I don't understand Health Care

Re: I don't understand Health Care


Maybe some of the explainations below will help to clarify things a bit.



True. An HMO has a "network" of doctors and facilities that have agreed to accept the rates set by the uinsurer. You pick one doctor and that is your PCP. From that point on, all you healthcare goes through that doctor or they won't pay for it and they usually won't pay for any services from anyone that isn't in their network unless it's in a emergency situation and no in-network providers are available.

With a PPO there is a similar network but you choose whatever doctor you want from the list. You don't have to have one PCP that you go to every time. You can also go to any doctor that isn't in their network and they'll still pay but you usually get stuck with a deductible and a higher co-pay for that portion of your care.

You do usually have a co-pay on both. Both will usually have deductibles of some sort and each individual policy is different on how they interact as a coinsurance.



A HMO policy is usually cheaper so if your in-network Primary Care Provider (PCP) can handle most of your needs then it probably is a better option. A PPO gives you a lot more options and if you travel a lot and need care in different locations then it's a safer alternative. You pay more for the added flexibility of a PPO though.



NO! Dental insurance is usually entirely seperate from a medical care policy. It's not mentioned because it isn't covered at all. (There are usually some emergency oral surgery procedures that would be covered if they were the result of a car accident or something similar but that's usually about it.)



With a HMO you have to go to/through your PCP first before you see anyone else. If you need a specialist they will refer you to a specialist that is also "in-network". You'd pay a co-pay for your PCP visit (if they require you to come in) and then a co-pay amount again to the specialist. Whether the co-pay to the specialist is higher or not depends entirely on the policy you have. With some it is higher, with others it isn't.

In most cases if you are referred to a specialist you only need one referral for the complete treatment with the specialist even if you need to visit the specialist 10 or 15 times. If you have a long term condition (diabeties, for example) then you usually have to get a renewed referral to the specialist once each year from your PCP.

With a PPO you ignore all of that stuff and if you need to see a specialist you pick one and go see them. The plan lays out the co-pay amounts for each type of doctor you visit.



Do a Google search on "HMO vs. PPO" and you'll get a few hundred sites that explain the differences.

IMO, The biggest thing is to seperate HMOs from PPOs. Then you have to compare the different policies (Only compare HMOs with other HMOs and PPOs with other PPOs!). You have to decide which one best fits your needs from there. For example, if you are young and healthy then you probably wouldn't need as many doctor visits so a policy with a higher co-pay that has a lower monthly rate would probably be a better bet. If you are older or have a chronic condition it may be worth it to pay a higher monthly rate and get the lower co-pay. Make sure any policy covers any known conditions right up front though! They all have limits.

fishin explained it well. i always think of it as if you have an hmo, you have a gate keeper. you have to see one doc everytime before you can do anything else. this just irritates me.

ppo, you can see any doc you want as long as he/she is in your network. you don't have to go see your gate keeper who then sends you to the real doc you need to see, you just get straight to the one you need.

i am a ppo kinda person. i would hate to have to call, get an appointment with my gatekeeper, then have him/her say, can't help ya, go see this guy, and then you have to start all over again. however, my dad is a doc so when something goes wrong, we know which doc to call.

That was a great answer, fishin'. The other thing about HMOs, is that you ARE limited. According to where you live, if you need a specialist, the specialist on the HMO list may not be convenient for you. Also, the HMOs do not tend to employ the best doctors in the field. So if a person has a serious, chronic condition, he cannot pick and choose from amongst the best docs.

One of the most important things when choosing a health plan is to get a copy of their physician list, and see if the docs are people who you would choose, if you had unlimited choice.

Also, with an HMO, some doctors have contracts with the HMOs that reward doctors financially for NOT referring to specialists, so as to keep costs lower.

http://healthinsurance.about.com/od/jobbasedcoverage/a/hmovsppo.htm

By law, an HMO is obliged to release information about their contractual arrangements with doctors. I asked for this information, which happens to be a Medicare HMO, when I had to switch my mother from regular Medicare for financial reasons. I would assume that these sorts of contracts are across the board with the HMOs.

Check out especially Arrangement D & E!

This information is some years old. I would suggest that if you are considering an HMO, that you obtain the information before signing up.

Thank you all for the tutorial. I believe I now have the knowledge to make the best decision that suits my health insurance need.