hi All!

It seems that there are plenty of learned people available in this community. I’m glad that I’ve found you. :D

I was all decided to buy health coverage before I was struck by the options available to me. I didn’t know that so many things you have to learn to choose the right coverage. :shock: And, therefore I’m here. I’d like to ask a very stupid question to y’all.

What are the differences and similarities between HMO and PPO plans?

Curious_kid

Total Comments: 22

Posted: Sun Nov 14, 2010 12:46 am Post Subject:

also does anyone know if a provider is the ppo and or hmo?

thanks

Posted: Sun Nov 14, 2010 01:04 am Post Subject:

Let's see if I am correct. I did some research and was able to find something. An or the insurance company is the HMO or the PPO right? And the policies they offer can be called HMO or PPO or more specifically for example Medicare HMO right? Can someone ellaborate if needed?

Thanks,
Nicholas

Posted: Sun Nov 14, 2010 03:09 am Post Subject:

The insurance company isn't an HMO or PPO. The policies that they offer can be HMOs, PPOs, POSs, etc.

Many carriers offer more than one type of policy. In my state Connecticare solo insurance sells both HMOs and POS policies.

An HMO policy is often cheaper because it offers out-of-network care only during a medical emergency. This costs the insurer less because they have negotiated lower fees with the doctors and hospitals in the network.

Posted: Sun Nov 14, 2010 04:50 pm Post Subject:

compared to what maxherr said in another statement it is. I will take what i learned from both. from "If I go to dr. who is in my network" post he said, "Yes. It's the company that creates the network. Originally, PPO networks were created by the doctors/hospitals to compete with the HMOs -- offering the advantage of more freedom of choice. But they were quickly overrun by the same companies offering the HMO plans -- doctors really don't know that much about running an insurance plan . . . they went to school to learn to take care of people instead.

There are, however, several HMO/PPO organizations that are "physician-owned". Doesn't necessarily mean they are better or have lower costs, but their motivations for being in business may be a bit different. Nevertheless, they are in business for the same reason as any other insurance company . . . to make money."

So I would say it is the insurance company.

Posted: Sun Nov 14, 2010 07:23 pm Post Subject:

An insurance company can offer HMOs only or they can offer PPOs only. They can offer both and many do.

An HMO is a type of policy. If an insurer only offers HMOs then I guess that you can say that the insurance company is an HMO.

But this can lead to the assumption that a carrier can only offer one type of policy and that the network will be the same regardless of which of their policies you buy.

Posted: Sun Nov 14, 2010 10:17 pm Post Subject:

yea if i remember correctly, blue cross offers mediblue ppo's and mediblue hmo's. so i don't know what to call the blue cross company.

Posted: Sun Nov 14, 2010 10:50 pm Post Subject:

To answer the original question:

If you have an HMO, you can only see doctors and other providers that are in the network unless there is a medical emergency. For this reason these policies are often less expensive.

With a PPO you are encouraged to see doctors in the network because you will have a lower cost share. Your deductible and /or coinsurance and/or copayments will be lower if you stay in the network. However, you will get some coverage when you go out of the network even for non emergency care.

Emergency care is usually reimbursed the same way whether it is received in network or not whether you have a PPO, a POS or an HMO.

Posted: Mon Nov 15, 2010 04:55 am Post Subject:

Emergency care is usually reimbursed the same way whether it is received in network or not whether you have a PPO, a POS or an HMO.



I beg to differ. In network emergency services are always covered at the negotiated HMO/PPO rates. But outside the network, whether HMO or PPO, the "usual, customary, and reasonable" provision usually applies.

This could mean that the subscriber has a larger out of pocket expense in an emergency outside the network. But the HMO must cover emergency care outside the network -- as long as it is a true emergency.

Posted: Mon Nov 15, 2010 05:28 am Post Subject:

The insurance company will not have the advantage of having negotiated a rate with an out of network provider. So the above is correct to a point.

However, the cost shares such as the deductible and coinsurance will usually be the same when one gets emergency care outside of the network.

When one attempts to get routine coverage outside the network with a PPO, they will pay a higher deductible or somehow have a higher cost share.

When one attempts to get routine care covered outside of the network with an HMO none of the expenses will be covered.

Posted: Sun Nov 21, 2010 12:03 am Post Subject:

Firey One, you said "I do not know if this applies but maybe someone will know. My plan is PPO. I know any time I need a test like say CAT scan, or maybe some type of medical equipment it has to go through an approval process. Sometimes this can take a few days even if the tests or medical equipment is labeled urgent. I never had HMO so I am not sure if they have the same rules and guidelines. I do know that it PPO is restrictive on some thigns. If you go out of network you must swollow a, lot of the costs but one good thing is a lot of places are in network." It is true working at a durable medical equipment company does take a while to get authorization for the itens. My work is backed up because of all the authorizations I need to get. I really like this post though. It really helped me understand a lot about the HMO's and PPO's.

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