Switching From HMO to PPO
Q: I am a 45 year old woman who was recently diagnosed with bradycardi, along with an irregular heartbeat. After undergoing several tests, including numerous EKG’s in my doctor’s office, it was determined that I should be referred out for another series of more complicated tests. Each test required that I see a different doctor and each doctor required a referral from my Primary Care Physician. The wait to get in to see these doctor’s was quite extensive. Almost a year has passed and I have yet to get any clear answers as I am still awaiting further tests. I am currently on an HMO plan and have been told by many that a PPO plan would be more beneficial to me in situations like this as the waiting period to see these specialists would not have been quite so extensive. For a person who is in need of more extensive medical care and treatment better off being on a PPO plan?
A: Well, this depends on many different factors. You do not mention if your health plan is an individual policy, or if it is provided through your employer under a group health plan. If your employer is paying for your health insurance, your out-of-pocket costs on an HMO plan will be considerably less than if you switch to a PPO plan. Most PPO plans have deductibles and coinsurance associated with most covered services. You will be responsible for paying these expenses, not your employer. Most HMO plans are comprehensive and your out-of-pocket costs are limited. You will need to weigh your financial ability to share in the cost of your health care against the inconvenience of waiting for treatment and specialist referrals through your primary care physician. We are assuming that your condition is not so life threatening where your doctor felt that it needed more prompt attention. Under an HMO, the amount of wait time to see a specialist is directly related to the urgency of your medical condition.
If you are on an individual health plan, you may have no choice but to remain on your HMO plan. You would need to check with your current insurance company to find out their policy on switching plans. Most health insurance companies will require you to submit a new application in order to move from an HMO to a PPO plan. Given your current medical condition, they may decline this request. Moving to a different insurance company may also prove to be difficult for the same reason.
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