#insurance::hmo-ppo

[ptlsalp]

Insurance: Details about Marketplace plans that were available to me

Based on notes I took while deciding on my new insurance plan, here are some limited details about Marketplace plans that were available to me in the state of Michigan. You may or may not have the same plans available.

Blue Cross Blue Shield PPO

-- Purchase decision: ✅ -- Certificate of Coverage published: ✅ -- -- No stated "one per lifetime" limitation on sterilization: ✅ -- -- Coverage for treatment of complications related to non-covered services: Doesn't exclude coverage: ✅ -- No referral to see specialist: ✅ -- Key providers and facilities in-network: ✅ -- Available plans: Secure, Extra, HSA -- Reject reason: None

Blue Care Network HMO

-- Purchase decision: ❌ -- Certificate of Coverage published: ✅ -- -- No stated "one per lifetime" limitation on sterilization: ✅ -- -- Coverage for treatment of complications related to non-covered services: Doesn't exclude coverage: ✅ -- No referral to see specialist: ❌ -- Key providers and facilities in-network: ✅ -- Available plans: Select, Preferred, Local, Metro Detroit; some of these weren't available in my region -- Reject reason: Need referral to see specialist

UnitedHealthcare HMO

-- Purchase decision: ❌ -- Certificate of Coverage published: ✅ -- -- No stated "one per lifetime" limitation on sterilization: ✅ -- -- Coverage for treatment of complications related to non-covered services: Explicitly includes coverage: ✅✅ -- No referral to see specialist: ❌ -- Key providers and facilities in-network: ❌ -- Reject reason: Need referral to see specialist; Key providers and facilities out-of-network, with smaller network overall

Molina Marketplace HMO

-- Purchase decision: ❌ -- Certificate of Coverage published: ✅ -- -- No stated "one per lifetime" limitation on sterilization: ✅ -- -- Coverage for treatment of complications related to non-covered services: Explicitly includes coverage: ✅✅ -- No referral to see specialist: ✅ -- Key providers and facilities in-network: ❌ -- Reject reason: Key providers and facilities out-of-network

MyPriority Health HMO

-- Purchase decision: ❌ -- Certificate of Coverage published: ❌ -- No referral to see specialist: ✅ -- Key providers and facilities in-network: ✅ -- Reject reason: Certificate of Coverage not published

McLaren HMO

-- Purchase decision: ❌ -- Certificate of Coverage published: ❌ -- No referral to see specialist: ✅ -- Key providers and facilities in-network: ✅ -- Reject reason: Certificate of Coverage not published

[missmisnomer]

i'd like to formally rescind my lifetime membership to Being An Adult, please

[poptartmochi]

your honor. i think my current insurance card is only intended for use in kuwait and nearby countries... 😳;

[amarisbella21]

Comparing HMO, PPO, And EPO Plans In Group Health Insurance

In the landscape of group health insurance, employers often face a myriad of options to offer their employees. Among the most common types are Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO) plans. Each of these options has distinct features, advantages, and drawbacks, making it essential for employers to understand their differences to choose the right plan for their workforce.

Health Maintenance Organization (HMO)

HMO plans are characterized by their focus on providing coordinated and comprehensive care through a network of designated providers. Members must select a primary care physician (PCP) who serves as their main point of contact for medical care. Referrals from the PCP are generally required to see specialists.

Advantages:

Cost-Effective: HMO plans usually offer lower premiums and out-of-pocket costs compared to other plans, making them an attractive option for employers looking to minimize expenses.

Coordinated Care: The requirement for a PCP ensures that all healthcare services are well-coordinated, which can lead to improved health outcomes for members.

Preferred Provider Organization (PPO)

PPO plans offer more flexibility in choosing healthcare providers compared to HMO plans. Members can see any doctor or specialist without a referral, although they will pay less if they use providers within the PPO network.

Advantages:

Greater Flexibility: Members can access a broader range of providers, including specialists, without needing referrals. This is especially beneficial for those who require specialized care.

Out-of-Network Coverage: PPOs generally offer partial coverage for out-of-network services, allowing members to seek care from a wider array of providers.

Exclusive Provider Organization (EPO)

EPO plans share characteristics with both HMO and PPO models. Like HMOs, EPOs require members to use a specific network of providers for their healthcare services, but they also offer more flexibility than HMOs since they do not require referrals for specialist care.

Advantages:

No Referral Requirement: Members can see specialists without needing a referral, simplifying the process of accessing care.

Lower Premiums: EPO plans typically feature lower premiums than PPOs, making them cost-effective options for employers.

Conclusion

When selecting a group insurance plan, employers must consider the specific needs and preferences of their workforce. HMO plans are cost-effective and promote coordinated care, making them suitable for employees who prefer a structured approach to healthcare. PPO plans offer flexibility and wider provider access but come at a higher cost. EPO plans to strike a balance between the two, providing some flexibility without the need for referrals while still maintaining a limited provider network. By understanding the differences among these plan types, employers can make informed decisions that enhance employee satisfaction and health outcomes.

[smartinsuranceagents]

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[health-insurance-struggles]

Types of Health Plans

This post is going to suck to read. I know it will, because it sucks to write it because it’s boring.

Time to put on your big kid pants, because it’s important.

Let’s talk about the three major types of plans and three major types of healthcare accounts, and the talking points of each.

Preferred Provider Organization (PPO) - A general health insurance plan, and (in my experience) the most common. You can go wherever you want for healthcare, but you’ll pay less if you stay within the preferred provider list (a fancy way of saying in-network providers). You don’t need a PCP to refer you to a specialist.

Exclusive Provider Organization (EPO) - You only have coverage for in-network providers. You have no out-of-network coverage, except for emergencies. You don’t need a PCP to refer you to a specialist.

Health Maintenance Organization (HMO) - A very specific insurance policy that covers only certain healthcare provider systems (think hospital systems across a large metroplex). It is usually cheaper, but your choice is significantly more limited. You will need a PCP to refer you to a specialist, and you’ll need special permission from your insurance for an out-of-network provider to be covered.

Fun, right? Not confusing at all. It gets better! There are also healthcare accounts that your policies can offer. Let’s talk more about them.

Health Savings Account (HSA) - Pre-taxed money lets you pay for medical expenses (that qualify). You can invest money into the HSA and it rolls over every year to any employer. Basically, the funds never go away—new employer, new policy, and retirement don’t affect your HSA. This is usually associated with a high deductible, lower premium plan.

Flexible Spending Account (FSA) - This is associated with more traditional health plans. It’s also pre-taxed money, but it expires at the end of the year. Both you and your employer contribute to the fund, but anything you don’t use goes back to the employer, not you. The money doesn’t roll over each year or accumulate between employers. There are FSA plans all over the map in terms of deductibles/premiums, so it’s hard to generalize which one it’s associated with the most.

Health Reimbursement Account (HRA) - I’m going to be honest, I don’t know as much about this one because I personally haven’t worked with one. From what I know, it’s an employer-owned and funded account to help members bridge the gap on their health insurance. You can usually use it to pay copays, deductibles, and coinsurance. This doesn’t roll over and you don’t carry it with you, but your employer is the only one who pays into it.

Confused? Yep.

So how do you pick one? Well. I can't tell you, because it's up to you. But in my opinion...

I have a lot of health problems, so I want the largest network possible. I don't want to try to make a PCP appointment every time I need to see my specialist(s). I'm young and I don't plan on staying at the same employer forever. I'd pick a PPO HSA plan, because of the flexibility of the provider network and the rollover of the account. This will probably be a more expensive premium each month, but for me, it's worth it.

Maybe you're in excellent health. You've worked at your company for decades and have no plans of leaving, and you go to your annual check-up and that's it. Great! Maybe you are fine with an EPO or HMO plan and an FSA. Those could be cheaper premiums.

It's up to you. It depends on your needs and your spending preferences.

[thedisablednaturalist]

I found a great provider that does a ton of integrative care and even does aquatic therapy (its the ONLY place in the area that has an aquatic treadmill) and its all in one building right near my apartment. The only issue is it costs $300-500 per appointment as they are out of network with all insurance companies and I have an HMO plan. I was hoping I could just go there for physical therapy but that's still like $300 per appointment.

Apparently I can petition for a gap exemption since literally no other place has aquatic therapy in my area? but it can be a bitch to get your insurance to approve it

I'm now looking into patient advocacy groups to help with getting me the care I need because at this point I'm fed up with the search. I'm tired of being constantly referred to scam holistic centers and told theres nothing they can do for my pain now pay us $50 dollars. Apparently Myofascial Release Therapy and aquatic therapy would do great for my pain but there's no place that takes insurance that does that.

I found a patient advocacy center but it costs $150 an hour so what's even the point. There is one that is free but its for people with "serious chronic conditions" and idk if they'd consider my chronic pain and spine stuff serious enough.

Im just so tired and i dont have the spoons to do this on my own anymore. I'm paying hundreds a month on insurance but can't get the care I need since its too specialized/out there or theres no specialists near me in network. I thought I picked a PPO plan but apparently not. All this stuff is so confusing and complex and I don't have the mental energy to deal with it all. And you can't ask insurance for advice because they will give you bad advice! bc they dont want to pay for shit!!

I just want to live and stop getting fucked over. I'm tired of the 15 minute appointments that don't do anything for me. That are just so I can get refills of medication. That dont explain everything or look at all my records or listen to me.

Has anyone used a patient advocate outside of a hospital before?

[intersex-support]

hello! i display a lot of the symptoms of having trisomy x and would like to find out for sure if i'm intersex or not, but afaik the only way to know for sure is to get a karyotype and i'm terrified of the medical discrimination i might face as a result of doctors knowing i'm intersex. is there any other way for me to find out but still have my doctor not know? or am i just overreacting (especially since most other intersex people don't get the choice of finding out or not)?

Hi anon!

I think it's totally understandable that you have a lot of fear about trying to navigate the medical system as a potentially intersex person. It can be really difficult to have to deal with the amount of discrimination we face when we're seeking a diagnosis and existing as an intersex person in the medical system. It's fucked up that we have to think through all these things when we're seeking care, instead of just being able to trust that we would receive compassionate and respectful care that honored our autonomy.

Unfortunately, I don't think there is any way for you to confirm a Trisomy X diagnosis without getting a karyotype/chromosomal microarray, just because there really is no other way to confirm what chromosomes you have. However, I think there are some ways that you could navigate it that might make it a little easier to avoid some kinds of discrimination.

This information is all based on the US healthcare and insurance system because that's what I have direct experience with, but feel free to send another ask if you live somewhere else and we can brainstorm some ideas for your health system.

My first thought is that if you want a diagnosis but don't want to impact the rest of the medical care you receive, you might be able to see a separate genetic counselor that's not linked to the rest of your medical record and medical care. There are a lot of services that do telehealth genetic counseling such as Genome Medical, and if they take your insurance, you might be able to get testing set up through them but not have it show up on the rest of your medical record. The nice thing about this is that you only have to deal with the telehealth clinician a few times and then get to choose whether or not you want to disclose this information to any future providers you see, and you don't need to have this information in your medical record if you don't want to.

If that's not an option but you have a PPO or POS health insurance plan where you can see any preferred network providers without referrals, you might be able to go to a separate genetic counselor that is part of a different hospital or clinic than where you normally receive care.

If your health insurance is an HMO plan where you have to get PCP referrals and can only see in network providers, that might make it difficult to seek care that isn't linked to your medical record. If this is the case but you're still interested in seeking a diagnosis, it might be worth brainstorming some things that would make you feel safer through the process. This could look like bringing another supportive person with you who could help advocate for you, preparing scripts for how you want to advocate for yourself, seeking out information about your rights as a patient, asking other intersex people for doctor recommendations, bringing in the "What we wish our doctors knew" brochure from InterACT. I won't lie, having an intersex variation on your medical record can make seeking medical care more complicated, but I think it can be slightly easier to navigate when you're a teen or adult who has more autonomy over their care, can consent to things, switch providers more easily, and has more of a say in their care.

If any followers have any other innovative ideas about how to seek diagnosis, feel free to add on.

Ultimately, the choice about whether to seek a diagnosis or not is always up to you. You're the expert on your own experience and know what would feel right for you at this point in your life. I don't think you're overreacting or being silly, and I wish things were different and it was easier for you to seek a diagnosis.

Truly wishing you the best of luck, anon.

[phregnancy]

as a non-usamerican living in the usa i did not realize how bad the healthcare insurance stuff was before today. i just got health insurance and i have no words to convey how i feel. first of all i hate all of these acronyms ppo hmo hsa. second, the pricing is the same for everyone so if you’re poor you just get bad insurance which makes no sense to me (not talking about government benefits because idk them i’m not eligible for them). if you make more money you can get more expensive plans that let you pay the doctors less up front but you pay the insurance company more every paycheck. if you make less money you have to choose the cheaper option and pay the insurance company less money but it costs more at the actual doctors. so then you have to choose if going to the doctors is worth it. there are also deductibles you have to meet like i have to pay them $2k before they start covering my doctors appointments so ? guess i’ll die until the insurance company takes $2k from me over time?? also most people get health insurance through their jobs?? apparently jobs offer discounts on health insurance so it’s usually cheaper to get insurance through work. so if you quit you have no health insurance and have to get it separately or get another job. how is this seen as normal why is it normal to pay taxes for your giant military but not for healthcare? obviously i know most average americans don’t like how things are currently set up and aren’t to blame but wow this is all still so shocking to me

[kickthecan-revolution]

My car is amazing and I am so glad I pulled the trigger. So many years of driving cars that barely worked, brakes down to the metal - I feel so fortunate that I can minimize that now.

I am completely obsessed with retirement. I spent a lot of time researching it on a few reddit websites on retiring early that linked out to some great websites. I am tracking every single bill including how much I currently spend on food, gardening, etc. Just to get a baseline of spending. I'm researching insurance, I could still get my company's benefits (which are awesome) via COBRA for 18 months but California actually has some pretty incredible plans. I never go to the doctor, I am so phobic about it so have no clue how PPOs vs HMOs even work. But the next 10 years is when shit goes sideways health wise. I really want to get a breast reduction but I am terrified to go under general anesthesia. If I do it, I need to plan that time of year next year.

It's not like I am terribly unhappy here. I am just coasting. I have been successful by being invisible. That's what I have done my entire life, get the right kind of attention to stay invisible. And I can feel that tugging at me, to be more vulnerable, to stop doing that. I could do that here, I just don't want to. I'm bored and irritated, I've done the same exact thing and not solved the same exact problems that can't be solved without a lot of infrastructure investment that will never materialize. I want to do something and see the result.

[ptlsalp]

Insurance: Certificates of Coverage for Marketplace plans -- is there no "one per lifetime" limitation?

I'll need to switch to a Marketplace plan effective 3/1 anyway, so I've been shopping for a plan.

What's a Certificate of Coverage?

Here's a good working definition: "A certificate of coverage is an official contract that outlines what an insured is entitled to, and what they aren't insured for, under a health insurance policy."

Of the Marketplace plans available to me, most haven't published Certificates of Coverage, but some have. In my unusual situation, I can only consider Marketplace plans that have published Certificates of Coverage.

Implications of Certificates of Coverage

Regarding the possibility of self-pay:

Some of the Marketplace plans' Certificates explicitly include coverage for treatment of complications related to non-covered services. Notably, none of them exclude this coverage. In contrast, my current private insurance plan explicitly excludes this coverage.

Regarding possible coverage as sterilization:

Under my current private insurance plan, coverage of sterilization under diagnosis code Z30.2 [Encounter for sterilization] is limited to one procedure per member per lifetime. However, these Marketplace plans' Certificates don't state the same limitation. Certificates are contracts, and typically insurers try to exclude everything they can; so, while the absence of an exclusion doesn't imply an inclusion, it's a good sign.

I also noticed that certain other procedures--like bariatric surgery, for example--are limited to one procedure per member per lifetime by these Marketplace plans' Certificates. That tells me that Marketplace plans can impose "one per lifetime" limitations in general, which makes it more notable that there is no stated "one per lifetime" limitation on sterilization coverage.

No stated limitation--I can't be sure yet that there is truly no such limitation, however.

Regarding possible coverage under gender-affirming care:

All Marketplace plans available to me cover gender-affirming care, so this is still a potential route.

Additional considerations

Network: I can only consider Marketplace plans under which all relevant providers and facilities are in-network.

No referral to see a specialist: I can only consider Marketplace plans that don't require a referral from a PCP to see a specialist. I haven't involved my PCP in this process at all. I'd prefer to keep it that way, even if it means I have to pay more for a PPO plan.

[contentment-of-cats]

I am lucky.

It's hard to see in the middle of everything that's been happening to me and around me, but I am lucky.

Cancer:

I was lucky that someone finally ordered the CT scan that resulted in finding a 10cm tumor in my guts. I'd been trying since October of 21 only to be told 'menopause' and 'covid after effects' and basically anything for my GP to pocket the copay and get my out of his office. GP is no longer in practice - which is lucky for someone else.

I was lucky the morning I woke up in unbelievable pain that I could get to Cedars Sinai. The tumor was closing off my left ureter. I was in a bed within hours.

I was lucky to have changed my insurance to a Silver PPO from a Silver HMO - otherwise I'd be dead.

I am lucky to have had support on the work front - including six months of my rent paid from March to August, when I was a chemo'ed mess.

I was lucky to have young, aggressive docs and a knowledgeable, experienced, and highly skilled surgeon (if he does say so himself, and he does - often).

I'm lucky to be in remission, because colorectal cancer is a killer. It's estimated that about 53,000 people will die from it in 2023, about evenly split between men and women. It is the second leading cause of cancer deaths in men, and third in women. I know that it is likely to recur, and if it does it is likely to be fatal. I am lucky to have each day, as hard as some of them are.

Mother:

I am lucky to have seen her when she was still somewhat herself, back in Ferbruary of 2020, literally weeks before COVID hit. We discussed her selling the house and going into assisted living. I said I'd be back in a few weeks, having to go hold down the fort while my boss did some trade shows.

If she had been in assisted living, she likely would have died in that year, when at the peak of COVID, the local paper had eight pages of obituaries, and a six-week turnaround for cremation, nine weeks for burial/ennichement.

I kept her at home, buying her groceries, getting home repairs and upgrades done, keeping up the maintenance.

In March 2022, the week I was hospitalized, she developed a severe and almost fatal UTI. She was two weeks in the hospital, three in rehab, before being transferred to assisted living and ultimately to memory care.

I wanted to give her safety, comfort, and dignity for however long she had left. I've done that. It's a great place, she had friends, companionship, and care all the way.

If she dies on my birthday, then well, it's the last one she gets to torpedo for me. I've done what I feel is my duty, and if I also feel like it wasn't enough, I never was enough. Mom had her own trauma from two traumatized people. I can let go of it, but maybe not forgive the string-pulling and button-pushing. There's things you have control over, and things that you don't. I'm guessing about some of her motivations, but others were billboards 20-by-30 in blinking LED.

I'm lucky not to be more of a mess, lucky to have had good therapy and good friends.

Most of all, I am lucky to have had the friends around me. Even moreso as I come out of treatment and surgery and into remission, survivorship, and recovery. I am lucky that they understand that it's not over when the chemo stops. I love them dearly and am endlessly grateful to them.

[compo67]

it has come to my attention that i will be better off enrolling in a medicare advantage plan. i just can't afford medigap insurance. i checked and plugged in all my providers/hospitals--all are in-network and covered. plus, at least these plans come in a PPO or HMO--that i understand.

i'll text my broker dude tomorrow. he'll be happy to know i made a decision.

the medigap plan G insurance i wanted was through BCBS. but it would be $400/month. then i'd have to buy a plan D, which was looking to be $79/month and i'd still have to spend $4,000. whereas the MA plan would be $34/month, spending $2800 for meds.

at least now things make more sense.

[chronic-cane]

Okay so far in my venture to get my first wheelchair I have:

Asked my doctor to give me something that would let me do that. I do not know what they are supposed to look like. It looks sketchy but since I have no idea how this works and don't expect it to be easy I don't ask.

When I asked my doctor where to go she gave me a medical supplier that only has the standard medical grade chairs... no. I want this chair to be active in and its not temporary by any means.

Checked insurance to see how they'd cover chairs, I have two insurance plans. The hmo requires an in network supplier and would fully cover it if so, but won't pay a cent otherwise. Other ppo plan would cover 70% of the cost with preferred providers and 50% with others.

There is no way online to find the in network suppliers on my HMO. When we called the insurance and med group for a list, they did not know which ones had what type of medical equipment. Out of the list of about 10 suppliers there were 2 that had wheelchairs anywhere near us. Some of the names given were of suppliers that were permanently closed. Of course this was found out by searching each one. The one my doctor named was not given as in network by the insurance.

We went to one of the two and they also only had the standard medical chair, but the main thought of going there was to get help more than anything. The store was run by a couple who were incredibly helpful in explaining what to do. The paper I got from my doctor was a prescription, not a referral, and I still need to contact my doctors office to tell them I need a referral or authorization to be able to get coverage.

They also suggested to look at used chairs to starting a gofundme. To their knowledge and to mine, there are no outside sources from the government or local services to help with these costs. And I have looked.

The PPO I have not looked more into because most new good chairs cost 2-3k and paying 30% of that is still not affordable to me.

I'm going to keep updating this to show abled people and people outside the US just how bullshit all of this is.

[smartinsuranceagents]

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[chiro19454]

Independence Blue Cross Personal Choice PPO health insurance chiropractor in North Wales Pa 19454. Accepting Personal Choice PPO Gold, Silver and Bronze plans. Also Personal Choice Classic PPO, Personal Choice Silver Proactive PPO, Personal Choice Silver EPO, Personal Choice Bronze EPO, Keystone Gold HMO plans as In-Network chiropractic provider for IBX