HMO or PPO

HMO’s simply put are the most managed of health insurance plans. You pick a doctor who you always go too unless there is an emergency. If he can not handle your symptoms in house he will then refer you to a doctor on an approved list. The list of doctors and hospitals are half the size of a PPO plan. HMO doctors are compensated on a salary basis. They make more money when they don’t see you. Also they can be penalized if there are to many referrals to other doctors. HMO’s for an individual and families are very hard to qualify for if you are not in the best of health. If you had trouble getting coverage with an HMO, try a PPO they are more tolerant of health issues. Other than chiropractic care HMO’s have all the bells and whistles. HMO’s have only copays and no deductibles. People who benefit best with an HMO are Women needing maternity, people aged 55 and older, and sometimes smokers especially for those who are 35 and older.

PPO’s are also a form of managed care. In network you can pick any doctor of specialty with out a referral. In other words no primary care physician or gatekeeper and for less benefits you can even see any doctor any where at usual and customary charges. PPO doctor lists also have 2 to 3 times the amount of hospitals and physicians compared to your average HMO. PPO doctors are paid by service so they are happy to see you. PPO’s are not as benefit rich as your HMO but they do offer chiropractic care. PPO’s include copays, deductibles and co-insurance. Copays are usually for office visit and prescriptions, not subject to your calendar year (from January to January) deductible or co-insurance. Since copays are separate, they are never subtracted from your deductible. Anything else that happens to you that is not covered under your copay will be subtracted off your deductible and then your co-insurance. Once your deductible and co-insurance have been satisfied, all that is left are your copays for the rest of that year. The co-insurance confuses most people. You just simply pay a percentage of your bill after your deductible has been met. Of course there is a limit, usually around $5000. You pay a portion of that $5000 which is typically 20%. So if you see a PPO that says you have a $500 deductible with an 80/20 coinsurance of the next 5000, you just add 20% of 5000 to your deductible of 500 and that will give a total out pocket maximum of $1500 less your copays.

Contrary to popular belief PPO’s are less expensive, with a lot better selection of doctors than your typical HMO. For more information on HMO’s and PPO’s call us at 1-888-627-0968.