HMO Vs. PPO - Chicago,IL

A PPO is a much much better option. There is a reason the HMO is cheaper. A lot of doctors won't even TAKE you if you have an HMO, and if you need a specialist you have to get a referral... it's so awful.

We have a PPO and can go to any doctor we want.

We have had an HMO for the past 7 years or so and haven't had any problems. I've had two emergency procedures, underwent IVF and had a c-section. My older daughter has had surgery to have cysts removed from her jaw and my younger daughter has had tubes put in her ears. Having to get referrals from a PCP is kind of a drag, but luckily we haven't had any problems. For some referrals I was able to just call my doctor and request one over the phone and not have to spend money on a co-pay to get seen by the PCP first. I have heard horror stories about HMOs, but luckily I haven't experienced any of them. Good luck!

i would call around to hospitals/dr's around you and find out which ones will take hmo......it does limit you with choices of dr's, but you will pay way way way less with the hmo as it covers almost everything 100 percent besides the 20 buck co pay. i have had 2 children on ppo and had a great doctor, but paid alot out of pocket. i had no choice in the last baby i had and was stuck with hmo, paid nothing out of pocket except for the copays and i actually got sick afterward and am so glad that i didn't have to pay anything for all the procedures i had. i also have a great doctor and go to a hospital that is rated one of the 50 best in the united states. so if i had to choose again i would opt for hmo everytime.

We have an HMO and I could not be happier. I'm not sure what the choices would be like for your plan, but ours includes nearly every major hospital/medical group imaginable. I knew that I could still go to the doctors I wanted to with my HMO, so a PPO was a complete and total waste of financial resources for our family. I use doctors primarily in the Rush Medical Group (there are tons), while my son is part of the Advocate Medical Group, and I used to be a part of the UIC or related group. Combine the three of those groups and there are tons of doctors, primary care physicians, womens health primary care physicians, and specialists...and I've only named THREE medical groups (ours includes several).

For my current pregnancy, I have paid one $20 copay yet have to go every other week due to a high risk pregnancy. This pregnancy has also necessitated me getting a cerclage - also known as an $18,000+ procedure (fully covered by insurance). With my last pregnancy, it was the same situation (bi-weekly then weekly visits and had a cerclage with that one too) but when it came to my labor & delivery and postpartum care (I was in a private room too) I exceeded my limit. I got a bill for a whopping $124, so not bad at all! Prior to becoming pregnant over 2 years ago, I did 3 years of fertility treatments - all of it was covered except for a copay each visit. My drugs, supplies, IUI attempts, bloodwork were all covered by the HMO; I paid nothing out of pocket. Had we decided to go the IVF route we would have gotten 6 attempts at successful implantation for the first pregnancy and then 4 attempts for each subsequent pregnancy.

I've been pretty fortunate that all of the doctors I've selected within my HMO are caring, dedicated, educated, and reasonable professionals. None of them have been money-grubbing ogres like people have suggested. And...there are many doctors out there who accept HMO, PPO, private, and self-pay plans, not just one exclusive type of insurance, so it's not like they change their attitude from patient to patient (my husband switched from a PPO to an HMO and the quality of service never declined).

And wow, some of the people here must have had horrible HMOs! Whenever I need a referral I basically just ask my doctor for a referral to someone in network and he writes it, no problem.

You should be able to find out ahead of time what doctors might be a part of the HMO plan. From there you can plan accordingly. I don't think I would ever use a PPO, mostly because no one in our family has really unique and complicated medical needs. Then again, each employer has different levels of coverage and payment so it would be best to do your research and decide which would be best for your family in the long run.

When my husband changed jobs late last year, we had to pick new insurance coverage. We had a great PPO plan that was very inexpensive, but his new company only offered a super-expensive PPO plan or a much cheaper HMO. After MUCH research & debate, we opted to go with the HMO to minimize our monthly out-of-pocket expenses. Overall I'm happy with all of the new doctors we were forced to pick, but if I had to do it over again, I'd probably go with the more expensive PPO. As much as we love our new pediatrician, the first time I said, "My son is due for a follow-up visit to his ENT for his ear tubes, can I please have a referral?" and the answer was NO, I hated that feeling. You are truly no longer in charge of your own healthcare. Of course the monthly savings and 100% coverage is wonderful, but handing over medical decisions to somebody else is more difficult than I expected. Just my two cents given my own experience. Best of luck to you!

PPO has always worked best for my family. It does cost more out of your paycheck. However, I appreciate the 3x I'be been in the hospital I was given a private room instead of having to share a room with a stranger. There's no need for any paperwork, no referrals required, etc. And don't quote me on this but I think, Michael Moore's movie called Sicko was based on people covered by HMOs and how they found out they were not covered after the fact. I think.... I'm sure another mom replying to your post may know more. But I think that's where the differences come in between the 2 plans.

Personally I would choose (and do choose) the PPO because I like the ability to chose my doctor and self-refer.

HMO is set up to save money. It saves you money and it saves the insurance company money. However that comes with drawbacks. You will be assigned a primary care manager. That person decides if you see a specialist or get testing, etc. That person gets paid more or less based on his or her ability to reduce costs i.e. prevent specialist visits and extra testing. In theory it is great and prevents wasted money but in my opinion I do not want the provider to have a monetary interest behind making these decisions My MD for instance does not make money by sending me to a specialist but he does not lose money either, in an HMO my MD would lose money by sending me to a specialist so he/she may try to treat me themselves or just ignore the issue.

It also severely restricts which providers you see because you are limited to those participating in that particular HMO and whoever your primary care provider refers you to.

So, obviously I am not a fan of the HMO. It will probably save you some money in the long run but to me I would rather pay a little more and know that I have more freedom in my health care.

It really depends on your situation. A HMO would not be good for my family since I have kids with allergies and we have had 3 broken bones on the growth plates which a regular doctor couldn't see. If I had a HMO, my kids would probably still be complaining about the pain which the ER doctor said was nothing. Since I have the PPO, I could take them to an othropedic dr. who found the break and put them in casts.

A HMO is great if you are healthy, but if you need to see a specialist, good luck. It's not easy to get a referral for a primary care doctor, at least that was my experience when we had a HMO. We had a HMO until we had kids and one had to stay in the hospital when he was born and we had problems with the HMO paying for it.

I have an HMO. I love my HMO -- it is Cigna but my employer (a law firm) wrote its own plan with Cigna so some of the coverages might be different. All of our doctors that we were currently seeing (me, my husband and the docs I wanted to use as peds based on referrals before I had my 2 kids -- now 9 months and 2) took Cigna HMO. I wanted to be associated with Northwestern Memorial as my OB and internal med docs were there. With an HMO you do not need a referral to see your Gyn 1 time a year for a pap nor for OB services. My deliveries (including an induction with #1 and an induction followed by emergency c-section with #2) were 100% covered. Now, we do need to pay co-pays of $20 every time we go to the doc and $30 or $50 I think for specialists or ER BUT we have never had surprise bills from the doc, ER, hospitals. I ALWAYS call ahead for referrals and they fax forms to specialists and I have never had a problem there either. I have been to visit derm and opthamologist and my husband has been to a gastroenterologist and auditory specialist. The people at my work with PPO complain often about unexpected costs associated with testing and receiving bills because the PPO does not cover 100%. If you have an HMO, there is a contract in place so that if the network docs normal charge is greater than what the HMO is willing to pay, the doc eats the remaining charge. If you have a PPO and it is larger or your plan is 80/20, you pay like 20 percent of the charges. That CAN add up. A lot of times you can check out a PPO by going on line and doing a doctor search to see what docs are accepting the insurance. Cigna has a great one online and you don't have to be a member to search. If you already have a doc, call and see if they accept it first. I went with PPO dental instead of HMO because there were only like 2 dentists that accepted the HMO in my area -- always worth checking out.

Also, the HMO covers 100% of our kiddos shots, well-care visits, etc. My sister-in-law's PPO does not cover any immunizations -- they end up taking their kids to Walgreens care clinic or the Mt Prospect clinic to get shots at a discount. She is a teacher in an awesome school district with high pay as well -- Ludicrous!

Good luck!

I agree 100% with what Courtney said. I would never choose an HMO because that is your last choice in your healthcare. You can not just go to an orthopedic surgeon when you break your arm, you have to go to your primary care doctor who may refer you, may set it himself. I personally know 3 people who were not referred in time to an oncologist and subsequently died. We will never know if they may have still been with us had the cancer been detected and treated earlier. So again, I would never choose an HMO. I choose to be a name and not a number in healthcare.

I would call your daughter's pediatrician to ask if they accept HMO. Our does not, they stopped about 5 years ago.

If you are generally both very healthy and you can find docs "in network" (from their list) that you like, then an HMO is fine, since you probably won't require referrals to other services, like allergy clinics, PT, specialists, or things like that. The pediatrician can provide all well-baby care, vaccines, etc. and you only have to pay the small co-pay per visit. Mine used to be $10 or $15 for a visit. In fact, my son was born for the grand total of $15 out of pocket (and he was a complicated c-section!!) So, that was a GOOD deal to say the least! Then, we switched to a PPO shortly after his birth.

For us, we went with a PPO since both of our kids require specialized care and those docs and therapists don't accept HMO at all.

Good luck and congratulations on your new job!!!!

Hi J.,

We have 2 kids and are quite satisfied with our choice of the HMO option. My older son is 2.5 and was born via emergency c-section due to a wrapped cord. He spent 13 days in the NICU. We were charged a total of $100 for his hospitalization, and $100 for my c-section. He had many follow up visits with Neonatologists, Cardiology, hernia surgery, abdominal ultrasounds and a whole list of other issues that required our HMO primary care provider to give us referrals. We trust our PCP 1000% and know that he always acts in our child's best interest, not his pocketbook's.

Our doctor is at Loyola and all of the specialists we saw were Loyola docs who took our HMO insurance.

It is not just the monthly fee that is less for HMO -- everything is less expensive.

Good luck to you!

I switched from United Healthcare PPO to Aetna HMO a couple of years ago. It was pretty similar in coverage and co-pay, but the deductibles are lower and my cost was lower out of my paycheck. I made the switch because all of the drs I was currently seeing took both UHC and Aetna. I didn't have to change my primary doc, OB, or Ped. If you know who the provider is, you can search their site for doctors in your area. That will give you an idea of provider choice.

I personally chose PPO over HMO.........HMO Dr.'s get paid on qutoas like quantity of patients not quality of services.......I had HMO because we are an overall healthy family until I had to go to a dentist & had to have an emergency root canal.....the quality of care was unreal....the dentist laid his tools across my chest & i just had a baby & was nursing......he had dental chairs lined up about 8 of them & they were all filled with patients & he would scoot his chair around to each of them as his hygentist needed him.......i ran out of their & never got my crown done til I changed to a PPO.....ThAT Dentist was Dr Andrews out of Oswego, beware......also my sis works in labor & delivery at Delnor & she has told me horror stories about working with Dr's that accept HMO, like they prefer to do c-section & give blood transfusions, etc.......quality care is very important you dont want to be just a number....good luck

It depends on your situation and the doctors you see. I had an HMO years ago and had no problems with it at all. They covered everything I needed, including triplets in the intermediate care nursery. I never did see that bill. I think we hasd that insurance for over 5 years. When I got a new job, I chose PPO because my son sees a specialist 2 times a year and gets expensive medication every month. The doctors we see are very flexible with providing referrals we request. When we had the HMO, I just called and said I needed it and it was sent. But with the change, we would have had to switch doctors. Getting referrals all the time would have been a big pain and hassle. I wish I didn't have such high out of pocket since there is a deductible and then the out of pocket max amount but I wouldn't change it at this point. I also use the before tax Flexible Spending Account option at work to reduce my annual income and cover the bills. The people I have talked to about this issue that are happiest with an HMO seem to really have flexible doctors willing to work with the family and do not have conditions that regularly require referrals.

It really depends on the doctors and the specifics of the plan. When I had an HMO, I did not like it at all, but a couple of years ago we had an EPO that was great. (it's like an HMO in that you can't go out of plan at all - but like a PPO in that you do not have to have a referral from a primary practice, or pick a primary practice.)

Normally I'd say pick the PPO for the most flexibility, but the costs and copays are going up so much that it's really hard to say.

The good thing is that the plan year probably ends at the end of the year, which means if you don't like it you will be able to change then (you'd want to check that.) If everyone in your household is pretty healthy, I'd probably take a chance on the cheaper plan for a few months and see how it works when you are in the system. Then change if you don't like it for next year.

ETA - definitely, as others have said if you already have doctors you want to keep, check with them. Our pediatrician does not take any HMOs.