It’s enrollment time at most companies. That time of year when you need to decide which benefits you will pick for you and your family. But, what should you pick? Is the PPO or HMO the best option for you? Do you give up my Medicare and move to a Senior Advantage Plan? These are questions we get over-and-over again. There is never an easy answer to these questions.

This is something that each individual must consider. What type of care they want if they do use it, whether it be by choice or in the case of an emergency. Being a business, we also offer different options for our employees as well. We are familiar with the costs of premiums of both HMO and PPO options. These are some of the answers that we provide to both our employees and patients who have asked in the past: 

CORE Physial Therapy Fullerton, Ca
  • Isn’t an HMO cheaper than PPO?


This depends on what is meant by the question. The premiums are pretty equal or can even be a little higher. You also do not have a deductible associated with an HMO nor a percentage to pay. Some PPOs have a deductible and pay 70 or 80%, which leaves you with the other 20-30% responsibility. However, there are now PPO options that pay 100% and the deductible does not have to be paid for simple office visits and some specialty care. Some have deductibles that only apply to emergent care or surgical procedures. We are also seeing HMO’s with copays that have cropped up to $30-$75 per office visit.

  • I’m looking at ________ HMO, do you accept that?


It is not if you sign up for Blue Cross, Blue Shield, Aetna CIGNA, etc… it depends on the medical group that you select. You should be very careful of the medical groups that you select. Each group will be managed differently and services allowed will vary from group to group. This tends to be a major adjustment for individuals moving off of a PPO and onto an HMO. If you are currently under the care of several providers and specialists, make sure that they are all on the group you are choosing. If not, it can be very costly for you to continue your care unless you are willing to change providers. Also, it is not unusual for people from the same company to receive different services based solely on the medical group selected.

  • Do I have to get an authorization for every visit?


Not usually. Most HMO’s provide for your initial evaluation and a few follow-up visits. However, their policies do change throughout the year so this can change at any time. Please understand that if you choose to be treated under your insurance, we are obligated by their rules.

  • Is Medicare and Medicare Advantage plans the same?


No. This is something that seniors are told regularly and is simply not true. We constantly have seniors who are moved to an advantage plan who later wish to move back. The advantage plan is simply a word used instead of HMO. Most seniors do not realize that they are actually signing up for an HMO plan and are now under the same rules that apply. Benefits and services will vary greatly on these and you should make sure that you fully understand the difference. On several occasions, we have been able to assist our senior members with their desired outcome without them losing their regular Medicare plan. Our seniors have worked hard and can sometimes need more care and attention at this point in their lives. Keeping them on their initial Medicare may or may not be in their best interest. Again, if your not sure which is best for you, a parent or grandparent, just contact our office.

  • Is one PPO better than another?


Maybe. Some pay your providers a little better than others, some don’t require added paperwork from the provider, etc.. This makes a difference for you in that some providers are no longer willing to work with some PPO’s due to delay in payment or additional paperwork. This, in turn, can make a difference for you when seeking medical attention. This is rare and not as prevalent as with HMOs.

Choosing a PPO, HMO or staying on your original Medicare, is an individual choice. A PPO or Medicare will not provide you “better quality” of care but could provide you additional visits and or services not covered on an HMO. All physicians and therapists provide the same quality when with a patient, but are obligated to manage each individual as per the restrictions of your insurance. If you want to give your physician the ability to provide you with any service that they may feel is in your best interest and you are financially able to do so, you may want to choose a PPO or stay with your Medicare. If however, you don’t mind your treatment be managed through a 3rd party vs your physician and cost is a factor, then an HMO or Medicare Advantage plan may be a better option. Again, insurance benefits have several options and facets that are to be considered and it may be best to ask about your specific needs. Should you wish to speak to our insurance specialists or business office in this regard, please contact us directly at 714 870-8478. CORE Physical Therapy is here to help with any of your needs.