honest opinions about HMOs

[wickedwanderer]

i have another question for everyone.  does anyone here have an HMO, and if so, what is your opinion about it?  i've never had one, and am considering switching over when our company's open enrollment occurs.  right now i have a limited PPO (small network of docs).  i know the basics of an HMO - referrals, ect.  i just curious about the quality of service and doctors.

[Maria Gomez]

An HMO (Health Maintenance Organization) is similar in many ways to PPO medical insurance plans. For example, you’ll still be expected to choose a PCP and to go through them for any referrals you require. One of the differences though is that your network of medical care providers is very limited. HMOs work with a small number of professionals, and you must stay within that network to receive any type of coverage.

Another difference is that most HMOs do not require you to meet a certain deductible before your coverage begins to pay your medical costs. Additionally, most HMOs do not split the costs with you. That means if your medical insurance covers a certain provider, then 100% of that bill will be paid by your individual health insurance. You do generally need to make co-payments for each of your visits. These co-payments can range from $10 to $40. You’ll also be expected to pay co-payments for your prescriptions if those benefits are included in your individual health insurance plan.
Marianne Selis
Health Insurance Terms</a

[Jordy]

No, I've never seen a difference in service by doctors.  Well, like I said, my main PCP I've had for years anyway, he always took whatever insurance I had, along with one of my specialists who dates back to that same time as well.  But I've never understood the concern.  Pretty much any doctor I've wanted to go to has taken whatever my insurance has been, HMO or otherwise.  But regarding what's covered...let's just say I've had to make absolutely no changes in my approach to my medical care because of my insurance switch (brought on by a job change.)  I still get the visits I need, the specialists I need, the tests I need, etc.  The only difference now is I pay a co-pay as opposed to paying up to a deductible.  Actually, one thing I like about my HMO is there's pretty much no problem getting any claim covered as long as there was a pre-referral.  With my past insurances that were not HMOs (I've had many, so I'm not sure which were PPOs or whatever), I've always had to haggle with them, sometimes for months, to get claims paid that they tried to deny after the fact because there were no true pre-approvals.  I always won, thankfully, but what a chore!  I've noticed with my HMO claim coverage has been quick and efficient.

I'm doing MAJOR knocking on wood right now! :)

[wickedwanderer]

glad you hear you've had success w/ an HMO.  i hear the horror stories too, so that's why i'm weary.  i know the differences (i worked in HR/benefits)...but soooo many people take the PPO (which is usually the most expensive).  

thank you for your opinion :D  one more question - so you don't see a difference in service, between the HMO and PPO, right?  i mean, of course it would depend on the specific doc you see, but in general....?

Thanks!!

[Jordy]

I was nervous about being on an HMO after years of PPO service, just all the horror stories and all that, but now it's been three years on an HMO, and I've been VERY happy with it.  I already had a PCP I was happy with who took me right back into his practice (I had moved away and now back) and accepts my HMO.  So I say the first step in HMO satisfaction is having a good relationship with your PCP.  He's wonderful about my referrals, and I've actually grown the like the "organized" aspect of having all my specialists connected through my one doctor's office.  For a while there I was going every which way with doctors because I didn't HAVE to have a referral and I was trying to figure out all my needs by myself, and now I'm much happier that it's all pulled back through one central point with one main professional opinion (the PCP).

As for my claims, I've had every single one (and there have been quite a few for various reasons and specialists) paid in a timely manner without any problem, as well as all my prescriptions.  Oh, well one was denied because of a screwup with the doctor named on the claim (the doctor's office screwed up) but the HMO told me just have them resubmit it with the correct name and it would be paid.  It was.

All in all, so far so good.