I have a choice, do I want an HMO?

October 9, 2007 2:20 PM

I have a choice of going on my employer's insurance plan or staying on the insurance plan my husband's employer offers. My plan would be an HMO with low co-pays and great coverage (100%), but it's an HMO. Everything has to be approved in advance, etc. My husband's plan is an EPO, with slightly higher co-pays, and all that. The difference in monthly premiums is slight ($50). What to pick?

I'm in good overall health with no chronic conditions, or prescriptions of any kind. My doctor and his group/hospital are in both networks. The only benefit I've ever used on a health plan, other than a few office visits, is mental health and that was many years ago. But for mental health, my husband's plan allows more visits. My gut feeling is that either one is good for now, but if I get a serious health issue I'll wish I didn't have the HMO and it's approvals.

Is my impression of HMO's correct? Does being in an EPO suck in a different way? On the HMO, everything is covered 100% so long as you get the referral, etc. That is pretty tempting...

posted by Mozzie to health (16 comments total)

HMO is fine, if you're young, aggressive, and bitchy. I'm all three, and an HMO worked just fine for me because I was aggressive about getting referrals and approvals and working the system.

If you have a 'kind' personality and are antiaggressive in the slightest, go for the EPO.
posted by SpecialK at 2:22 PM on October 9, 2007

How lazy are you? Me, I'm pretty lazy, and with an HMO I ended up never going to the doctor. So now I pay for the more expensive plan. If you're more motivated, save your money and go for the HMO.
posted by Mr Bunnsy at 2:32 PM on October 9, 2007

Pick the one that suits you. I personally prefer PPOs over HMOs because they're more time efficient - I avoid the whole level-of-indirection thing where I get seen by one doctor and then passed on to the doctor I already know I need. PPOs also tend to have better out-of-network coverage, and in my opinion the HMO doctors have too large a patient load for you to have a decent chance of actually seeing your regular doctor (you're more likely to get the on-call doc of the day or a physician's assistant).

Of course, this can vary a great deal from one insurance carrier to the next, so ask around, and ask your regular doctor which carrier they think is better.
posted by zippy at 2:38 PM on October 9, 2007

One thing to check is what providers are in each network - that could be the deal breaker. I had a choice between an HMO and a PPO - I pay an extra $20 a month for the PPO and wondered why I did since I almost never went to the doctor. Last month I broke my leg and needed surgery. As it turns out, what is considered one of the best hospitals for orthopedics here in NYC is in the PPO's network and not the HMO's.
posted by Calloused_Foot at 2:38 PM on October 9, 2007

I'm awfully glad that I didn't have to go through referrals and all when I had surgery this month. My doc recommended my surgeon, I made an appointment ASAP, and we scheduled the surgery for the following week. No fuss. I have a PPO, for which I pay more than the HMO that my employer also offers.
posted by desuetude at 3:05 PM on October 9, 2007

The 100% coverage is only useful if you can get an HMO doc to actually provide the referral. Primary care docs in an HMO are strongly encouraged to minimize referrals to specialists. So what happens you get an internist or GP trying to manage treatment on stuff that is beyond their training.

I would go with the option that provides you the greatest freedom in choosing who to see. You don't want to be sick or injured down the road and find yourself stuck in situation where you are fighting for the right to see the proper doctor. Been there, done that. It's not fun.
posted by COD at 3:07 PM on October 9, 2007

Could you tell us what HMO? That might make a difference.

My partner switched jobs semi-recently and as a result went from an HMO to a PPO. He didn't view it as much of a step up. In fact, he's mentioned once or twice that he's jealous of my ability to just make a single call and get into see a doc the same day for urgent issues (UTIs, sinus infections, that sort of thing). Meanwhile, he has found it impossible to make an initial appointment with almost any type of doctor when he has a problem (most of the ones in network aren't accepting new patients) and so ends up going to the local urgent care center and waiting for a couple hours to see a doctor.

I have Kaiser Permanente, which actually runs its own medical centers (I imagine it's a different experience to go with an HMO that does not), while he has a not-top-shelf PPO.

If I were forced to generalize, I'd say an HMO that has actual staff (rather than a network) is not a bad choice for the type of person that doesn't have and doesn't particularly need a personal relationship with their doc, and puts a premium on getting in and out as quickly as possible. (Soviet medicine, but in a *good* way.) If you're the type of person that likes having your own doctor that you know and go to for everything, I imagine a PPO might be a better choice. Since it sounds like you already have a doctor you like, and he or she is in your husband's network, I'd probably stick with the PPO.
posted by iminurmefi at 3:21 PM on October 9, 2007

My thoughts are similar to those above. HMOs vary widely, so it really matters a) which HMO it is, and b) what the provider network is like. I will share two brief anecdotes.

My work offers HMO and PPO style dental insurance. The HMO insurance is much cheaper, but not one of the dentists that were recommended by friends accepted the HMO insurance.

Second, I live in Arizona and the state laws here make the HMOs much better. The provider networks are virtually identical, you don't have to get referrals for everything. So here, being on an HMO isn't much different than the PPO and it is cheaper.
posted by bove at 3:31 PM on October 9, 2007

The difference between an EPO and an HMO is basically one thing: no referral needed to see a specialist. They both limit coverage to their network providers. If there's no substantive difference in network, go with the HMO.
posted by MarkAnd at 3:31 PM on October 9, 2007

Nothing like consensus is there. If you or any covered family members use health care on a frequent or regular,or have a chronic or recurrent illness thatis NOT life threating and does not require specialized care you might go with the HMO. If you are generally healthy then I would go for the EPO. If you are (young) and healthy then you are more likely to use health care for something that is in fact major ( accident, unexpected illness, etc) in which case I would want immediate and unfettered access to a specialist(s). Regardless, good health.
posted by rmhsinc at 3:57 PM on October 9, 2007

FWIW, my experience recently has been that if you're pretty healthy overall and only see doctors for routine check-ups, etc, a PPO will do nicely for you. On the other hand, if you should happen to get seriously sick or injured and need major treatment/hospitalization, being on an HMO may end up saving you from a tsunami of medical bills.

When I changed jobs a few years ago I changed from the old job's PPO to the new job's HMO. Don't get me wrong, I did find the referral run-around and bureaucratic nonsense with the new HMO to be annoying. Then, about a year later, my wife became really sick. She ended up needing two abdominal surgeries in a 6-month period, each one involving 7-10 days in the hospital followed by weeks of hospice care as she recovered at home.

Both times, for all of the main bills the HMO covered 100%. How much did I have to pay in medical bills? A couple hundred bucks each time. Of course, this doesn't take into account our lost wages, etc, but we're talking about health insurance here.

For the same type of situation, PPO's generally pay between 30%-50%. If I'd still been on the PPO from my old job during my wife's illness, I would have owed about $30K.

p.s. in case anyone was wondering, my wife did make a full recovery.
posted by JustDerek at 5:03 PM on October 9, 2007

Last month I broke my leg and needed surgery. As it turns out, what is considered one of the best hospitals for orthopedics here in NYC is in the PPO's network and not the HMO's.

I had the very same experience with my PPO after being hit by a car this summer. However, after the accident, I was rushed to the ER and did time in the hospital. I discovered that the PPO only pays 80%, which sounds great until you realize that even basic inpatient hospital care can run around $3000 a day. I'm not sure if I made the right choice, but keeping my experience (and JustDerek's) in mind can help you figure out what compromises you want to make.
posted by foxy_hedgehog at 5:28 PM on October 9, 2007

Thanks everyone for the information and suggestions. I have some additional details and a follow-up question.

I'm in Los Angeles, CA.
The EPO is United Healthcare
The HMO is Blue Cross of California

My doctor and his whole group are in both the networks.

My follow-up question is this... when I asked my mom about this, she asked why I can't just do both. She said people used to often have secondary insurance. My employer pays 100% of my premium. So the cost to me each month is the same if I were to do only the EPO [which we pay a small amount per month for] or if I did both. But this seemed weird, I guess I didn't think you could have both.
posted by Mozzie at 9:38 AM on October 10, 2007

You can check out relative quality ratings for managed care companies in California at the Department of Managed Care.

Looking at Blue Cross--they don't rate the highest overall, but they aren't at the bottom either. If you look at the left panel, they have scores for specific things that you might care about (for example, under "Providing Quality Care," they compare HMOs across the care they provide for mental health treatment. Note that Blue Cross ended up #1 among all HMOs on the measure of whether someone diagnosed with depression at least 3 times during the initial 12 weeks of treatment). Also be sure to look at the "Members Rate HMO"--it has information on how often people had complaints with their plan, how they rate their doctors, and how quickly the received care. (BC is pretty high on all counts.)

It unfortunately only compares across HMOs (so it doesn't compare to EPOs), but that should at least give you a sense of how much to weight concerns people usually have about HMOs. The HMO will probably be cheaper overall, as long as you don't end up going out of network because you can't get a referral (or it takes too long to get a referral). But if you're already going to the doctor who would be your primary care physician, why not ask him whether there would be any difference in his ability to make referrals (or referrals to specialists he thinks are particularly good) between the HMO and EPO?

In any case, if you end up thinking it might be better financially for both you and your husband to go through one insurance company, you (or your husband, if he drops his insurance) should definitely ask HR whether they'd be willing to up your salary to compensate for forgoing health insurance. It wouldn't be 1 to 1, since companies don't have to pay taxes on insurance premiums like they do on wages, but you might be surprised--if it's a neutral financial change for the company, they might be willing to work with you.

(You can have two insurances; one is generally the primary insurance and one is secondary. It would be way better to have one of your companies compensate you salary- or wage-wise for the cost of forgoing insurance, though.)
posted by iminurmefi at 10:31 AM on October 10, 2007

I have BCBS CA for my PPO. You don't want them. Stay as far away from BCBC-CA as you can. I've written several blog posts about our experiences with BCBS-CA. Email me (it's in my profile) if you want links to them. The very short summary is that BCBS-CA is the most anti-customer organization that I ever dealt with. If I had any reasonable choice at all I would find another insurance company tomorrow.
posted by COD at 12:26 PM on October 10, 2007

With an EPO, you don't need a referral. It's a pretty nice perk. But, it's offset by slightly higher premiums. Six to one, half-dozen to the other, really. I'm on an EPO, and I love it. Best coverage I've ever had. Never been on an HMO, though.
posted by PandemicSoul at 7:43 PM on October 10, 2007