The Traditional HMO vs. the PPO
Traditionally structured Health Maintenance Organizations or HMO’s are ideal health plans for individuals and families alike who’d prefer to spend less to access medical attention and care. For a forty one year old in LA County a Silver 70 Direct HMO with Anthem Blue Cross is $283 monthly as opposed to their Silver Pathway PPO 2000/25% for $315. But, traditional HMO organizations do require that their subscribers select a single primary care doctor who’ll thereafter essentially serve as their general health care coordinator-referring them to specialist health care practitioners as needed.
Anthem Blue Cross currently offers one Silver one Gold and one Platinum HMO option for their individual portfolio. These plans are available both on and off the exchange. All plans offered on the exchange have their mirrored counterpart off the exchange. Additionally, carriers may offer additional off exchange options too. For small groups now defined as under 100 full time employees Anthem Blue Cross offers three HMO Network Options:
- Ca Care –largest
- Priority Select
If you’re an employee benefit decision maker you might want to send out an email asking the staff if they have specific doctors and if so who. Your Agent can prepare a report to see what percentage of doctors is among each network. For example, if almost everyone’s doctors are part of the Select Network it might make more financial sense to offer that network. Dual Option means that the employee can still opt for a PPO plan if they want to continue to see their same doctor. Anthem Blue Cross now offers two PPO networks:
- Prudent Buyer – nearly 60,000 doctors and specialist and more than 330 hospitals
- Select PPO- more than 40,000 doctors and specialist and more than 300 hospitals
PPO & HMO Individual plans have only one network which more closely resembles the skinner employer group network options. Whether or not you choose your individual health plan through the Coveredcalifornia state exchange the provider network is identical. Many people have been confused since they say they don’t have a Covered California plan but for all intents and purposes they have a covered California Plan as far as your doctors are concerned. Preferred Provider Organizations or PPO‘s offer both individual and family consumers the freedom to choose their health care providers from among a network of physicians without first obtaining a referral. Insurance carriers such as Anthem Blue Cross have direct contracts with their providers within their PPO network. It’s important to note that many smaller medical insurance carriers actually “rent” their networks from independent PPO networks such as CCN.
Generally speaking, there are three major advantages of having PPO Organization coverage:
- PPO networks are usually quite extensive, providing their plan subscribers with the freedom to move back and forth between general practitioners and specialized health providers.
- Both primary care and specialist providers within the PPO network must accept pre-negotiated fees for the specific healthcare services rendered. In other words, the doctors aren’t allowed to balance bill the patient.
- Within PPO structures, when their consumer/subscribers are willing to have somewhat larger deductibles, they can realize a substantial savings on their healthcare premiums compared to an HMO.
Anthem Blue Cross currently offers many PPO Plans:
- Off: Anthem Bronze Pathway PPO 5000/25%
- Off: Anthem Bronze Pathway PPO 5750/20%
- Off & On: Anthem Bronze 60 PPO
- Off: Anthem Bronze Pathway PPO 5750/20%
- Off: Anthem Bronze Pathway PPO 6600/20%
- Off & On: Anthem Bronze 60 d Health Savings Account PPO
- Off: Anthem Silver Pathway PPO 1750/30%
- Off: Anthem Silver Pathway PPO 2000/25%
- Of & On: Anthem Silver 70 PPO
- Off & On: Anthem Gold 80 PPO
- Of & On: Anthem Platinum 90 PPO
By accessing care from in-network providers, you’re only responsible for a pre-negotiated fee rather than an individually billed amount. For example, if you have the Bronze Health Savings Account PPO you don’t have a copayment before the deductible like most of the other plans. That being said, the current allowable amount for an office visit is around $60- it doesn’t matter if the doctor bills a $100 or more they have to accept the negotiated fee. Your $4,500 deductible would then be reduced by the sixty ($4,440). If you do have the Bronze Health Savings Account PPO, you can pay your out of pocket cost with pre- tax money if you open up a designated Health Savings Account with a financial institution. Every dollar you deposit into your account, up to $3,350 for an individual or $6,750 for a family reduces your taxable income in kind.
Should you enroll through the Ca exchange?
If your employer doesn’t offer benefits that’s affordable, defined as an employee contribution of less than 9 ½% of your income and your spouse’s work doesn’t make benefits available to you than you can qualify for advanced premium tax credits (APTC’s) if your income is above 133% and less than 400% of the Federal Poverty Level (FPL)
Below 133% of the FPL than you should qualify for MediCal. A single person making more than $15,800 and less than $47,080 should qualify for APTC’s. The less you make the more premium assistance will be available. For a family of four the household income can be between $33,534 & $97,000. It’s often easier to deal with a Certified Insurance Agent or CIA who is familiar with all of the in/outs of the exchange in terms of income, specifically for the self-employed and Special Enrollment Periods or SEP’s. The agent is paid by the insurance carriers and doesn’t cost the consumer any additional fees
Not having insurance will cost you money and could cost you your health
The “shared responsibility payment” is a new tax penalty that Americans have to pay this year if they can afford health insurance but choose not to buy it. It’s called a shared responsibility payment because everyone in the United States is now required to be part of our health insurance system. The penalty for 2016 is the greater of $736 or 2 1/2 % of your income. The average stay at a hospital is more than $40,000 but worse of all is if you need care and you can’t get it. Your health is too important to go uninsured!