Switching from PPO to HMO but already seeing a specialist

[vvvvv]

Hi,

My wife has a chronic condition and is already seeing a specialist under her parent's PPO health insurance. After starting her new job, we are thinking of switching to a HMO plan since it costs less. Was just wondering whether we can keep the current specialist or we would have to seek advice/change specialist from the new PCP in order to get a referral? How does it work?

Any help is appreciated! We are millennials trying to navigate this crazy world that is health insurance |:

 

[Yagents]

Stay on PPO wide choice of doctors given her health.

Large chance your specialist does not accept the new HMO network.

Cheaper cost equals cheaper quality of care in small HMO network, along with referral delays

 

[leevena]

Hi,

My wife has a chronic condition and is already seeing a specialist under her parent's PPO health insurance. After starting her new job, we are thinking of switching to a HMO plan since it costs less. Was just wondering whether we can keep the current specialist or we would have to seek advice/change specialist from the new PCP in order to get a referral? How does it work?

Any help is appreciated! We are millennials trying to navigate this crazy world that is health insurance |:

You should check the HMO network first and see if your wife’s specialist is in it. Also spend some time reviewing the different options you have and how they work, an HMO is different than a PPO. Then look at how the benefits work with your requirements and your costs. This should lead you too a fairly obvious answer.

 

[InsuranceGuy29]

Both HMO's and PPO's have networks. If you can find providers that are in-network with an HMO, costs will usually be drastically cheaper. If a provider isn't in-network with an HMO, that means, if you want to go to them, 100% of cost is on you.

If a provider is in-network with a PPO, costs will also usually be drastically cheaper, but here's where it differs from an HMO. If the doctor is out-of-network with a PPO, you'll pay a percentage of the cost, not 100% of it like in an HMO.

HMO generally equals more restrictive networks, cheaper cost-sharing, and more extra benefits.

PPO generally equals less restrictive network (with added cost-sharing bonus if provider is in-network), ability to go to most any provider (even if they're out-of-network), but with higher cost-sharing (which can sometimes be astronomically high), and usually higher premium.

Doctors routinely jump from plan-to-plan, and switch contracts. There's very little stability in it. They may take the plan on Wednesday, and then not take it on Thursday. If the specialist is in-network with the HMO plan you're looking at, it may definitely be worth it to go with that plan. If they end up declining to contract with it the following year, you can always switch to the PPO.

 

[Lee Vena]

Hey VVVV,

I stumbled upon your insightful article about navigating the intricacies of health insurance plans, and it resonated with my recent experience. Your breakdown of PPO and HMO was particularly enlightening!

I actually wrote a piece on my blog recently about "What to expect when switching from PPO to HMO" It delves into the considerations, benefits, and potential pitfalls one might encounter when transitioning between these insurance plans. I thought your readers might find it valuable, especially given the thorough analysis you provide on similar topics.

If you're interested, you can check it out [EXTERNAL LINK] - What to Expect When Switching from PPO to HMO. I'd love to hear your thoughts on it, and I'm always open to discussing this crucial aspect of healthcare coverage.

Best of luck

Best, George

I found your piece very enlightening, similar to what I think about every other piece on this subject I have read over the past 35 years. And by the way, VVVV did not discuss the intricacies of health insurance plans.

 

[Newby]

Hi,

My wife has a chronic condition and is already seeing a specialist under her parent's PPO health insurance. After starting her new job, we are thinking of switching to a HMO plan since it costs less. Was just wondering whether we can keep the current specialist or we would have to seek advice/change specialist from the new PCP in order to get a referral? How does it work?

Any help is appreciated! We are millennials trying to navigate this crazy world that is health insurance |:

You just call the insurance company that her worksite plan is through and have them look up if he is in network. If he is, have your primary doctor give you a referral to him.
If he is not in network, your primary doctor can give you a referral to a different specialist.

 

[Lee Vena]

You just call the insurance company that her worksite plan is through and have them look up if he is in network. If he is, have your primary doctor give you a referral to him.
If he is not in network, your primary doctor can give you a referral to a different specialist.

Sorry, but they should all the doctor office, not the plan. It is possible that the provider is no longer in the network and the carrier may not yet know.

 

[Newby]

Sorry, but they should all the doctor office, not the plan. It is possible that the provider is no longer in the network and the carrier may not yet know.

Well maybe. But in my experience the people at doctors offices don’t understand any of it and are full of wrong info.

 

[Jim Wright]

Well maybe. But in my experience the people at doctors offices don’t understand any of it and are full of wrong info.

Definitely agree with this. Often, the person that answers the phone has no idea what insurance is accepted or not but will offer information that is not verified.

I would also add that depending on where you are and if you're on an individual plan HMO, most of them do not require referrals to see specialists anymore. If they are in network you can go to them. Using the provider lookup pages on carrier websites is the easiest way to see if they are in network.

 

[Lee Vena]

Definitely agree with this. Often, the person that answers the phone has no idea what insurance is accepted or not but will offer information that is not verified.

I would also add that depending on where you are and if you're on an individual plan HMO, most of them do not require referrals to see specialists anymore. If they are in network you can go to them. Using the provider lookup pages on carrier websites is the easiest way to see if they are in network.

I hear what you both are saying regarding calling the carrier. Personally, I call both, but consider this about calling the carrier. Carrier websites/database can be notoriously behind. So it is possible that the carrier data reflects participation when in fact the provider had already opted out.