hmo, ppo or pos? | Arthritis Information

Hi,

I have had RA for 10 years, and have been under Tricare (military healthcare) the entire time. My husband recently got a civilian government job at Ft. Meade, Maryland and we now have to decide on which healthcare plan to choose. I am so unfamiliar and overwhelmed with the process, I don't know where to start. I think I understand the basic differences between the three, but am wondering if anyone here can give me their opinion on which is better for someone living with RA. We are on a tight budget, which makes me think HMO, but the ability to go without referrals has me questioning PPO's. Will the cost be that much higher? Will co-pays vary greatly between the different insurance companies? I would greatly appreciate any advice or suggestions.

Thanks -

Tracy

tracy it is hard to say which would be better for you because all insurance plans are different. No matter which plan you choose you want to insure your doctors take that plan. Also make sure that any you might want to see are in there. You want to verify prescription coverage especially for any biologic meds that you may currently or in the future take.

the basic differences are an HMO requires you to have a gatekeeper to provide referrals to specialists (other than gyn); ppo has a preferred dr netwark but generally has an out of netwark option for a higher price; POS you can see anyone anytime.Thanks for the reply, buckeye. Like I said, I have the basics down, I just was hoping for some opinions based on your experience. I am moving to Maryland in 2 months, and am not familiar with any docs there, so worries about that. Thanks for the head up on prescription coverage.

Anyone out there have an opinion they would like to share? Are the HMO's more restrictive because of their need to keep shareholders happy? How about a group like Kaiser, that is non-profit? Do those of you on PPO's find you have to pay a lot extra to cover labs, etc? I am not trying to start any debates, just interested in what people have to say. Tracy, Hi and welcome to the forum. I've had an HMO, POS, PPO and now am covered by Tricare for life. Each of them have their positives and negatives depending on your health and your family's health and budget.

I lived in the DC/Baltimore area for many years and there are excellent physicians and facilities in that area. I think I remember Ft. Meade as being south of Baltimore. I wouldn't worry about the quality of the healthcare. It sounds like you need to look very closely at your budget and if you can afford the % of copay that a POS requires and in some cases a PPO. Also make sure you look at the availablity of RDs in the PPO and HMO. You might want to call their offices and see how quickly you can be seen or if they're making appts. many months ahead.

You can call your husband's new employer and talk to the human resource office about the insurance and they may be able to give you some guidance and also you can call the insurance company themselves for information. Basically it boils down to what fits your budget and if the RA meds are a covered benefit. It's a big decision. Remember each state have their own rules and regulations regarding health insurance and what someone in Pennsylvania tells you may not be so in Maryland. Lindy

First of all Welcome to Maryland! Didn't your husbands employer give him handouts on each of the plans detailing the costs and benefits provided by each? I've had HMO and PPO. I absolutely hated the HMO. It was a long time ago though, that I was enrolled in one, but after the experience I had I'll never pick one again. I didn't have health issues at the time but my son did with his ears. He needed to see a specialist every 3 months and 3 weeks before his appointment I had to start my fight to get his referral letter. My mother had an HMO (same company) later on and never had a problem. I think it had to do with the center I picked. I switched to PPO and have never regretted it. I get to pick my own doctors and I don't need any referrals. May have cost more but I didn't have to put up with the headache. I have a ppo and my copays are for a reg. dr. and for a specialist. But, that is just for my particular plan. Yours may be totally different. You actually ask a very difficult question. I have had an easier time with my PPO than my friend. She also has a PPO but her employer bought into a cheaper plan.

I grew up at a military brat and it is hard switching insurances. My dad was stationed at the pentagon when I was diagnosed. Couldn't ask for better health care. The military actually sent me out to a civilian rheumy-probably cause I was a minor. I know at that time if they could not offer appropriate services you could go out of the military network.

you do want to try and set up appts. Those waits can be crazy!

I have BCBS PPO...... and I love it. I will say it is definitely a deciding factor (in addition to my accumulated PTO time) for staying at this job.
I like the freedom my PPO gives me.. to see any doc at any time..... no referrals...and we have the same for ALL doctors.. from PCP to RD and Opthalmalogist.....
I've had HMO's and it always seemed to me that the company ruled the docs..... that is why I elected to pay the little extra for PPO.
Good luck on your move... and welcome!!

Is your husband still entitled to coverage under Tricare or Tricare Plus? If so, stick with that would be my advise. I've had them all, too. And they all vary based on the contract. I currently have Anthem Blue Cross PPO and each year I see a very slight degradation in coverage. For example, the drug formulary kills off more and more drugs each year, and there are caps on the outpatient surgeries if performed at an out of network ambulatory hospital. Still, compared to other plans I hear about, mine is one of the best.

However, my opinion is always the same:

~ Get the best policy you can afford with the goal being group coverage in a PPO plan.

I mean no offense to those who have other coverage but recently I've been paying attention to people when they talk about knee replacement. [Once those rooster shots no longer work for me, it's TKR time.] I'm convinced the suceess of the surgery is in the skill of the surgeon. The best surgeons do not typically practice for HMO's.

I also suggest that when deciding on insurance coverage to ask for a list of physicians by specialty who are in-network. Most insurance companies [or the HR or Benefits rep where your husband works] can give you the link to the online list of names. Of course, being in a new neighborhood the names might be useless. But at least you can check to see if there are more than one or two rheumatologists in your immediate area. This way if the first one is Godzilla.......

Good luck!