The Great Debate – PPO vs. HMO

 

Both HMOs and PPOs have benefits and downfalls. This will be
dependent on what you are looking for and what kind of coverage
that best suits your needs. Many people swear by one or the other
and have no desire for the opposing insurance. But they are very
similar in many cases and the things that make them different, are
where the benefit or deficit lies for the individual.

A HMO is a collection of health professionals, doctors, hospitals,
mental healthcare workers, and other specialists, who work for a
set fee. There are independent HMOs in where all the staff members
that work there work directly for that private HMO. A broader
spectrum of doctors and other health care workers can agree to a
set fee for service with many different HMO plan companies and are
not actually owned by the HMO itself. HMOs are designed to save
people money while getting the entire healthcare they need. Co-pays
for visits and prescriptions are usually very low and there is no
deductible to be met. However, HMOs do have their downside. HMOs
are in business to make money and so if you have many health care
issues
, you may not be accepted or have to pay more. If you have a
chronic medical condition that requires many visits, tests, and
treatment you will cost the HMO lots of money. They balance this
out by keeping a tight hold on your health care. They must approve
all visits prior to you going.

HMOs are usually extremely restrictive and have lots of rules that
must be followed if you want them to pay. You can only see the
doctors on your HMO list, and you must see your primary care doctor
first, no matter what is wrong with you. If you have to go to the
hospital you must have your primary doctor’s permission prior to
going. Many people find that way too restricting and choose to not
go with HMOs for that very reason. When and if you need to see
specialist, you must have seen your doctor first to make sure they
can’t treat you instead of going to a more expensive doctor. The
HMO makes sure it is their doctor who has control over all your
medical needs, not you. Most doctors are excellent and will hand
out referrals and most doctors these days are enrolled in HMO plans
so this isn’t a problem for many people. If you are not one of the
lucky ones, getting the care you need could be difficult or
non-existent. HMOs can also be a bit fussy about you wanting to
change your primary doctor. So be sure that you like your doctor
and you have spoken to other people who are patients of him or her.

Most HMOs also have a patient quota that the doctor has to comply
with. He or she must see a set number of patients per day to avoid
penalization or being removed from the group. This is why there is
never enough time to talk with your doctor past your examination
point. They need to keep it short so they can see more patients.
There is also the concept of Capitation that gives contracted
doctors a set amount of money for each patient each month. This is
given no matter if the patient is sick or well. Lastly you must
make sure any labs or tests you need are covered with your plan or
they won’t be covered. But for most people who have HMOs this is
not a problem and their doctors are great, so they don’t have any
problems at all.

A PPO is a collection of private-practice doctors, labs, cares
facilities, and hospitals that contract with insurance companies
and receive an agreed set rate for their services. These plans have
much less restriction but cost more to the patients. The patient
has more control over their own medical needs and doesn’t need a
referral as long as the doctor they are seeing is a member of the
PPO. The co-payment is higher because the plan only covers usually
80% of the fees. So that makes you the insured responsible for 20%
of all your fees from all medical treatment including hospital
stays. You may also have a deductible to meet before your coverage
starts each year. PPOs hire nurses and medical professionals to
handle patient cases and make decisions about hospital visits and
diagnostic tests. You have more freedom, but you end up filling out
claim forms.

PPOs are great for people who have the money and want to have more
freedom in their healthcare choices. If you are a person with many
health issues that require several different opinions, extensive
tests or treatment, and need specialists, this plan gives you a
better choice and fewer restrictions on what you can do. You won’t
have to wait months to see the specialist; you will be able to just
go. It will cost you more money, but you ill have your needs met
faster.

So which type of insurance do you choose and is one better than the
other. HMOs can be a lifesaver to many people who need insurance
but don’t have a lot of money. But for many people it is just a
personal preference based on their own needs and the needs of your
family. So, one needs to take a look at all options and make an
informed decision. Neither one of the plans is perfect, so pick the
one that best suits you.

DISCLAIMER: This information is for educational and informational
purposes only. The content is not intended to be a substitute for
professional advice. Always seek the advice of a licensed Insurance
Agent or Broker with any questions you may have regarding any
Insurance Matter.

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