HMO vs. PPO. Which is better for you?

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It’s crunch time – and not just for holiday shopping. As the annual open enrollment for health insurance dwindles, you must decide: Should you stay or should you switch?

You may lean toward the latter, as a rising number of insurance companies hike rates and whittle options for 2016.

Whether you rely on your employer-sponsored insurance plan or individual coverage through the Affordable Care Act, finding the right plan for you and your family can be daunting. There are two types of individual and family insurance plans: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs)

Although annual open enrollment is open until January 31, 2016, to ensure coverage by Jan. 1, 2016, you must enroll in an individual or family plan by Dec. 15, 2015.

Here’s how to cut through the confusion, understand the terminology and read the fine print so you can decide what program works best for you.

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THE BIGGEST ISSUE: Who’s in the Network?

When choosing the right plan for you and your family, you must decide whether you  will use in-network providers – the doctors, urgent care facilities and hospitals on the insurance company’s approved provider list.

If so, an HMO may be the way to go.  HMO health plans generally limit coverage to in-network providers. So if you see a doctor outside the program’s chosen list, you’ll have to foot the whole bill, unless it’s urgent or an emergency or there is no in-network provider for your needed service.

This makes HMOs generally less expensive than PPOs for consumers, but it also means those programs are only as strong as their rosters of doctors and hospitals.

“Should you choose an HMO, seek a plan that not only includes your preferred providers, but also has a deep bench of top-tier performers,” says Neil Kennish, associate vice president of marketing and sales at Memorial Hermann Health Solutions, Inc.  “It’s a winning formula whether it’s a football team or an insurance program.”

“As the largest health system in the country’s fourth-largest city, Memorial Hermann has thousands of affiliated doctors,” Kennish adds. “It’s a vast network.

“We also are uniquely positioned with hospitals, providers and health plans   that work together throughout Houston’s greater metropolitan area,” says Kennish. “This makes health care a seamless, coordinated experience with less duplication and faster resolutions.”

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The HMO plans offered by Memorial Hermann Health Plan, Inc. eliminate a common drawback to HMOs: the use of a gatekeeper. When patients need specialized care, they first go to their primary care physician (PCP). He or she decides whether they require further treatment from another doctor, such as a dermatologist, gynecologist, cardiologist or rheumatologist. This expert will be among those contracted to accept discounted pay from a health plan. If patients already know they need a specialist, treatment is delayed and cost swells.

Memorial Hermann Health Plan, Inc. stands apart from other HMOs by offering “Open Access,” so patients can go directly to needed specialists as long as they’re within Memorial Hermann Health Plan, Inc.’s network.

“This makes us unique,” Kennish says. “We absolutely view the PCP as the quarterback for the patient’s healthcare experience. But if a member needs to see a specialist, they shouldn’t be waiting to see their PCP just so they can be allowed to see the specialist.”

WHEN A PPO MIGHT SERVE YOU BETTER

If you crave flexibility in choosing doctors or hospitals – and are willing to pay a little more for it – then a PPO might be a better option but could be harder to find.

Many insurers are eliminating their Preferred Provider Organization (PPO) insurance plans. That means your doctors, hospitals and prescriptions may be deemed “out of network,” and there may not be an out-of-network benefit under the plan.

Kennish says many insurers are not offering PPOs because it can be harder to manage costs when people go out of network.

Memorial Hermann Health Insurance Company has nine PPO plans for individuals and families.

“It ultimately comes down to which doctors you are going to use,” Kennish says. “If you’re staying completely in the network, then you should probably choose an HMO because it’ll cost you less. If you’re consistently going out of network, a PPO may make more sense.”

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KNOW THE TERMS

Whether you opt for an HMO or PPO plan, you’ll likely be offered multiple options with different deductibles, co-pays and premiums.

“You can have a high deductible with lower monthly premiums or vice versa,” Kennish says. “It’s up to consumers to decide what makes the most sense for themselves and their families.”

THE FINE PRINT

The more you pay, the more you get when it comes to benefits. But why pay for more than you need?

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When choosing a plan, consider your past and future medical care. If you know you regularly need blood tests, X-rays, MRIs, hearing/vision exams or prescription drugs, then more benefit-rich plans may be a better deal, since a greater percentage of costs may be covered.

If you are young and single or you and your family are in good health, requiring little more than annual physicals, an HMO will consistently save you money, with lower monthly premiums and out-of-pocket fees.

But the older you get, the more likely you’ll fall ill, and the higher your premiums will be. According to Kennish, age drives prices for individuals.

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If you see plans labeled as bronze, silver, gold or platinum, take note that the higher the metal grade, the more benefit-rich the program.

Also heed exclusions and limitations. Generally, insurance companies pay 100 percent of “preventive services,” such as screenings and immunizations. Be aware which costs won’t be covered. Many companies pay for pediatric dental exams, but not exams for adults. Often insurers do not reimburse services viewed as experimental or medically unnecessary. These may include cosmetic surgery or LASIK, procedures deemed motivated by vanity versus health. So, post-mastectomy implants usually would be covered, but not otherwise.

Plans also tend to reward consumers who take less expensive routes. So a visit to a primary care physician is cheaper than one to an urgent care location, and far less than one to an emergency room.

Insurance companies also may encourage customers to adopt a healthy lifestyle through smoking cessation and added exercise programs. You might even get a financial reward for answering a health-risk questionnaire or completing a health screening.

Why is that? “Because when people are more health-conscious, everyone wins,” says Kennish. “The sooner conditions are faced, the more likely recovery will be speedier and treatment less extensive.”

To learn more about individual and family health insurance plans offered by Memorial Hermann Health Insurance Company or Memorial Hermann Health Plan, Inc., visit Memorialhermanninsurance.org.

This content is provided to discuss health benefit plan coverage in general, and it is not intended to provide legal advice or advice tailored to your specific health benefit plan coverage needs.  It is also not intended to fully describe the plans offered by Memorial Hermann Health Plan, Inc. or Memorial Hermann Health Insurance Company.  For more specific information about our plans, please visit our website.

You cannot obtain coverage under the health benefit plan until you complete an application for coverage.  Benefit exclusions and limitations may apply to the health benefit plan.