All this HMO PPO POS stuff has me quite confused! I am very lucky in that I have always had great insurance coverage through my dad's work. In November I am getting married and will be covered by my husbands work insurance until I get a job. He just started this job and has three choices when choosing insurance. Blue Cross Blue Shield HMO, Blue Cross Blue Shield PPO or United Healthcare POS. Can anyone explain the differences in these three? With the information he recieved, it looks like the HMO is the best deal, but I do NOT want to get bad health insurance b/c I know what a headache that can be. If anyone can explain, give suggestions, or even point me to a website that might help, I'd appreciate it! Thanks! Oh, and I'm in NC if that makes a difference.
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Insurance help please!
- Thread starter jenhum
- Start date
With an HMO you HAVE to get a referral to see a specialist, or any doctor other than your PCM (Primary care manager/Primary care physician). If you could find a primary doctor who took the HMO insurance and would be willing to have an "open" referral to a CF specialist that would be the best way to go as you will pay the least that way. Trouble is finding a doc who will refer you. My husband was on an HMO for a while but it worked well for us because common colds and stuff he would see the PCM but the PCM would always say, "do you want a referral to the CF doc". Usually he would say no but if he ever did say he needed a referral to the CF specialist/clinic it happened in a heartbeat.
With a PPO, you can pick whichever doctor you want BUT you pay much more out of pocked, and with some PPO plans, you have to still choose someone who accepts their insurance but is "out of network".
As far as POS, I am not familiar with that but recommend you type United Healthcare POS into the MSN or google search engine and you will be able to get a description.
Julie (wife to Mark 24 w/CF)
With a PPO, you can pick whichever doctor you want BUT you pay much more out of pocked, and with some PPO plans, you have to still choose someone who accepts their insurance but is "out of network".
As far as POS, I am not familiar with that but recommend you type United Healthcare POS into the MSN or google search engine and you will be able to get a description.
Julie (wife to Mark 24 w/CF)
A
arabeth
Guest
Hi Jenny,
Unfortunately it's very hard to give any real helpful info on insurance in a general sense because so much is dependent upon the employer who provides the coverage. They determine most of what's covered and what's not. However, to just sum up the differences between HMO/PPO/POS it's basically what Julie already said. HMO's require a primary care provider who will determine everything you are allowed to do medically (what drs you can and cannot see, what hospitals, etc...). If you have a great primary care provider who is willing to give you the referrals you need, it's not that big of a headache. I worked for BCBS for several years and therefore had that insurance. I had an HMO and my Primary care clinic would give me 4 referrals a year for the CF Center automatically to cover the 4 visits we usually made and if we needed more it was never a problem. Unfortunately many drs aren't that nice about it. Primary care providers do not usually like to give referrals unless they have to. With CF it's always a have-to case so most are fine with it.
PPO stands for Preferred Provider Organization and that basically speaks for itself. To be "in-network" you just have to see drs who are within the Preferred Provider Organization with your insurance company. Usually that is a great big list so it's not a problem. You don't need a primary care provider and can change drs every day if you want so long as the dr you choose is in that organization. And you usually have out of network benefits too, but you will pay much more of the cost. PPO's are great if the policy you have is a good one. Again, that depends on where you (or your spouse) work. Most PPO's have copays for dr visits and sometimes deductibles for hospital stays. They vary greatly though.
POS stands for Point of Service. POS is a cross between an HMO and a PPO. You have to choose a primary care provider and you have to get referrals, but there is a second level of benefits if you choose not to see your primary care provider. With an HMO you cannot go anywhere without a referral but with a POS you can, it's just that you will pay more out of pocket.
Insurance can be such an overwhelming part of life, especially for those of us who depend on it so much more than the average person. It's important for everyone but can be life or death for people in our situation. HMO's will almost always be less expensive because the insurance company is saving so much money that they lower the premiums. They have a set fee that they pay your primary care clinic and don't have to worry about you running around seeing all these different doctors and racking up bills so it's great for them. And as long as you have a primary care clinic who is willing to work with you, I'd say go for it. Just make sure of that up front. Otherwise it will be a huge headache for you. Ask the dr you want to choose as a primary care provider up front if he/she is willing to give you a referral for so many (however many you need) visits to your CF dr. Have that done beforehand to prevent problems. With an HMO you have absolutely NO coverage without a referral so that's very important.
Hope this helped a little...Best of luck to you!
Unfortunately it's very hard to give any real helpful info on insurance in a general sense because so much is dependent upon the employer who provides the coverage. They determine most of what's covered and what's not. However, to just sum up the differences between HMO/PPO/POS it's basically what Julie already said. HMO's require a primary care provider who will determine everything you are allowed to do medically (what drs you can and cannot see, what hospitals, etc...). If you have a great primary care provider who is willing to give you the referrals you need, it's not that big of a headache. I worked for BCBS for several years and therefore had that insurance. I had an HMO and my Primary care clinic would give me 4 referrals a year for the CF Center automatically to cover the 4 visits we usually made and if we needed more it was never a problem. Unfortunately many drs aren't that nice about it. Primary care providers do not usually like to give referrals unless they have to. With CF it's always a have-to case so most are fine with it.
PPO stands for Preferred Provider Organization and that basically speaks for itself. To be "in-network" you just have to see drs who are within the Preferred Provider Organization with your insurance company. Usually that is a great big list so it's not a problem. You don't need a primary care provider and can change drs every day if you want so long as the dr you choose is in that organization. And you usually have out of network benefits too, but you will pay much more of the cost. PPO's are great if the policy you have is a good one. Again, that depends on where you (or your spouse) work. Most PPO's have copays for dr visits and sometimes deductibles for hospital stays. They vary greatly though.
POS stands for Point of Service. POS is a cross between an HMO and a PPO. You have to choose a primary care provider and you have to get referrals, but there is a second level of benefits if you choose not to see your primary care provider. With an HMO you cannot go anywhere without a referral but with a POS you can, it's just that you will pay more out of pocket.
Insurance can be such an overwhelming part of life, especially for those of us who depend on it so much more than the average person. It's important for everyone but can be life or death for people in our situation. HMO's will almost always be less expensive because the insurance company is saving so much money that they lower the premiums. They have a set fee that they pay your primary care clinic and don't have to worry about you running around seeing all these different doctors and racking up bills so it's great for them. And as long as you have a primary care clinic who is willing to work with you, I'd say go for it. Just make sure of that up front. Otherwise it will be a huge headache for you. Ask the dr you want to choose as a primary care provider up front if he/she is willing to give you a referral for so many (however many you need) visits to your CF dr. Have that done beforehand to prevent problems. With an HMO you have absolutely NO coverage without a referral so that's very important.
Hope this helped a little...Best of luck to you!
I used to work in insurance, so here it goes.
HMO: DO NOT PICK THIS EVEN THOUGH IT IS THE CHEAPEST! Reason being is there is no out of network coverage. You have to pick a doctor and go inside the network for ALL your health care. So, if there is a doctor right now in the plan that is a CF specialist, you will have to coordinate your care with your primary doctor to go see the specialist. The primary and specialist ALL have to be in the network or you can not see them, including the hospital.
PPO: BEST PLAN TO CHOOSE. You have in network coverage and out of network coverage and you do not need to pick a primary doctor and coordinate your care thru that person. You go to doctors and hospitals as you choose and if the docs and hospitals are in the network than it will cover at a higher percentage than out of the network. The beauty of this plan is if a doctor or hospital does drop out of the network( and this does happen) you can still see them out of network and the plan will pick up a percentage. Granted it is not as high as if you went in the network but you still have coverage and once you reach your out of pocket the plan would pick up 100%
POS: This works similiar to a PPO, but you do need to pick a primary care physician and coordinate your care thru that doc to see your CF doc and hospitals. There is the same in network and out of network coverage like the PPO which is nice, but it functions like the HMO in the way that you have to pick a primary doctor and coordinate thru that doc. With the POS the primary doc is more likely to be okay with referring you to an out of network CF doc( if the CF doc is out of network, he/she may not be) because the POS offers and out of network benefit. BUT with the HMO there is not out of network benefit so you have very little choice and NO COVERAGE if you do not use network docs in the HMO plan
I suggest first the PPO because there are no hassles, no primary care docs to coordinate care and you go to the doc as you please and you see who you please. If your docs and hospitals are out of the network ( which hopefully they are not, because in network has the HIGHEST Coverage) then you can still go to them and receive benefit coverage. But if you have to POS 's are fine too. Just I do not reccomend HMO because of the fact of no out of network coverage and with Docs and hospitals dropping in and out of networks you do not want to be in a position where your CF doc is not in the plan and now because you have an HMO there is no coverage. There are Rare instances where an HMO doc will refer you to an out of network doc, but it is a gamble and a hassle . So I would not take the chance.
Pick the PPO or POS. If you can afford it and you use the docs and hospitals alot then go for the PPO
Hope this helps!
Jennifer 33yrs old with CF and CFRD
HMO: DO NOT PICK THIS EVEN THOUGH IT IS THE CHEAPEST! Reason being is there is no out of network coverage. You have to pick a doctor and go inside the network for ALL your health care. So, if there is a doctor right now in the plan that is a CF specialist, you will have to coordinate your care with your primary doctor to go see the specialist. The primary and specialist ALL have to be in the network or you can not see them, including the hospital.
PPO: BEST PLAN TO CHOOSE. You have in network coverage and out of network coverage and you do not need to pick a primary doctor and coordinate your care thru that person. You go to doctors and hospitals as you choose and if the docs and hospitals are in the network than it will cover at a higher percentage than out of the network. The beauty of this plan is if a doctor or hospital does drop out of the network( and this does happen) you can still see them out of network and the plan will pick up a percentage. Granted it is not as high as if you went in the network but you still have coverage and once you reach your out of pocket the plan would pick up 100%
POS: This works similiar to a PPO, but you do need to pick a primary care physician and coordinate your care thru that doc to see your CF doc and hospitals. There is the same in network and out of network coverage like the PPO which is nice, but it functions like the HMO in the way that you have to pick a primary doctor and coordinate thru that doc. With the POS the primary doc is more likely to be okay with referring you to an out of network CF doc( if the CF doc is out of network, he/she may not be) because the POS offers and out of network benefit. BUT with the HMO there is not out of network benefit so you have very little choice and NO COVERAGE if you do not use network docs in the HMO plan
I suggest first the PPO because there are no hassles, no primary care docs to coordinate care and you go to the doc as you please and you see who you please. If your docs and hospitals are out of the network ( which hopefully they are not, because in network has the HIGHEST Coverage) then you can still go to them and receive benefit coverage. But if you have to POS 's are fine too. Just I do not reccomend HMO because of the fact of no out of network coverage and with Docs and hospitals dropping in and out of networks you do not want to be in a position where your CF doc is not in the plan and now because you have an HMO there is no coverage. There are Rare instances where an HMO doc will refer you to an out of network doc, but it is a gamble and a hassle . So I would not take the chance.
Pick the PPO or POS. If you can afford it and you use the docs and hospitals alot then go for the PPO
Hope this helps!
Jennifer 33yrs old with CF and CFRD