15 answers

HMO Vs PPO

Hi Everyone,

I'm curious about your opinion of HMO's & PPO's. I grew up with PPO and love it for the convenience of going to anyone I want but I've recently realized how much more money is out of pocket for us (and others). My husband and I are young (20's) and don't have any pre-existing issues. We rarely see a doctor (ob-gyn annually and maybe a doctor visit or two every year). We're thinking of getting pregnant in the near future and I've heard from other friends who are pregnant that the PPO friends have had to pay a lot of out-of-pocket. Basically, my (PPO) sister-in-law is pregnant (and very healthy) and has already paid more in doctor visits & ultrasounds than the total her (HMO) friend paid who has already had a baby (they both had the same dr office). I'm wondering if we should switch since we can't exactly afford to pay thousands of dollars in visits/hospitals/etc when it is offered for a much lower cost (HMO). I hope this all makes sense, it's sort-of a confusing situation.

Basically, I'm wondering if it's common that PPO-plan people pay more for their pregnancy/childbirth/etc than those with HMO. I understand the differences and prefer PPO but also know that we can't afford to pay a whole lot in unexpected bills. I've done some research and I've noticed HMOs are "recommended"/good for young families since doctor visits are so common and such. What do you think? Thanks for your help.

What can I do next?

So What Happened?™

Thank you everyone! Your help has been very helpful. We have to wait until June when we can make our changes but I think we may end up switching to HMO since I've heard so many great things and very little negative (which I was wondering about). Thanks again!

Featured Answers

We have Kaiser, and I love them! I always had a PPO in the past, and I have found that I like my doctors at Kaiser much more, and it's less expensive.

1 mom found this helpful

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Hi!
I struggled with this same problem since my husband's work pays for him to be in their HMO program, while I pay to participate in my PPO program. It seemed like it would be more cost effective for me to join his program so I did a little research on his medical program vs. mine. The one thing that was the decision maker for me what that the hospital and medical group I wanted to be a part of (St. Joseph's and CHOC) did not accept HMO's.

Hope this helps give you another avenue to think about.

Good luck!

J.

1 mom found this helpful

I have worked in healthcare insurance for 15yrs and i would recommend for you to pick an HMO that is less out of pocket for you. I understand that you are very limited to doctors and have to get everything pre-authorized verses the PPO you can just go. But the PPO usally only pays 80/20 meaning that you would have to pay 20% of the entire hospital bill for you. Maybe you can you all that extra money for your new baby instend of paying lab,office visits, and radiology bills and lets not forget hospital bills sometime it can be very expensive. hope this helps

1 mom found this helpful

We have had an HMO all along. I have six year old twins and have had nothing but good HMO experiences with them. My daughter has had a LOT of trips to specialists and everyone we have seen in Northern and SOuthern California has been great. Most pediatricians take any HMO so we have been able to change with our moves and if we don't like one. HMOs are a problem for things like pscyhiatry/psychology; chiropractors/physical therapists, basically any doctor who doesn't want to deal with insurance companies. This is a problem for adults, but we end up paying out of pocket and probably still pay less than if we used a PPO. Hope this helps!

1 mom found this helpful

Go HMO -- I go to the same Dr. as my PPO friends. I get the same care -- they just pay more. The only thing about HMO is you have to wait a few days/weeks to get a referral to specialists.

Everyone w/ PPO has to pay a percentage of each procedure.

I was taking my daughter for physical therapy several times a week for years. They were charging $475 per HOUR!! If I'd had PPO that would have been nearly $50x3 = $150 per WEEK With HMO, for maternity checkups for the 1st baby I paid $5 TOTAL for the entire pregnancy and delivery. I splurged and paid $75 out of pocket for a private room after delivery. For the second I had to pay like $10 per check up and nothing for delivery. Had I had PPO, it would have been thousands -- for normal delivery is must be over $10K now.

Good luck

1 mom found this helpful

As an HMO, I would suggest Kaiser. They are non-profit, and that can be a night and day difference. I have had three children with Kaiser, and my three daughters among them have had five. Our families have had good care from Kaiser, including some very dangerous emergencies with two of my children, breast cancer for me, etc., since 1963.

S. Toji

1 mom found this helpful

I had my two children quite a while a go (now 15 and 19) never the less, I had them while I was a member of an HMO. I could not have afforded the PPO at the time. The good news was that everything was paid for and I left the situation with no debt. The routine baby care afterward that would have cost me a bundle was all taken care of. The care my babies recieved was standard and adequate. From a physical sence the care I recieved was perhaps adequate. From an emotional sence dreadful. I had seven different obgyns, I missed standard tests because of the confusion. The doctors I liked were leaving in droves. The man who delived me I had never seen before in my life, though I will never forget him. I had 32 hours of labor. I saw him twice in that period of time. The first was less than a 5 minute visit, the last visit was longer because by then I had to have a c-section, my son was in distress after being in the birth cannal so long. Perhaps I would have been successful pushing my son out if my nurse was not totally new to the profession and could have given me some helpful advice. My second child's delivery was better. I had switched hmos. Though, my daughter being born naturally went OK and I was better because of it, I did not like taking that chance just to save the hmo money. My best advice is to be careful when choosing your HMO. Try to find one where the doctors have been there a long time. Don't choose one based on it being close to home. There is a wide variety in quality of care even with in the same HMO. The better the doctor the harder it will be for you to see that doctor and with an HMO you will get the doctor who is avaliable at the time. If things go well, you will leave being very happy not to be in debt.

1 mom found this helpful

Most important is to find a doctor you like and find out what kind of insurance he or she accepts. My husband and I choose our own medical insurance because we have our own small business. My doctor accepts all types of insurance so we went with an HMO plan. Everything for maternity was covered - I didn't even make co-payments for my check-ups! Also, I ended up with a c-section and a subsequent related surgery and every dime of it was covered - probably over $100,000 with of medical bills. The other thing to consider is what is actually covered under the plans you are offered by your employer. Some HMOS mandate that you see the "on-call" doctor for all appointments. My medical group allows me to see my preferred doctors. Anyway, if I can be of more help, let me know.

R. (I am a 45 year old mom of one 2 year old son).

1 mom found this helpful

An HMO is almost always going to be less expensive than a PPO. That is the nature of healthcare. If you have more restrictions and less freedom, you pay less for the service. I had an HMO with my second child and we paid about the same that we intend to pay for this child (with a PPO). It depends on a number of things. Does your hosiptal charge for both the mother and the baby or do they charge it together? What kind of participation does your doctor have with the HMO (they might have a deal where thy charge less for each service and so you don't have to pay certain charges)? Does your doctor charge a global fee for the whole pregnancy and labor or does he charge for each visit? Does your current PPO have a maturnity plan (one that limits the amount you need to pay for all your maturnity services) or do they have an out-of-pocket maximum that will limit your costs? Take a look at both options open to you and determine which one is more likely to be what you need.
As a guideline, when you are young, in good health, and don't travel a lot (so you don't have to worry about unexpected out-of-town doctor visits) an HMO will offer less expensive service and still meet your needs.

1 mom found this helpful

You can call your insurance (PPO) and see what the costs would be for a "standard" pregnancy. I too love the PPO and don't recall paying very much to have my daughter. I know I didn't have an office co-pay, they bundled it up a certain way that I paid a certain amount over a couple of visits.

From what I recall, I maybe paid $500 max and got EXCELLENT treatment and care at the hospital (my own room, etc.)

Also, I know my employer has some benefit resources that allow us to compare the plans HMO v. PPO so maybe check with your human resources dept.

Good luck!!

1 mom found this helpful

Is your insurance coverage through an employer or are you and your husband paying for your own insurance premium? I would suggest you look into a plan that's between a PPO and HMO. It's what some calls POS (Point of Service). I believe you pay lower premium than PPO (I'm not sure about that since I have insurance through my husband's employer). But you have the option of using HMO or PPO benefit when you see a doctor.

HMO is very economical if you find a good Health Group and see the doctors in their network. (groups such as Monarch, Greater Newport, Memorial Health, etc.) If you can find a good primary care physician (PCP) from a particular group and stay within their network then you only have to pay $10 to $20 per visit. That's all you pay. When you need to see a specialist, you'll have to get a referral from your PCP and you usually don't have to pay extra $ - just the same copay.

POS - you can see the doctor within your Network and pay the lower copays $10 to $20 per visit. However, if you find a doctor (esp. a specialist) who's outside of your network, then you can use your POS option. You will probably pay a higher copay like the PPO (usually 20%) and sometimes you may have to pay an deductible.

PPO - higher premium, deductibles and copays, but you have the option of seeing ANY doctor you want. That's the benefit of PPO.

In conclusion...if you have a good PCP, find out which group (if any) he/she belongs to, research that Health Group and see how they're rated for other specialists. And go HMO within that group. I know Greater Newport (Hoag Hospital) have very good doctors.

Hope that answers your question.

1 mom found this helpful

We have Kaiser, and I love them! I always had a PPO in the past, and I have found that I like my doctors at Kaiser much more, and it's less expensive.

1 mom found this helpful

Hello!
Well I am also a first grade teacher and I found this website through the parent of one of my former students. I am pregnant with our first child, and with our HMO we paid a co-pay at our first doctor visit. Since then, that first co-pay has covered every doctor visit and both ultra-sounds. I am very happy so far,especially since we now see the doctor every other week. However I am also curious to see how much of the delivery and recovery at the hospital will cost.

1 mom found this helpful

I had one HMO and one with PPO...it IS VERY expensive. Since you are not pregos yet, research your PPO of choice and the doctors in it and see if there is one you like. I interviewed doctors before I switched and toured their hospitals to make sure I liked both. Otherwise, I felt the care was the same.

1 mom found this helpful

I have 2 children,a 9 year old daughter and a 7 year old son. I have an HMO plan and it has suited us well. I too use it very litlle other than the ocassional dr visits but of course my children use it much more! I have had to be referred out to specialists...ENT and now an allergist and have not ever felt we weren't getting great care with an added bonus of a $10 copay!! I do not believe I payed one penny for either of my childrens birth! So, based on my experiences HMO has been great.

Although just so you know I had a neighbor who also had a HMO and tragically her 2 year old son was diagnosed with a rare form of cancer. He ultimately lost his life at age 4 to the disease but I did speak with her about HMO vs. PPO and asked her what she thought and she told me that it didn't matter if she'd had a PPO because she was referred to the best specialists regardless if that Dr. was a PPO or HMO carrier. So from someone who has lived the ultimate nightmare and sufferred with the loss of a child-PPO was just fine. Hope this helps...

1 mom found this helpful

Hi LC,

Just wondering if you would like to have an absolutely free consultation and discuss not only your health insurance but also your life insurance, investments, college funds for your little one.

More often than not a new family will have the need to look at the whole financial picture not only short term but also long term.

You can email me directly to take me up on that free talk.
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P. Breakstone

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