HMO Or PPO?

Hi M.
I have HMO and have never had any issues with it. I think the reason some doctors don't take HMO is because it is a LOT of detailed paperwork on THEIR end and it is a limited network. However, I have wonderful doctors that I trust completely (Res Hosptial on Harlem & Talcott) and all my visits regarding pregnancy are covered. I'm pregnant with my second child and don't even have to pay a co-pay for my visits or deductible regarding labor, etc. My husband has PPO through his work and the nice thing about a PPO is, you can go wherever & whenever you want. But it's more money and since he doesn't go to the doctor often, it's a better choice for him. So I think really, you just need to figure out what you would prefer (saving money on an HMO or staying with your current doctors). Good luck!

I had an HMO when I had my first kids and very glad I did. I did not have to pay anything. I never thought I would switch off of it. However, my son requires special meds and seeing a specialist every 6 months or so. I have a PPO now because I do not have to deal with getting referrals. If you don't mind switching doctors and don't think you will need referrals often, then an HMO might suit you. I have more out of pocket but I also take advantage of Flexible Spending accounts at work. One way to save money with a PPO is going to a hospital or doctor's office that does not charge as much, such as Resurrection over Rush Medical Center. I would say look at doctors first.

Hello M.,

We deliberately chose to take the HMO option since we were planning on having kids. My first son was born via emergency c-section at 36.5 weeks and spent 13 days in the Neonatal ICU (NICU). Thank God that we had the HMO, because his hospital charges for Loyola were close to $70,000 and, had we had the PPO at that time we would have been on the hook for 20% of that charge! YIKES! Under the HMO we paid a whopping $100 dollars.

My son did have to see some specialists and have several tests/procedures done, but our Primary Care Provider was always very swift to provide us with the needed referrals and we never had any issues which prevented us from taking care of his health needs promptly.

By the age of 3 months my son had had hernia surgery, for which we paid $100, a trip to a pediatric cardiologist for which we paid $20, several ultrasounds to monitor issues with his kidneys, an echocardiogram which found a hole in his heart, and a few follow up visits with the NICU staff. He also had frequent blood tests done as there were some concerns about his liver function.

My son is now 2.5 and healthy, but had we been on the PPO option at the time, we probably would have had to declared bankruptcy from all of the bills.

We just had our 2nd child and he was also delivered by c-section, but our bill will only be $100.

I think the main thing is to make sure that your primary care provider under the HMO system is responsive and efficient at filling out the referrals. Make sure that if he or she recommends a specialist or a special procedure, that they request the referral on the same day. This will help to eliminate any potentials delays with acquiring referrals. Ours has been fantastic and I have been very pleased with our HMO plan.

I actually received financial assistance through the state when I had my daughter. I delivered at Resurrection on Harlem/Talcott as some others have said and had a great experience there. Their family practice clinic is great and they probably take an HMO. I have since gone under my husband's insurance and we now have a PPO. My daughter has had to see alot of specialists and the PPO has been indispensable for that reason. I think you might want to consider the HMO for pregnancy and then see what happens. Keep in mind when you are allowed to make a change between HMO and PPO, perhaps only at open enrollment? Another factor to think about is, even though you may have more out of pocket expense with a PPO, usually there is a limit. For instance, my PPO covers 80% of hospital, and we have to pay 20%. But, we also have a maximum out of pocket expense for the year at $1500. So we will never have to pay more than that in one year. $1500 wouldn't be great, but its doable and wouldn't put us in the hole. Definitely call your insurance and hash out the details comparing exactly what % you pay with PPO and your deductibles/copays/max out-of-pocket expenses with hospital stays and office visits before you go and switch. Once you do, you probably have to wait another year before open enrollment comes again to switch back. I took the HMO for dentist at first and had a hard time finding a good one to take it. I ended up waiting an entire year to switch to PPO and go back to my dentist. Kind of a pain.