We recently shared Blue Cross Blue Shield’s announcement that they will no longer offer their individual Blue Choice PPO plans – Off Marketplace (nonsubsidized) and On Marketplace (subsidized) – for 2016 and going forward. Further, they will automatically transfer policyholders with Affordable Care Act (ACA) compliant plans to their HMO plans for 2021.
Q: What is a PPO plan?
A: PPO stands for Preferred Provider Organization. It is a managed care network comprised of hospitals, physicians, labs, and other healthcare providers. Here is an overview:
- Participants in the PPO network have contracted with an insurance company to provide services at a predetermined discounted rate. For that agreement, the carrier has agreed to endorse the provider as a preferred supplier of their particular healthcare services.
- PPO plan policyholders receive significant discounts when they use services from providers in their PPO network.
- PPO plan policyholders may use any provider, but if they go outside their PPO network, discounts are not as significant, and their benefits will be subject to a higher deductible and out-of-pocket expense structure.
Q: What is an HMO plan?
A: HMO stands for Health Maintenance Organization. HMO plans also have a managed care network structure, but with many more restrictions than PPO networks. The big differences:
- With an HMO plan you must designate a Primary Care Physician (PCP) who acts as a “gatekeeper” to other network service providers. Your PCP is the doctor you will always see first for your healthcare needs. If you need to see a specialist or require other additional care, your PCP will refer you to an in-network provider.
- HMO plans offer no out-of-network benefits. If you are treated by a provider outside the HMO network, the insurance company will pay nothing. This restriction does not apply in cases of medical emergencies – defined as the potential loss of life or limb.
- HMO plans are typically more cost competitive than PPO plans because HMO networks are more restrictive.
PPO OR HMO? WHAT’S BEST FOR YOU?
It is important to understand that the ACA requires both plans – HMO and PPO – to provide mandated benefits such as preventative care, maternity benefits, mental health benefits, and comprehensive coverage including hospitalization, outpatient surgery and prescription benefits.
HMO Plans: Upsides and Downsides.
HMOs are best suited for healthy people who do not need to see specialists often. For people needing frequent specialist care, the requirement for a Primary Care Physician’s referral may be inconvenient and not worth the HMO’s lower premium. Further, HMO plans have very restrictive networks, so provider choices are limited. In urban areas, limited networks may not be a problem because the pool of network providers is still ample. But in rural areas of Texas, the restrictive HMO networks may not provide enough options for policyholders wanting choice in selecting their healthcare providers. According to Blue Cross Blue Shield, they are working to expand their Texas HMO provider network and will provide updates closer to Open Enrollment.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.