Question:
I have two insurance options blue cross hmo or blue cross ppo, which do i choose??
I would like to get as much of the surgery covered as possible. — kara J. (posted on April 12, 2003)
April 12, 2003
Even though HMOs are more expensive, it makes up for it on the other end.
I have Aetna HMO and all I was responsible for was $10 copay for my initial
consult with the surgeon, $200 for the nutritional consult (almost no
insurance covers this), $200 for the psych consult (ditto) and my TV &
telephone charges at the hospital. Everything else was covered 100%.
With PPOs & POSs and straight indemnity plans like BC/BS, you have to
worry about in-network and out-of-network and deductibles and 20-30% copays
up to out-of-pocket maximums. Also, with the non-HMOs, they will only pay
what is called R&C or reasonable & customary amounts for it - and
you may be left being liable for the balance between the R&C amount and
what your surgeon charges...JR
— John Rushton
April 12, 2003
I have Keystone Health Plan East (HMO) from Philadelphia and I was approved
in 2-3 days! Good Luck ! Michele :)
— Michele D.
April 12, 2003
I have Healthnet Select which allows me to choose either the HMO portion or
PPO portion of the insurance. I chose to start out with the HMO and if I
got denied then I would go through the PPO...In fact this was the
recommendation of the nurse at the surgeons office. Anyway the HMO paid
for all and when I received the hospital bill of $35,000 and the line on it
that said "patient not responsible for bill" did I ever sigh for
a moment of relief! So I think your best best is to try through the HMO
first. Good Luck
— Jenny B.
April 12, 2003
I have blue cross/blue shield of California PPO and I paid 0 for my
surgery..just my office copay visit..they also paid for my TT, breast lift,
brachioplasty & thighplasty 100%..only had to pay for my office visit
copays there as well..also paid for me to see a nutritionist and also paid
partial coverage for my joining the gym they have at the hospital..it's a
GREAt place..all the latest machines and only have to pay half of what i'd
normally pay. I've had HMO's in the past and wouldn't go back..I can't be
bothered with referrals and having to ask permission from my PCP to see
other doctors..the bc/bs I have is wonderful..I can see whateer doctors I
want and it's paid for..I can also see any doctor I need to out of
state..which happened a few times when I was in NYC..good luck :)
— [Deactivated Member]
April 12, 2003
One more thing..I never had a deductible! Insurance companies can be so
horrible :( good luck again :)
— [Deactivated Member]
April 12, 2003
I have Blue Cross POS which has both an HMO component and PPO component. I
did not want to pay anything so I started through my HMO. They made me
crazy and approval, if it ever came, was going to be a long and drawn out
process. I also wasn't going to have a say in what surgeon I would use and
the one they used had a waiting period of over 6 months just for a consult.
In other words, they made it as difficult as possible. I decided to go
PPO and my out of pocket expenses were 3500.00 but I picked my own surgeon,
got right into see him, was approved within 24 hours of my paperwork being
submitted and my surgery was 3 weeks later. If you can wait and jump
through the HMO hoops, do that but if you can't, go with PPO.
— susanje
April 12, 2003
I have Bcbs PPO. I have not had a problem with them covering anything,
including 2 nutritional consults, and the sleep study. The only thing I
had to use my major medical for was the psych consult. But I've only had
$15 co-pays with all of my other consults, and my surgeon. And they
approved me for surgery within 2 weeks.. I have my surgery may 15, 2003 :-)
— KellyJeanB
April 12, 2003
I also have Blue Cross POS. I used the HMO portion for my open RNY 3
months ago. Approval was immediate, no appeals letters, no co-payment,
nothing. It was incredibly easy. My bills came to about 40 grand, and I
paid zero. I think it all depends on the medical group you use more than
the insurance company. I live in Southern California and have Greater
Newport Physicians as my group.
— kelly D.
April 12, 2003
Do you have a surgeon picked out yet? Do you know if he takes both HMO and
PPO? With HMO you will have to be referred by your PCP, get an
authorization and have very little out of pocket cost. With PPO, you can
straight to the surgeon, still have to get the surgery pre-approved and
depending on the policy could have a $500.00 - $1000.00 deductible that you
will have to pay 1st, then a 10 - 20 % co-insurance up to probably $1500.00
...so you could be looking at $2000.00 out of pocket. You need to do what
is best for you.
I have BCBCSFL HMO - I paid only my $10.00 office visit co-pays at each
visit and $200.00 for the hospital only because I wanted a private room.
This year they added a $150.00 a day deductible for inpatient, so I would
have paid $600.00 if I had the surgery now.
Good Luck !!
— Sharon H.
April 12, 2003
There are probably differences in policies, but, with my PPO(I'm in NY,) I
do NOT have a deductable at all, just $15 co-pays. No referals needed, and
every Doctor that I have been to is within network. And my hospitalization
is covered completely. As I said before, the only thing I had to us my
major medical ( that's a $200 deductable per year then covers 80%) is for
the psych consult.
— KellyJeanB
April 13, 2003
I have Anthem Keycare PPO here in VA. I had to meet my deductible ($300
for hospital) and my out of pocket totaling $2000. The did not cover
private hospital rooms but the hospital wrote that portion off since there
were no double rooms available on the gastric bypass floor when I had my
surgery. The only problem I have had with them is they JUST NOW (surgery
12/13/02) paid the anesthesia portion because they wanted to make sure it
was a needed service.. can you say DUH?! The hospital is great and are
allowing me to pay $20 per month minimum on my balance owed after
everything was paid. I do have the $30 per visit copays now since they
went up $10 more a visit at the beginning of the year. Another thing....
if you have any prescriptions that you fill monthly there is a way to save
money on the copays. Have you doctor write you a 3 month script if possible
and then send it to the mail in pharmacy to have it filled. we use
Merc-Medco here for our Anthem and instead of paying the huge copay each
month I only was charged $20 for a three month supply. Helps to save money
in the long run.
— Diane C.
April 13, 2003
You really have to look at the policies themselves. I have a PPO, but my
in-network deductible the year I had my surgery was $1,000 and my
in-network out of pocket maximum was $5,000. Both of those figures have
doubled this year. I had quite a few out-of-network bills, but my
insurance paid them at in-network rates because they were for things I
didn't get a choice on. The anesthesiologist and surgeon's assistant were
both out-of-network, but my surgeon picked those. I didn't. Generally
HMOs are cheaper because you have to go to providers in their networks.
PPOs cost more because you can choose to go out of network. Out-of-network
providers have not signed contracts with the insurance companies, so they
can get pretty expensive. The insurance won't pay them any more than they
would pay an in-network provider and you will end up being responsible for
the difference, plus whatever portion of the insurance payment is.
— garw
April 13, 2003
This is impossible for any of us to answer accurately. Only you have
access to the details of the policy's. No two BCBS HMO's or PPO's are
alike. The employer can add and delete things etc. So the only way you
can make a choice on this is to look at the exclusions section of both
plans and see what it states about WLS. I have BCBS POS through the State
of WI. It was clearly a covered benefit as long as I met the required
criteria, which I basically blew away. Others have made comments about UCR
(usual, customary and reasonable charges) and while this does enter in when
you have a POS and PPO if there are UCR charges left over it very likely
has to do with the provider charging too much. My surgery total was
$26,025 and not one doctor or hospital had a contract with BCBS.
Everything has been paid and paid in full. I was actually shocked how low
my hospital charges were. Some doctors and hospitals just charge way more
than is truly reasonable and that's why UCR charges show up. In 15 years
of having a POS with BCBS I have almost never run into UCR charges. The
few times I have the doctor wrote it off in all cases except one. Not bad
for the $30-35,000 of claims per year I've had since 1994. Sometime things
initially look like there is a big UCR but typically either the claim has
not been filed correctly or processed correctly and if you keep working
with them, it usually can be resolved and paid in full. Anesthesiology
bills are always and issue because they are billed so weird. If one tiny
modifier is left off the claim it won't pay in full. Put the modifier on
and WALA it's paid in full. So never accept the initial EOB if it isn't
paid in full.
<p>I pay a monthly premium of $130 and have a $500 deductible and 20%
co-pay up to $1500 for each year, for a total of about $3600 out-of-pocket
plus any drug or mental health co-pays but it's worth it to me to be able
to go to any doctor in the world without anyone saying yes or no. I have
the monthly premiums taken pre-tax and also do a medical expense
reimbursement account to cover the remainder of the $2000. This works
great and only costs me about 50% off my paycheck of the amount the
actually take.
<p>Any of the HMO's availabe to the state employees clearly exclude
WLS, so you do need to be careful. Even if you end up with more money
out-of-pocket for a PPO it might be that is still cheaper than paying for
the whole thing because the other policy doesn't cover it at all. Like I
said you need to research in detail because there is no uniform answer to
this question. Good Luck!
— zoedogcbr
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