HMO My, the Choices!

Frankly, I find an icy shiver in my spine whenever someone mentions an HMO-HMO-phobia, I suppose. My eyeballs bulge to the size of boulders; my teeth clench into my gums. Ordinarily, surrounding Samaritans commission an ambulance and I emerge from my fugue in the very clutches of that afeared word-an HMO. You can see my dilemma.

Healthcare coverage, despite its unpleasantness, is an absolute necessity. Imagine being simultaneously struck down by a boating accident and the subsequent hospital payments. You can see the dilemma-personal injury is more than enough without having to undergo financial ruin. Under coverage of an HMO, patients share the responsibility of the thousands of dollars in costs for recuperation, which amounts to patient peace of mind-while the doctors are fixing your remaining pieces. But not all HMOs are the same. And not all healthcare providers are HMOs. Here's what I mean:

HMO vs. PPO

There are an incalculable amount of three-letter words associated with healthcare. HMO and PPO are two of the more popular. An HMO (health maintenance organization) operates under Managed Care procedures, a fixed set of guidelines and options. In an HMO, patients go to specific locations and visit specific doctors. Aside from the monthly premiums that consumers must pay (premiums are ordinarily established based on previous health records and number of dependents covered under the plan) HMOs and PPOs charge deductibles and co-payments or co-insurance.

A deductible should be a fairly familiar term-a specified amount of out-of-pocket money a patient must pay before healthcare coverage begins. Therefore, if one's deductible is $500 and the hospital bill $2,000, the HMO will only pay all, or a portion of, $1500. A co-payment (usually associated with an HMO) is a set amount of money patients must pay per visit (ordinarily $20). Afterwards, the HMO will underwrite all subsequent charges from the visit (although X-rays are not typically covered). Co-insurance denotes a percentage agreement between HMO provider and patient. The most popular co-insurance ratio is 80% paid by HMO and 20% paid by patient. Normally, the deductible only applies to large hospital bills, not to routine visits.

The main difference between a PPO (preferred provider organization) and an HMO is flexibility. PPOs offer a wider range of options for patients-chiefly, subscribers in a PPO can select their own doctors. PPOs, however, are typically more expensive than HMOs. PPOs offer discounted doctor rates to patients, who can refuse these services and seek outside doctors. The PPO generally pays outside doctors the discounted rate, leaving patients to pay the difference in cost. The less bureaucratic approach of PPOs (versus the intensely rigid and bureaucratic approach of HMOs) leaves subscribers with better overall care. Being able to select one's own doctor is a privilege most consumers will pay for. Additionally, many HMOs have strict referral policies when dealing with specialists-a PCP (primary care physician) must explicitly authorize specialty procedures, as well as the number of allowable visits and overall timeframe. Patients suffering from debilitating and recurring diseases typically find HMOs stressful and impeding to their convalescence. Consequently, consumers with a history of medical problems should definitely examine the differences between HMOs and PPOs.

Despite their detractions, HMOs and PPOs are necessary entanglements. The trick, therefore, becomes deciding between them and deciding upon a specific carrier. Consumers should carefully research which provider offers the best overall coverage for their situation, because there are plenty of discernable differences between coverage choices. When it comes down to it, HMOs and PPOs are insurance policies on your health, and, while you don't want to pay exorbitant amounts for healthcare, the most important thing is, after all, your health.