Medical Plan Comparisons

What should I consider when choosing between the PPO, HMO, and HCA plan options? The premium rates are not the only things to consider when choosing a medical plan. There are significant differences between the plans that should be looked at. Here are some factors to consider.

1) Benefit design – There are notable differences between the plans, which impact the coverage and the out-of-pocket costs you’ll have when you utilize your benefits. The BlueLincs HMO is a health maintenance organization type of plan, otherwise known as a “managed care” plan. It requires selection and use of a primary care physician (PCP), and referrals are usually needed for specialty care. The BlueLincs HMO has very low out-of-pocket costs with just applicable copays. And, there is no calendar year deductible to satisfy.

The BlueChoice PPO plan is a preferred provider organization type of plan, which gives
you the flexibility to choose between a PPO provider or non-PPO provider. Benefits are almost always higher if you use a PPO provider. The BlueChoice PPO has a calendar year deductible to satisfy before coverage begins. But, like the HMO plan, many services are covered with just a copay, so depending on the type of services you need, you may not even need to meet your deductible during the year.

The BlueEdge HCA pairs a high deductible PPO plan with a health fund. It has a notably higher deductible to satisfy each year, and most services, except for some of your preventive care benefits, are subject to that deductible before your coverage begins. To help offset the higher deductible with this plan, money is put into a health care account each year on your behalf, which can be applied to your deductible or other eligible out-of-pocket medical expenses.

2) Choice of doctors and facilities - If you are considering the HMO, make sure your current physician(s) is in the HMO network. If you are joining the HMO and want to choose a new primary care physician, make sure that physician is accepting new patients.

3) Medical management - The HMO plan has a higher level of medical management, meaning that some tests or prescription drugs may take longer to be approved, more substitutes may be suggested, and more tests may be denied, relative to the BlueChoice PPO or BlueEdge HCA.

4) Price - The HMO premium rate is lower, and generally, out-of-pocket costs are less, than the other two plans.

5) Out-of-state coverage - Generally on the HMO plan, out-of-state coverage for the employee is limited to emergency treatment. If you have a dependent living out-of-state or moving out of state during the year, and are considering the HMO, call Blue Cross Blue Shield at 1-888-881-4648 to learn about your options.

PPO members (BlueChoice PPO and BlueEdge HCA) have nationwide access to contracting providers through the BlueCard® Program when you or your covered family members live, work, or travel anywhere in the country. Additionally, when you travel outside the United States, PPO members have access to contracting providers in more than 200 countries through BlueCard Worldwide®.

6) Medical procedure availabilty - Some elective procedures may be available only under a particular plan. Bariatric surgery (obesity reduction) is currently covered only under the BlueLincs HMO plan.

7) Pre-existing conditions - The BlueLincs HMO and the Community Care HMO plans have no pre-existing condition restrictions. In some instances where individuals have had no prior group insurance coverage immediately before enrolling, the other Blue Cross plans may have pre-existing condition limitations.