HMO vs. PPO in Eastern PA

November 6, 2015 9:09 AM

I think I'll be okay with the HMO. What am I missing?

The HMO is Keystone Eastern PA. Any direct experience with them is welcome. I've read that some HMOs are great, some are awful -- how do I tell?

I'm a middle-age woman with somewhat-higher care use, but mostly for fairly routine things. I expect a bit less care use next year, as a medical event fades further into history.

All of the providers I saw last year appear to be covered under Keystone. When I search for docs on their website on the plan, it returns hundreds for most routine things (gyn, derm).

The care group I use appears to be covered. They are fairly modern, so I expect that referrals would be reasonably easy, electronic or phone.

Prescription coverage would not change. The HMO is $1500/yr less than the PPO, with the same copays and same out-of-pocket max.

What else should I look for?

posted by Dashy to Health & Fitness (5 answers total)

We've used them (two middle-aged adults, one kid) outside Philly for years because our doctors' office is covered by them. We've had no problems. I don't know that they limit your provider choices any more or less than any other HMO. Mental health is not covered, but all the physical therapy we've had over the past few years has been the $35 co-pay. So much is how well your care group can work with the insurers.

Our prescriptions are basically through CVS's insurance arm which tries to stong-arm everyone into using mail order, as we stubbornly stick to our mom-and-pop pharmacy.

One data point: a resounding meh.
posted by JawnBigboote at 9:26 AM on November 6, 2015

I am not in KY, I am in Georgia, but I'd guess things might be the same.
I looked at HMO v. POS/PPO last year, my navigator clued me in that the HMO's generally don't have any doctors out of the immediate area, so if you travel and need health care, you could be out of luck - not just "out of network" prices, but "not covered" at all.
So, it's a gamble.
posted by rudd135 at 4:29 PM on November 6, 2015

I've had both HMO and PPO insurance. For me, it was a mixed bag. With HMO, the continuity of care was much better. My specialists had access to my files from my PCP, etc. With PPO, I've had a lot more choices in my care providers and the options available to me for treatment. My SO has been dealing with a very difficult health issue this year and I think we got better care for having a PPO. But for routine stuff, the HMO was if not better, at least easier. Also cheaper.

My HMO was Kaiser Permanente, which is a massive hulk of an HMO, so things might be quite different in an HMO in which most of your providers are already covered.
posted by kamikazegopher at 5:56 PM on November 6, 2015

I've had pretty good experiences with HMOs. The biggest pain is having to get referrals - sometimes I do need to see my primary care doc first to figure out which TYPE of specialist I might need, but other times I pretty much know and it just slows down the process, which is a pain. On the other hand, both HMOs I've been on have had multiple things in one building (primary care, physical therapy, immunization clinic, urgent care, pharmacy, etc.) which I found super convenient.

I can also speak a bit to this:

I looked at HMO v. POS/PPO last year, my navigator clued me in that the HMO's generally don't have any doctors out of the immediate area, so if you travel and need health care, you could be out of luck - not just "out of network" prices, but "not covered" at all.

At least in my experience, this will tend to be true for routine care (i.e. getting your yearly physical) but not for emergency care. So, for example, if you regularly spend 4 months a year in a vacation home and want to have a regular doc in both places, an HMO is probably not for you. But my lifestyle is such that it is never a problem to schedule my regular medical appointments in my home area -- and if I break a leg or have some other emergency out of the area, I can go to the ER and still have that covered with no issue. Of course check the specifics of your particular plan, but I think it would be very unusual (maybe even illegal under the ACA??) to see a plan with no emergency room coverage.
posted by rainbowbrite at 6:38 PM on November 6, 2015

You can check out the rating of various health insurance plans at NCQA, a resource recommended by Consumer Reports.

Don't confuse the benefits of an HMO with the benefits of being part of a large clinic. Some HMOs are both - they have their buildings & doctors and you do the convenience that comes with it. Some just contract with lots of separate practices, then no so much. I have a PPO but I go to a large clinic so I get all the same benefits of central record keeping and one location. Since you already know who your doctor will be, that won't change.

Some HMOs have small # of doctors (especially specialists) so you are very limited in choice and it can be very hard to get in to see them. But if you already know the doctors you want and they are in the network, then I think the risk is much lower for you. My family has used out of network doctors for psychiatrist and therapists and the occasional really special specialist who doesn't take insurance. If those aren't likely to be in your future, it might well worth saving the $1500 and running this risk you might be in a situation where you will have to settle for the less than ideal option that is in-network.
posted by metahawk at 3:34 PM on November 8, 2015