1. I’ve moved to a different state. In order for medical care to be covered under the HMO, it has to be performed in Illinois, not Indiana, and since the move, that means an extra trip into the city and spending at least 3 hours locked in freeway gridlock. (Commuting is easy, since I work nights, and half the time work from home anyway. But during the hours doctors offices are open, it’s a nightmare.)

2. I added someone female to my insurance. Us Y-chromosome types tend to think of “specialist” as meaning “guy who does really exotic stuff that’ll probably never ever happen to us, or at least not until we’re way older than we are now”, at least as long as we’re single. Women, on the other hand, know that a gynecologist counts as a specialist too. So does a pediatrician if we ever have kids.

3. Six months ago, I suffered a significant but not life-threatening injury (I broke my ankle and wrist) while visiting family back in Michigan. Now, I’m having to cope with a Kafka-esque nightmare of bureaucracy and legalese fighting between the ER that treated me and my insurance carrier, as to whether two simultaneous fractures constitutes an “emergency” under my HMO policy. I go to Michigan a lot, as both my family, my SO’s family, and a great many of my friends still live there, so this is a situation whose recurrence is not wholly outside the realm of reasonable possibility. And if I’d had the PPO instead, there wouldn’t be any fight, because it would be covered. Indeed, since (see #1) I’m not currently covered at any facility within a reasonable daytime drive of my house, this would be a problem even if I rarely “travelled”.

If you’re confident that no caveat like these could ever possibly apply to you, then go ahead and use the HMO to save the money. But I’d reccomend putting those savings aside into a dedicated account, to be used to cushion the blow when the HMO screws you over.

Yeah, in THEORY. As I found out the hard way, most specialist will not accept patients without a referral from their primary care physician, regardless of the type of your insurance! It’s not a matter of insurance, it’s just their personal policy. I think most specialists are overloaded, and so they don’t want to waste their time/priority seeing patients that don’t need specialists.

I’m not sure if this is just a regional thing, or if it’s nationwide, but just make a few calls to some specialists in your area and ask if they require a referral for PPO. If the cost difference is large between PPO and HMO, and you won’t even be able to directly see a specialist (realistically speaking), then the PPO may not be worth it.