Little leery about PPO's. I've seen billing mistakes in HMO's where the supplier has to eat it. With a PPO they can say "out of network, but we got good news, you still get 60% paid." Aetna covers just about every provider in metro St Louis. Barnes is usually top ten in major teaching hospitals. Just can't see going to Cleveland Clinic if my heart screws up, although they have a relationship with a medium sized hospital. Smaller market a PPO might pay off.
Yes, I can see you know your stuff. This can be very true. With Medicare you have some protection I think but I would imagine it could become a hassle. One thing for sure if its non medicare and a company policy you are out of luck.
In medicare A LOT of burden rests on the medical faculty to make sure of your insurance coverage and as you said, you maybe covered with a PPO plan but at the higher co-pay.
Let me back up a bit (oh no another long story) Agreeing with you 100% at least of what could happen.
My first 2 years of United Health Care (UHC) Advantage C plan was an HMO. I lived in the Capital of SC area. This was my first time getting medicare and I selected this policy known as UHC Advantage C Plan 2.
IN South Carolina this plan is an HMO. I looked up every major medical center and all my doctors, I mean EVERY place was part of the HMO including a heart hospital. I never found one Dr or Network that didnt take UHC and even more so, available across the nation where they accept UHC.
Amazing, loved it.
But I love shopping and I even shopped for family member and his wife who wanted to drop his ever getting more costly Medigap G and Medigap D plans
So I moved to a new state next door to NC I got concerned because I knew my current plan wasnt available here so needed to switch, well, UHC made the plan available to me here and everyone else. Before that they didnt offer Advantage C in this massively fast growing area. I think I was the catalyst. However they made the plan better and made it a PPO. I thought great but then read if I am out of network I will be POSSIBLY responsible for much larger CO-Pays. Ummm ... I didnt want that because like SC I KNOW all medical facilities here take Advantage C plans... so I looked at others and had Aetna in my sight because they offered more perks, less co-pays, more payouts and no month fee at all and it was an HMO. Last UHC plan was $29 a month.
Anyway to back up what you said, I thought to myself I dont really want a PPO because what if they look up that I am covered but as a out of network, I could get stuck with higher bills, even it if is just a lab or radiology center. SO I went with Aetna because the extra benefits were there was the main driving factor followed by the removal of any uncertainty of how I will be covered. Anyplace I go with Aetna I know I am in network. One nice thing about Medicare, the medical center has to confirm your coverage, the weight of confirming falls on them. But with a PPO it is interesting, does that weight still exist?
Ok, so back to that family member and his wife. Sticking to what (he is my brother) they wanted I showed him my policy and one from Humana. Since he was in Medigap G and D he felt more comfortable choosing the Humana Plan that I found for him. He has MAJOR heart issues and this was a big switch for him so he went with the Humana plan for this reason, get this. The Humana is a true PPO in the sense that pays are the same in and out of network, also he takes many expensive drugs and the drug plan worked better for him.
The cost is a little higher in the sense he DOES have a deductible which is rare but no monthly fees. The deductible is $750 (or $650) a year and for that he does get a nice low $2,900 out of pocket limit, though that has gone up a little. Might be 3500 now.
First year on that Advantage C plan he had a retail cost of $500,000 (five hundred thousand) in medical bills, his cost was the deductible and $2,900.
He has lived in this area for 7 years now once I moved here I search every known medical center I might ever end up at. They all take my Aetna Plan which is an HMO. I know at the least his wife may go into my plan for the new upcoming year. For him might be a little more complicated to check all the prices of his drugs and if it is worth it for him to switch with his major issues.
Ok, so back to shopping. I like my Aetna plan and I also liked my UHC plan. What I love most off all I get to shop every fall and decide if I want to stay with that plan and switch to something that might work better for me the following year. Just like when I switched from UHC to Aetna last year. All I do is log into my Medicare.gov portal search plans and if I want to switch, all it takes is one click of the mouse into that box, confirm one more time ( I think) and I am done, starting in the new year medicare sets it up.
