HMO vs PPO

[somarco]

What follows are notes to myself based on 30+ years of observing the managed care market. Notes are factual but should not be misconstrued as applying to ALL plans EVERY time.

HMO HAS LOWER FIXED COSTS
LOWER PREMIUM, COPY, MOOP
MORE ATTRACTIVE EXTRA BENEFITS (DENTAL)

NO REFERRAL TRICK
INSURED GOES OON, CLAIM DENIED, MORE COST SHIFTING

ACCESS TO FEWER SPECIALISTS
ACCESS TO FEWER HOSPITALS
FEWER FORMULARY DRUGS
GREATER HMO CONTROL OVER CLAIMS

MORE PRIOR AUTHORIZATIONS, DELAYS, DENIALS

HMO LOOKS MORE ATTRACTIVE TO CONSUMER

AGENTS WHO DON’T UNDERSTAND THE HMO PLAN WILL HAVE MORE ATTRITION
AGENTS LOOKING AT COMP, IGNORING IMPACT ON CONSUMER, WILL HAVE MORE ATTRITION
AGENTS SELLING HMO ON PRICE, BENEFITS IGNORING HMO LIMITATIONS, WILL HAVE MORE ATTRITION

YMMV


All caps and shorthand are for my note taking benefit and should not be seen as shouting. I find all caps easier to read, especially when summarizing.

 

[axeman462]

What do you mean by "no referral trick"?

 

[somarco]

"no referral trick"?

HMO plans use referrals in an attempt to keep the patient in network. What happens if the patient wanders OON in a non-emergency situation?

The carrier can deny the claim.

Chances of staying in network are greater with mandatory referrals.

 

[AgentGeneral]

What follows are notes to myself based on 30+ years of observing the managed care market. Notes are factual but should not be misconstrued as applying to ALL plans EVERY time.

HMO HAS LOWER FIXED COSTS
LOWER PREMIUM, COPY, MOOP
MORE ATTRACTIVE EXTRA BENEFITS (DENTAL)

NO REFERRAL TRICK
INSURED GOES OON, CLAIM DENIED, MORE COST SHIFTING

ACCESS TO FEWER SPECIALISTS
ACCESS TO FEWER HOSPITALS
FEWER FORMULARY DRUGS
GREATER HMO CONTROL OVER CLAIMS

MORE PRIOR AUTHORIZATIONS, DELAYS, DENIALS

HMO LOOKS MORE ATTRACTIVE TO CONSUMER

AGENTS WHO DON’T UNDERSTAND THE HMO PLAN WILL HAVE MORE ATTRITION
AGENTS LOOKING AT COMP, IGNORING IMPACT ON CONSUMER, WILL HAVE MORE ATTRITION
AGENTS SELLING HMO ON PRICE, BENEFITS IGNORING HMO LIMITATIONS, WILL HAVE MORE ATTRITION

YMMV


All caps and shorthand are for my note taking benefit and should not be seen as shouting. I find all caps easier to read, especially when summarizing.

You left out HMO-POS

No disrespect. Just sayin...

Personally I do mostly PPO, but on occasion and ever since ACA I've done more HMOs....for one, in U65 HMO was only option until recently, but no one complained. ever....and still don't