HMO Blue vs. Preferred Blue PPO

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Small Law Survivor
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HMO Blue vs. Preferred Blue PPO

Post by Small Law Survivor » Fri Jan 12, 2018 3:29 pm

My health insurance is through BC/BS of Massachusetts. This is an employer plan, and we have a choice, every year, of enrolling in HMO Blue or BC/BS's "PPO".

The annual premiums for the HMO is about $2,600 less expensive than the PPO ($5,700 vs. $8,300).

I have to admit that for many years I enrolled in the PPO without revisiting this issue each year - I was making a lot of money, and I just didn't pay attention to this. There was a reason to enroll in the PPO about 10 years ago - I did that and forgot about it - I just reupped with PPO every year.

Now that I am semi-retired, I'm trying to examine my expenses, and this is one that needs looking at!

The only material difference, from what I can see, is that the HMO requires that each family member have a primary care physician. That's no problem, my wife and I, and our 23 year old daughter (who's on this plan) have a PCP.

On top of that, you need to get a referral from the PCP for any medical care, with a couple of minor exceptions (emergency, OBGYN). This seems like a small inconvenience to suffer for $2600/year, and I'm wondering - "what's the catch"? Is it that difficult to get a referral from PCPs? Why would anyone buy the higher priced option (yeah, I know, I did - but I was making big bucks, and a couple of grand for a minor convenience wasn't a big deal).

Here's an example of how this will come into play right away. My wife went to COSTCO for an eye exam recently. The eye doctor there said she had cataracts. We then made an appoint at the eye clinic my parents and I have used for many years, and she was in to see a doctor there right away - within just a few days. He said, "you need cataract surgery, my dear," and she is now arranging the date for the first of two surgeries. But, before she does that she needs to get what they called a "stand-alone test" to measure astigmatism - that will determine her options for the surgery (Toric lenses, yes/no).

I assume that if we go on the HMO she'll have to go through this process again - the "new year" (for insurance purposes) starts on February 1st, and the cataract surgery is scheduled for May. I assume she'd have to go through this whole process again - get a referral from her PCP, make an appt. with another eye doc (unless the doctor refers her to the same place), get another stand alone test for astigmatism at the request of the new doc.

Any advice on this? I guess the drawback would be if the PCP couldn't been seen promptly, delaying the referral to a specialist. This system makes the PCP the manager/general contractor for all of the patient's health care. Will this be a problem?

Thanks!

gtaylor
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Re: HMO Blue vs. Preferred Blue PPO

Post by gtaylor » Fri Jan 12, 2018 3:53 pm

Not sure about the referral thing, although specialists sometimes ask us about it, since so many people are in the same boat. For anything routine, I think it's just a routine waste of time. It's when you have something interesting and want a second or third opinion that things get interesting.

At our company (also using BCBS of MA), the PPO has in-network coverage and lesser out-of-network coverage. The HMO only has in-network coverage; go out of network and coverage is zero except for urgent / emergency care. Furthermore, with our plans the BCBSMA HMO network is regional, whereas the PPO network is national. So with the HMO there's no way to go to, say, MD Anderson or whatever if warranted. Never mind even going to a local out of network specialist.

The day-to-day hoot is probably not with the referrals as such, but in the cases where random parts of a bill turn out to be out of network. Radiologists, anesthesiologists, the odd lab test, these things are often out-of-network surprises, and you have no way to prevent it. With only in-network coverage that could get ugly if you can't badger BCBS into covering it.

DetroitRick
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Re: HMO Blue vs. Preferred Blue PPO

Post by DetroitRick » Fri Jan 12, 2018 4:01 pm

It's not quite apples-to-apples, because we are with the Blues in Michigan and have an ACA plan rather than an employer plan, but we did make the switch last year to HMO from PPO, and have been totally satisfied over the last 13 months. We're not dealing with anything medically complex, but have been surprised at how fast we get the necessary specialist referrals. That was the one thing that worried us initially. In the last year, got quick referrals to 4 different specialists within times ranging from same-day to a few days. And none of those referrals were medically urgent.

We did speak to both our PCP's office managers before making the switch (rather than trust the online directory) to make sure there would be no issues. Our state might also be unrepresentative because of the high market share held here by the Blues (both HMO and PPO, employer and ACA plans). Pretty much everybody participates here making this especially easy. I'm sure there is an exception for everything, but as far as I know we cannot go out of network and get any coverage (there are provisions for emergency care when out of our area of course).

The premium differential was dramatic and we basically couldn't stomach the huge PPO premium bill anymore. In our case, we've not experienced anything detrimental. Nothing. Had I known, I would have made this switch several years earlier and saved some money.

One thing I've noticed here in Michigan with Blue Cross (again, this is under ACA so maybe your experience would be different) is the number of different HMO's within the Blue Cross system (Blue Care Network). They all have somewhat similar names, but differ radically in breadth of network. Naturally the cheapest is the most restrictive. But we were able to find a plan that included all the physicians we cared about. There is at least one HMO plan offered by Blue Cross that is extremely restrictive as to provider, but ours is not. Worth researching before taking the plunge, of course. Best of luck!

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dm200
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Re: HMO Blue vs. Preferred Blue PPO

Post by dm200 » Fri Jan 12, 2018 4:25 pm

Small Law Survivor wrote:
Fri Jan 12, 2018 3:29 pm
My health insurance is through BC/BS of Massachusetts. This is an employer plan, and we have a choice, every year, of enrolling in HMO Blue or BC/BS's "PPO".
The annual premiums for the HMO is about $2,600 less expensive than the PPO ($5,700 vs. $8,300).
I have to admit that for many years I enrolled in the PPO without revisiting this issue each year - I was making a lot of money, and I just didn't pay attention to this. There was a reason to enroll in the PPO about 10 years ago - I did that and forgot about it - I just reupped with PPO every year.
Now that I am semi-retired, I'm trying to examine my expenses, and this is one that needs looking at!
The only material difference, from what I can see, is that the HMO requires that each family member have a primary care physician. That's no problem, my wife and I, and our 23 year old daughter (who's on this plan) have a PCP.
On top of that, you need to get a referral from the PCP for any medical care, with a couple of minor exceptions (emergency, OBGYN). This seems like a small inconvenience to suffer for $2600/year, and I'm wondering - "what's the catch"? Is it that difficult to get a referral from PCPs? Why would anyone buy the higher priced option (yeah, I know, I did - but I was making big bucks, and a couple of grand for a minor convenience wasn't a big deal).
Here's an example of how this will come into play right away. My wife went to COSTCO for an eye exam recently. The eye doctor there said she had cataracts. We then made an appoint at the eye clinic my parents and I have used for many years, and she was in to see a doctor there right away - within just a few days. He said, "you need cataract surgery, my dear," and she is now arranging the date for the first of two surgeries. But, before she does that she needs to get what they called a "stand-alone test" to measure astigmatism - that will determine her options for the surgery (Toric lenses, yes/no).
I assume that if we go on the HMO she'll have to go through this process again - the "new year" (for insurance purposes) starts on February 1st, and the cataract surgery is scheduled for May. I assume she'd have to go through this whole process again - get a referral from her PCP, make an appt. with another eye doc (unless the doctor refers her to the same place), get another stand alone test for astigmatism at the request of the new doc.
Any advice on this? I guess the drawback would be if the PCP couldn't been seen promptly, delaying the referral to a specialist. This system makes the PCP the manager/general contractor for all of the patient's health care. Will this be a problem?
Thanks!
Years ago, we had experience with both PPOs and this type of HMO.

There was very little practical difference with the HMO. It really depends on whether specific providers are on the HMO list AND how much trouble you must go through to get a needed referral. Maybe check with those who have the HMO, as well as your PCP's office to see what they say. Yes, I would incur a modest inconvenience for $2,600 a year. The "details" for your plans matter, though.

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Pajamas
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Re: HMO Blue vs. Preferred Blue PPO

Post by Pajamas » Fri Jan 12, 2018 4:34 pm

At least with my primary care doctor, getting a routine referral is merely a formality. I can call and leave a message on an answering machine in the morning and have a referral to specialists that I already see that afternoon or simply stop by the office and pick one up. I don't need a paper referral for doctors in the same health care system as it is in the electronic medical record. I have even seen patients who showed up at a specialist's office without a referral call their doctor's office and get one entered electronically on the spot.

Your primary care doctor might want to see you before referring you to a new specialist under some circumstances, but might even give a referral under other circumstances without seeing you. Many things that you might go to a specialist for on your own, a primary doctor can appropriately treat.

Many specialists don't see patients without a referral, anyway. Sometimes a visit to a specialist is much more worthwhile if you show up with labs or imaging studies already done, and the primary doctor can take care of that ahead of time.

Have you asked your primary care doctor's office how such referrals work there?

My current coverage is the first time that I have had coverage that required me to get referrals. I was apprehensive about it, but it has been only a minor annoyance about on par with getting a prescription refill without seeing the doctor. The referrals are good for a year in my plan and that is probably the standard.

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eye.surgeon
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Re: HMO Blue vs. Preferred Blue PPO

Post by eye.surgeon » Fri Jan 12, 2018 4:42 pm

I can speak to your issue from some experience as an ophthalmologist that doesn't take HMO insurance.

Firstly, yes you will need to go through all the screening and testing and exam prior to your cataract surgery.

Secondly, if your primary care doctor and specialists all take your HMO insurance, the PPO advantage is fairly small, mostly one of convenience. If, as is often the case, your specialists don't take HMO insurance, as I do not, you will have to switch specialists, which is a significant hassle IMO.

My experience with HMO vs PPO practices at least in my region is the HMO doctors, being paid by lives managed instead of fee for service, have to make up for the lower average reimbursement per patient encounter with volume. You will find a higher preponderance of physician extenders in an HMO practice where you may end up seeing the nurse practitioner or physician assistant instead of the doctor. You may have longer waits for appointments. You may have less time per visit with the care provider. All of these factors are highly region dependent, some areas have high HMO penetration and the differences are fairly minor, other areas like mine there is a not a lot of HMO coverage and the differences are notable.
"I would rather be certain of a good return than hopeful of a great one" | Warren Buffett

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dm200
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Re: HMO Blue vs. Preferred Blue PPO

Post by dm200 » Fri Jan 12, 2018 4:43 pm

One other consideration - if you choose the HMO and are not satisfied, can you switch to the PPO next year?

Small Law Survivor
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Re: HMO Blue vs. Preferred Blue PPO

Post by Small Law Survivor » Fri Jan 12, 2018 5:05 pm

gtaylor wrote:
Fri Jan 12, 2018 3:53 pm
when you have something interesting and want a second or third opinion that things get interesting
Very good point - I'll inquire into second opinions.
gtaylor wrote:
Fri Jan 12, 2018 3:53 pm
The day-to-day hoot is probably not with the referrals as such, but in the cases where random parts of a bill turn out to be out of network. Radiologists, anesthesiologists, the odd lab test, these things are often out-of-network surprises
Yes, I've read a lot about this. The way to handle it, from what I've read, is to insist that all providers be in-network. And hope that request is honored.
DetroitRick wrote:
Fri Jan 12, 2018 4:01 pm
We did speak to both our PCP's office managers before making the switch (rather than trust the online directory) to make sure there would be no issues
Yes, we are doing this.
dm200 wrote:
Fri Jan 12, 2018 4:25 pm
The premium differential was dramatic and we basically couldn't stomach the huge PPO premium bill anymore. Had I known, I would have made this switch several years earlier and saved some money.
No kidding :annoyed
eye.surgeon wrote:
Fri Jan 12, 2018 4:42 pm
Firstly, yes you will need to go through all the screening and testing and exam prior to your cataract surgery.
Yup, spoke with BC/BS, and they confirmed this.
eye.surgeon wrote:
Fri Jan 12, 2018 4:42 pm
My experience with HMO vs PPO practices at least in my region is the HMO doctors, being paid by lives managed instead of fee for service, have to make up for the lower average reimbursement per patient encounter with volume
I think, in Massachusetts, many doctors are in both systems - I see my PCP at Harvard Vanguard as a PPO patient; if I convert to the HMO, I'd see him as an HMO patient - does that sound reasonable? I think I'm already paying the price (in terms of patient encounter time) for the HMO patients. :?
dm200 wrote:
Fri Jan 12, 2018 4:43 pm
One other consideration - if you choose the HMO and are not satisfied, can you switch to the PPO next year?
Yes, but we'd have to wait until February 1, 2019.

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dm200
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Re: HMO Blue vs. Preferred Blue PPO

Post by dm200 » Sat Jan 13, 2018 10:11 am

Yes, as another post said, with the HMO, your PCP is probably receiving payments irrespective of how much or often he/she sees you - and 'incentive' to keep you well. I suspect that how this would work for you may have a lot to do with having a good relationship with your PCP - and perhaps the characteristics of the PCP and his/her staff. Again, our experience for a few years with this type of HMO was fine - only some very slight and inconsequential inconveniences.

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Re: HMO Blue vs. Preferred Blue PPO

Post by adamthesmythe » Sat Jan 13, 2018 1:55 pm

Small Law Survivor wrote:
Fri Jan 12, 2018 3:29 pm
I guess the drawback would be if the PCP couldn't been seen promptly, delaying the referral to a specialist. This system makes the PCP the manager/general contractor for all of the patient's health care. Will this be a problem?
It's a definite maybe, it's not a problem until it's a problem.

I have known people who would had a better result if they had gone immediately to a specialist. The PCP is a gatekeeper and in addition to the delay in getting an appointment may decide you don't need a specialist. Sometimes they might be wrong.

I had a PPO when working. I couple of times I directly made an appointment to a specialist. Oddly it very easy and fast to get appointments- maybe a week or so. But I think I may have been overtreated. Went in with a complaint of shoulder pain, and had a complete set of xrays before even seeing the doctor.

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dm200
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Re: HMO Blue vs. Preferred Blue PPO

Post by dm200 » Sat Jan 13, 2018 3:37 pm

adamthesmythe wrote:
Sat Jan 13, 2018 1:55 pm
Small Law Survivor wrote:
Fri Jan 12, 2018 3:29 pm
I guess the drawback would be if the PCP couldn't been seen promptly, delaying the referral to a specialist. This system makes the PCP the manager/general contractor for all of the patient's health care. Will this be a problem?
It's a definite maybe, it's not a problem until it's a problem.
I have known people who would had a better result if they had gone immediately to a specialist. The PCP is a gatekeeper and in addition to the delay in getting an appointment may decide you don't need a specialist. Sometimes they might be wrong.
I had a PPO when working. I couple of times I directly made an appointment to a specialist. Oddly it very easy and fast to get appointments- maybe a week or so. But I think I may have been overtreated. Went in with a complaint of shoulder pain, and had a complete set of xrays before even seeing the doctor.
Yes - that is the whole "theory" of the HMO "model". Sometimes, depending on the condition and the expertise of the PCP, he/she can treat you vs a specialist. The "delay" factor can be at play as well. The other issue is how well the patient can "know" the appropriate specialist. It is not always obvious. So, with a PPO, you see a specialist directly - and it is the wrong specialist (for one of several possible reasons). Even the "right" specialty could be some aspect that a particular specialist may not deal with.

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