HMO's vs PPO's

You’ve narrowed your choices down to an HMO or a PPO. There’s PPOs with their greater access to providers on one side and the lowered costs of HMOs on the other. Choose HMOs and you get fewer out-of-pocket costs and lower premiums— but also get more restrictions. Go with a PPO and get an expanded assortment of care options— and higher out-of-pocket expenses and co-insurance rate.

How Do I Decide?

he decision between HMO and PPO can be complicated because the distinctions between them have blurred in recent years. Some HMOs have loosened their restrictions to woo consumers and while some PPOs that have tightened restrictions to lower costs.

The PPO May Be Best for You If:

• You want to be able to choose any doctor
• You have a chronic condition, such as back pain or arthritis
• You’d prefer to use alternative medicine services such as acupuncture or chiropractors.

But, It May Not Be Right for You If:

• You’d be unable to afford the added costs
• You’ll need to be in regular contact with customer service. PPO members tend to have more trouble than HMO members contacting their plan
• You’ll mind the extra billing problems that PPO members encountered compared to those enrolled in an HMO

What Will Your PPO Cost You (averages as of 2002):

• Your employee deductible will be around: $276.00
• Your co-insurance rate will be around: 10% to 20% in-network, and 20% to 30% out-of- network
• Your co-pay will be in the area of: $10.00
• Your annual family plan premium will be around: $2,152.00

For most of us, the choice of doctors available through a particular health plan is the most important factor in determining our overall satisfaction. So before you decide to enroll in either a PPO or HMO, ask around, see the physicians-roster of the plan you’re considering and be sure that it offers plenty of acceptable choices. Finally, call any doctors you’re interested in and make sure that they’re still members of the plan and open to taking on new patients.

The HMO May Be Best for You If:

• You’d prefer fewer billing hassles
• You will need to keep your out-of-pocket costs as low as possible
• You have a family that will need annual physicals, well-baby visits, and OB/GYN care.

But, It May Not Be Right for You If:

• You’d prefer to keep your healthcare options more open
• You regularly make use of specialist care and the need to get approval before doing so will be difficult for you
• You have a chronic medical condition and longer waits for needed care will be unfairly debilitating.

What Will Your HMO Cost You (averages as of 2002):

• You won’t be responsible for a deductible or a co-insurance rate for in-network care
• Your co-payment will be around: $10.00
• Your family premium will be around $1,960.00 annually

Before Selecting a Managed Care Plan…

Do you have a chronic illness? If so, ask if the plan you’re considering offers a disease-management program that will provide for intensive monitoring. Or, if you’re a smoker or have experienced problems with your weight, you’ll want to find out whether the plan offers a stop-smoking, weight-loss or any other alternative-medicine treatment program targeted to your needs.

Finally, don’t stop scrutinizing just because you’ve made your selection. If you find something about your plan disappointing, report your problems immediately. Considering how much money you’ll be shelling out, you have the right to demand the highest quality healthcare.

6 Important Factors to Determine Your Overall Satisfaction with Your HMO or PPO Plan:

1. How difficult is it for you to get the care that you and your doctor feel is necessary?
2. Your choice of doctors.
3. How difficult is it to get in to see a doctor?
4. The quality of your plan’s customer service department.
5. How often do you encounter billing problems?
6. How satisfied are you with your “primary-care physician”?