To switch, or not, from HMO to PPO? (3 months after surgery)

[realkarl]

My company's open enrollment period has started, and I am considering switching from the HMO I have always been on, to Regence PPO.

I didn't really utilize my insurance benefits much until I was diagnosed with my heart problem, and I have been very happy with how my surgery turned out, incl the choice of surgeon, which I realize now was very fortunate considering the limited choices I really had with my HMO.

However, now the limitations of the HMO are starting to become problematic. I am no longer very happy with my cardiologist, and would like to choose my own. I am not sure if I am going to be able to get home INR monitoring equipment (I will have to ask Regence about that before the deadline as well).

Did anyone here switch from an HMO plan to a PPO plan before or after your surgery? I am a little hesitant mostly because I am not sure how to best go about finding a PCP, and a new cardiologist I am happy with. It will be more expensive, but that's OK. I will also have to setup a flexpay account to cover the 20% cost of follow-up echocardiograms etc.

Any thoughts?

Karl.

 

[Lynlw]

I know many people have HMOs and are very happy with them. I don't know if the fact they are generally pretty healthy and don't have to deal with specialists, ect helps, but you asked our thoughts.
We Never had a HMO, but chose PPO when that became a choice. I LOVE it now ours is BCBS/ (NJ) so I don't know about your company, but I am so glad I do not need to get referals for anything, that would drive me nuts having to ask permission from our doc to go to any specialist we wanted/needed to go to and that was why I didn't pick the HMO years ago. Since then and everyone in my family goes to some kind of specialist, I appreciate it even more. Often when you need to go to a specialist like cardiology or OHS, it is already a stressful time, I can't imagine having to add another step (getting referal for every doctor) to the process not to mention mention getting referals for each test the specialist thinks you need. This is about Ears, but I just grabbed one of the first examples I saw. http://www.childrens-healthcare.com/hmo.html
"Occasionally a specialist may wish to perform a test on your child. For example, if you are seeing an ear-nose and throat specialist, and you have a referral for a consultation only, he may not do a hearing test on your child unless that has been authorized prior to the visit. This is because HMO says we can do hearing tests at Children's HealthCare, and therefore can not give a referral for a service which can be provided for at our office. If you want the specialist to do a test, eg. a hearing test, without prior authorization, you are free to pay the specialist yourself."

and the last thing I would want to do is have to worry about getting a referal when you need to go to the ER, would be calling to get a referal and most plans I've read, won't approve it after the fact, even in emergencies, so you would have to pay out of pocket. Also with our PPO we've never picked (found) a doctor that wasn't in network, even going out of state ect was not a problem, as long as that hospital was in network for the people that live in that area, it was in network for us.
Even in chronic problems, like my monthly pain management, I don't know if this is how all HMOs work) but I go every month and have for years, but the patients that have HMO, need to get new referals every few months, which I think is ridiculous, I think if that doc was approved for the first appt for an ongoing problem, that should be fine for ever or at least a year or so.

PS I don't know if this is any help, but when I was reading the best of hospitals the other day I noticed they have an article on best healthcare plans http://health.usnews.com/sections/health/health-plans/index.html

 

[dick0236]

Karl, normally HMO's (Health Maintenance Organization) are more restrictive in the joice of providers....most require that you use "in-network" providers (hospital, physicians etc). If you go "out-network", usually there is no coverage. HMO's often cover more preventative services than other health plans. HMO premiums and out-of-pocket costs often are lower than plans like PPO's. Fundamentally, PPO's (Preferred Provider Organization) offer both "in-network" contract benefits and "out-network" benefits at a higher co-pay or out of pocket cost....and usually are a little more expensive than HMO's. If you can't find acceptable providers in your HMO, go ahead and switch from the HMO to PPO during the open enrollment. During the open enrollment, any pre-existing conditions that were covered by the HMO should be covered by the PPO. Make sure that this is true.

I've had both type plans over the years with equal satisfaction....or equal dissatisfaction.

 

[ALCapshaw2]

Two points of Caution:

Be SURE that you have Coverage At All Times
when making a switch.

Be SURE that your Pre-Existing Conditions will be covered if you switch.

I am biased against HMO's due to my Strong Preference to be able to Choose my own Doctors without the need for a referal.

 

[Debster]

Two points of Caution:

Be SURE that you have Coverage At All Times
when making a switch.

Be SURE that your Pre-Existing Conditions will be covered if you switch.

I am biased against HMO's due to my Strong Preference to be able to Choose my own Doctors without the need for a referal.

Absolutely! I am not the valve patient-but I love our PPO-not having to deal with pain in the butt referrals is awesome!

 

[james]

Karl,

As has been said. Make sure you have no lapse in coverage. Most company offered plans with choices do not lapse but, look anyhow. I believe that I got very lucky in getting to the clinic in Seattle I found and they are in the Regence network. That being said when I was healthy I really liked being with Group Health. I also lived on 14th at the time so the one block walk to the hospital was easy....