HMO vs Trad. National Plan, Which Would You Pick?

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Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 12/8/2009 6:27 AM (GMT -7)   
My husbands company is being bought next week. To make a long story short, it was suppose to happen in March but they announced late last week that it would actually be on the 15th. Of course that means all benefits will be changing with no notice or time to do any research. I have been frantically trying to figure out their whole insurance package which we didn't get until yesterday.

We have had an HMO since just after my diagnosis. My first hospitalization cost us a fortune on a more traditional plan (80/20) and so we chose to go with the HMO even though it cost more per year. But by using their worksheet, it would seem that the cost is fixed with their traditional plan and that it is quite a bit cheaper. That of course is scary, you usually get what you pay for. I can't ask their HR people because it is a company owned insurance plan administered by United Health, so it is to their benefit if all employees participate. One of the big differences seems to be the prescription rules, what can be filled at a pharmacy, what needs to be mailed in, that type of thing. But of course, its all just glossed over in the package and there is no place to find out what my medications will actually cost on either plan without really doing the leg work.

I know we just had a thread on United health, but what I'm really interested in is if anyone has experience with both an HMO and a company owned plan and how it affected things like emergency room visits, specialist appointments, how much prior approval did you need, prescription coverage (changing types of meds?).
Basically is the evil I know at a higher cost better than the evil I don't at a lower cost?
Suzanne

CD 20 years officially, 30 unofficially. 3 resections '93, '95 '97
Managing with strict low residue diet, keeping symptoms to a minimum. All test show small amount of ulceration, still have occasional blockages. But still have a great time with my 2 daughters and husband!


Prednisone, 6MP,Prevacid, B12 shots, Bentyl, Xifaxan.....


Nanners
Elite Member


Date Joined Apr 2005
Total Posts : 14995
   Posted 12/8/2009 7:30 AM (GMT -7)   
I have been in a HMO for 27 years. I have found that they are much easier on my pocketbook. My co workers have to pay out of pocket on the other types of plans and it seems have to pay a little more than me for meds and tests. I might be prejudice, but I have always liked the care I've gotten and the money I saved with an HMO. JMHO
Gail*Nanners* Co-Moderator for Crohns Disease & Anxiety/Panic
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

HabsHockeyFan
Veteran Member


Date Joined Jan 2006
Total Posts : 3130
   Posted 12/8/2009 8:05 AM (GMT -7)   

Zanne...I work for health insurance and we also buy UHC coverage.  I just had to make a determination on buying the more expensive plan or the high deductible less premium plan.

without seeing exactly the benefit plan highlights,  I can't say which would be best, but here were my thought processes.

The higher premium plan had co-pays on mail order drugs versus ded and coinsurance for the lower premium plan.  The math came out that the premium savings would more than offset the cost difference in my meds.   BUT I do not order my meds with the coinsurance + ded plan becuase the sticker shock scares me, then i am not taking my meds (personal issue...I know i'm just born and bred cheap)  So I am paying the higher premium to get my meds on a co-pay figuring I will order them every quarter instead of every half year.

If the Rx plan differ by co-pay versus ded+ coinsurance, you will likely be better off with the co-pay plan assuming you do not have enough medical expenses elsewher in the year.

As far as HMO versus traditional...the co-pay thing comes into play again.  If you utilize many visits, the co-pay may be more effective for you.

I wish we could email together so you could scan and send me the highlights.  I just did a review for a few friends who do not know their benefits or understand what they are buying.  Can you take your current year expenses and figure out how the claims would have been adjudicated under each plan option...that wil help really clear up the differences in cost.


Dx'd '90 (emergency rupture), symptoms ignored long before that, '03 fistulas and bad flagyl reactions, B12 weekly, Pentasa [until I surrender to the bigger meds]
I'm riding on the escalator of life....


aronk
Regular Member


Date Joined Jun 2006
Total Posts : 229
   Posted 12/8/2009 8:21 AM (GMT -7)   
I agree with Nanners about the HMO. I have HMO and I literally have only paid my co-pays for all care over the last year or so.

Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 12/8/2009 10:04 AM (GMT -7)   
So the traditional plan would demand that I order all my maintenance medication by mail order which I have so far resisted on the HMO's I have been on for the last 20 years or so. On the new HMO my Co-Pay's for office visits will be doubling which will increase all of my expenses, but I just feel comfortable with HMOs and am afraid of the unknown. Pros and Cons for each. All my families doctors are accepted by both.

Habs - Unfortunately, I am not good about keeping records, I have no idea what my medical expenses are. I know what the company deducts from my husbands pay check and that is about all. I don't even get receipts all the time when I go to my appointments. I never see a bill. The HMO takes care of everything. So it really is a crap shoot for me. And to make matters a bit more complicated I have 2 kids who are always coming down with something that they need to see the doctor for, just minor stuff, but still usually needs an appointment and a script. No real set way to plan for expenses.
Suzanne

CD 20 years officially, 30 unofficially. 3 resections '93, '95 '97
Managing with strict low residue diet, keeping symptoms to a minimum. All test show small amount of ulceration, still have occasional blockages. But still have a great time with my 2 daughters and husband!


Prednisone, 6MP,Prevacid, B12 shots, Bentyl, Xifaxan.....


HabsHockeyFan
Veteran Member


Date Joined Jan 2006
Total Posts : 3130
   Posted 12/8/2009 11:12 AM (GMT -7)   
Zanne....if the HMo makes you more comfortable and you feel secure in the financial parts of it, I would go with it. but that is my feeling. If I can have my docs and less worry, i take it.
I fought against mail order myself for a long time. I actually like it now becuase I don't like my local pharmacies and I only have to think about my meds quarterly. Personal preference would be to keep mail order if I had a choice, but I know the struggles.
Dx'd '90 (emergency rupture), symptoms ignored long before that, '03 fistulas and bad flagyl reactions, B12 weekly, Pentasa [until I surrender to the bigger meds]
I'm riding on the escalator of life....


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 12/8/2009 12:58 PM (GMT -7)   
I would pick the plan with the best doctors. Where I live, I wouldn't touch any HMO available. Sticking to PPO. 
 
Since you were recently diagnosed, you might not know who the best docs are so what you can do is find the leading docs, by specialty, on www.castleconnolly.com and then go to the website for the insurance provider(s) and see if any of these docs are on both plans.
 
If you have already found and love great docs, you would of course want to check them out, too.
 

not creative
Regular Member


Date Joined Mar 2007
Total Posts : 466
   Posted 12/8/2009 4:23 PM (GMT -7)   
I have almost always had an HMO- I like it, the only thing I have to pay for is my co-pays. I think this saves a lot more money in the long run.
Laurenne, 25 Graduate from University of California, Davis. BA-Anthropology
Dx'd w/ IBS and CD in 2002. Three abscesses that are now fistulas, with three setons!
On: 6MP, Zoloft, Cimzia (working so well, I'm on Miralax too!), folic acid, b12
Tried: LDN- Did nothing good, Remicade- allergic, Humira- no reaction

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