By: Revanche

Should I stay or should I go?

October 25, 2006

I’ve been sticking with my HMO for the past 2 years, doggedly, against my supervisor’s recommendations because it’s cheaper.

The HMO is more complicated than the PPO because it’s 20 minutes east of my home, whereas work is 1 hour and 20 minutes west. This means that I have to take a half or whole sick day for an appointment, make arrangements to drive to work instead of taking the train which can inconvenience my parents who might need the car, and getting a convenient appointment is not always simple.

With the PPO, I could just go to the doctor during the work day, any work day, and usually be seen with or without an appointment. I would not have to take more sick leave than the amount of time required to see the doctor. Of course, using up sick leave is not really an issue because I still have about two weeks’ worth now.

Since Open Enrollment starts next week, I thought I’d take another look at some of the most important factors that I would be paying for if I switched from HMO to PPO.

[Excuse the lack of presentation, I can’t figure out how to do tables in Blogger]

Monthly Cost
PPO: 72
HMO: 41
Monthly Difference: 31
Annual Difference: 372

Office Visit Copay
PPO: 10%/20%
HMO: $10
*** PPO could be cheaper, do visits run more than 100/visit? If I go to an on-campus office, it’s 10%, if I go to an in-network/ off-campus provider it’ll be 20%.

Preventative Care (vaccines/screenings)
PPO: covered
HMO: covered
*** PPO only covers the first annual screening

Prescription Copay — this is where it gets complicated:
PPO (30 day supply)
15% of cost, minimum of $5 (generic)
20% of cost, minimum of $20 (for brand, when no generic available)
40% of cost, for brand when generic available

HMO (up to 100 day supply) — at the HMO pharmacy, not covered at other pharmacies
$10 for generics
$15 for brand name drugs

*** I probably pay about $30, 4 times a year for prescriptions right now. That’s usually a 100-day supply per prescription. Each drug would have to be <$25 each to come close to the prices I'm paying now. But they DO have mail service available. Emergency Care
PPO: $75, waived if admitted directly to hospital
HMO: $35, waived if admitted directly to hospital

PPO: not available on campus, 20% if taken to off-campus site AND it’s a “true emergency”
HMO: no copay, plan pays 100%

In-hospital Expenses
Skilled nursing facility – 100/day, max of 500 on-campus
– 150/day, max of 750 off-campus
Surgery – not available on-campus
– 150/day, max of 750, limited to 60 days per calendar year regardless of cause
Dr visits (related to surgery) – 10% on-campus
– 20% off-campus

Skilled nursing facility – 100/admission
– 100/admission, plan pays 100% up to 100 days per year
Dr visits (related to surgery) – no charge

I know that I’m not likely to need the last few categories of Emergency Care, Ambulance and In-hospital expenses, but it’s always good to know what I’ll be expected to pay in case of an emergency. Overall it just looks like I’d be paying about $500 more per year simply for the sake of convenience. [Or about $400 more, if the prescriptions are much cheaper at cost than I realize.] I know it’s taken out of my check pretax, but I feel like I’d be paying more for the privilege of getting less coverage. I can’t really argue for the quality of care, even though ALL pro-PPO people insist you get better doctors this way, because I know plenty of people who work at the current on-campus facilities who aren’t gung-ho about the idea of actually being treated where they work.

I suppose the other part of the equation is the recouped work time: will I make enough during those days in which I visit the doctor without having to leave work for a half or whole day to make up for the extra cost? [6 appointments/year, approximately 2 hours each = ~$200]

And if I factor in gas/mileage, does not having to drive an extra 120 miles that day also make up that cost? [A trip calculator estimates that it costs approximately 10.50 per day I commute which = $63 for six appointments/year]

Huh, I guess, assuming I see the doc 6 times a year which is what I’m supposed to do now, I would only be paying a little over 100 more per year. If I see him/her more frequently, my difference in cost actually decreases even more. The convenient option could actually save me money. I’ll go ask some questions at the Health Benefits Fair next week and see if I can get a ballpark estimate on visit and prescription copays. The switch may not be such a bad idea after all.

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