Thursday, November 3, 2011

Uh Oh... HMO or PPO?

Ok, I need your feedback. Right now we’re trying to navigate our health insurance for next year. We can choose from an HMO (Anthem Blue Cross) or a PPO (Aetna for basic health and Magellan for mental health). I’ve read a little about the positives and negatives of each, but was wondering what your experience and preference was. Care to share?


11 comments:

  1. My experience is that PPO might cost more but you have more choices and it works much more smoothly with less referrals, etc.

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  2. Navigating the health system over there must be so incredible hard. I don't know how a person with a mental illness could possible do it for themselves. My daughter struggles with the shopping list at times. Once again high five to you mum!

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  3. We always choose PPOs because we like to have more choices and control of our healthcare.

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  4. PPO's. I have had that for awhile and enjoyed the choices and not needing referrals for everything but now we are only going to have the HMO this coming year :(
    I vote for PPO :)

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  5. Well, I know that the quality of your policy is largely based on what the company who purchases it for their employees is willing to pay for. Now, having said that, over the years, we've had Blue Cross coverage and now are under Aetna. We HATE Aetna. It has been a nightmare because they do not cover anything that involves a pediatric specialist. I live in a town with a large university medical center and a large children's hospital. All of the pediatric doctors are employed by the medical center but work at the children's hospital (technically, the children's hospital doesn't employ any doctors). At first glance, we thought Aetna was fine because all of our specialists were "on the list" of approved providers. The problem is that NO TREATMENTS at the children's hospt are covered! Therefore, we can get the actual doc charge covered, but not the tests or treatments. It's been a nightmare. In one case, we had one of our sons tested for growth hormone disorder. There is only one place in the entire state that does this test on children - the children's hospt - and one doc who is over those. The doc charge was covered, but the $4,000 in testing was not. I argued it - because there was no other choice, but lost. Also, my son qualified for growth hormone under Blue Cross's guidelines, medicade's guidlines, and even the state's supplemental insurance program for low income kids. But Aetna wouldn't cover treatment. That has been an ongoing problem for us - they don't cover many things my kids need, but that was never a problem with BC/BS. I understand that Aetna policies in other states have the same set up with not covering the children's hospital's treatments. So make sure you look into that before moving forward. Also, I agree with the above posters who say a PPO is definitely worth it. Good luck!

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  6. Boxturtle-Your comment is one of my concerns I have with the PPO, I have come across other stories of people going into surgery with an approved surgeon, but the anesthesiologist wasn't covered so they got the full bill. Scary stuff! With my son and his kidney issues, I am scared of the variables we may come across. That makes the HMO a little more inviting.

    I also like that the HMO has all his records in one system, so the meds & psyc issues are all connected with the Kidney issues. That is what I liked about our current HMO.

    Also, I'm checking into the hospitals that he may be sent to if admitted, this may help with our decision and from what we know, the HMO may be better. I have confirm that the PPO is connected to the hospital that many say to never let our kid go to. Even the doctors admit that the hospital has a bad past and is working on it.

    But I have heard a lot of people mention they like the PPO because of the options available.

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  7. PPO PPO PPO!!! I only wish I still had Aetna PPO...it was the best plan ever. I could go to almost anyone I wanted. Sounds like Box Turtle had a horrible experience but it sounds more like poor planning on the hospital she went to . Their insurance people should have planned better. I used to work in a hospital and at a doctors office and filling with Aetna is so much easier. Plus you sound well educated on your insurance know how so I doubt you will run into any big issues like that. At least I hope not.

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  8. @ In the Pink - I believe you misunderstand what I'm trying to describe. It was not poor planning, there was no way to get coverage for the tests and treatments my kid(s) need. Period. No where in the state. IT DID NOT EXIST. The reason is that in my rural state, the only place for many specialized treatments is the only children's hospital in the state. That's it. And even though the doctors who work there are "in network," nothing done at the facility is covered. But those doctors only treat at that facility. Make sense? For us, that means that growth hormone test wasn't going to be covered, period. There was one place that does them, and oddly, only one doctor in the state who does them. The doctor is covered by insurance, but the tests and treatments were not. He doesn't/can't do those tests anywhere else. It's a catch-22. Also, because we are a rural state, the only place for a child to get dialysis is that children's hospital. The only place for a child to get treatment for some rare forms of cancer....is at that hospital. So see, for Aetna children, they will not be covered. Surprisingly, my husband and I have numerous options - because as adults, we aren't under the same type of limitations. I think that's why you had such a great experience. Plus, my research exposed the fact that Aetna has a "No Children's Hospital" coverage in several other states. It's a sneaky way to get out of paying for some expensive illnesses that strike children. I never had any such issue with BC/BS. I just want Mama Bear to make sure she's not getting into such a dilemma, especially given the kidney issues and such. We'd love to switch to most anything but the Aetna policy we're stuck with.

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  9. Boxturtle: That sounds so stinking frustrating... How complicated does treatment have to be? I must admit I have no kids and have never worked in a childrens' hospital but I think that the Shriner's Hospital for kids has a contract with Aetna and several other. My fiance had BC/BS and he got ripped off. His company decided to stop using BC/BS. Geesh this is like a no win situation. Best luck choosing what will fit your needs.

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  10. Mama Bear,
    I have no idea on how t help you, but I wish you luck to find the right solution.

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  11. Late weighing in on this, but I think a PPO is the way to go. That's what we have, and I agree with some of the other commenters--it's worth it to pay a little more to have more choices and not deal with the hassles of getting areferral to a doctor you may not like anyway.

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