No. of Recommendations: 6
Hullo Fools! I'm back! I'm not in trouble and I wish to remain that way.

Some of you will recall that I paid off 44k in credit card debt back in 2007. Last year I decided to have my numbers run to see how much I'd qualify for in regards to a mortgage. 130k, which is pretty good considering I've never owned a car or a house.

The last time I posted was last year after my February procedures for carpal tunnel and trigger figure release.

I'm posting today because of my new health plan coverage. I feel like only the poor and the rich can afford health coverage these days. My plan is killing me.

I was a member of Kaiser HMO for 30 years! 3 weeks before 2014 my employer emails us that they are dropping Kaiser as an option for 2014.

Welcome to the world of PPOs! Due to chronic diseases and conditions I have to replace 5-7 doctors.

I tried to keep my old HMO but it was impossible. I couldn't afford the individual plan. Turns out I qualified for federal assistance but because my employer offers insurance that disqualifies me. Catch-22 situation.


So my new PCP refers me to an ortho and sports medicine clinic. I look them up and learn they are not in network. But I thought PPOs meant you have more choices than a HMO. Yes, but they are not all affordable choices.

So I also learned today that I have a 1k deductible for in-network P.T. and a 3k for out of network P.T. My HMO had co-pays for P.T.

So I called the clinic to see how much an evaluation would cost me -- $500.00! *gasp*

What the heck ever happened to healthcare plans that one can afford?!

I know what I need to do, start putting money aside each paycheck for healthcare costs. No, we don't have health savings accounts.

I still haven't learned how to keep my mitts off money in an E-Fund.

Shire
Print the post Back To Top
No. of Recommendations: 1
I used to have Kaiser and miss it. I love the simplicity of going into the office for a visit and them telling me upfront how much I would owe. I'm now on a PPO also and not only is it pain finding different doctors and specialists but also dealing with all the "explanations of benefits" from the different care providers. And it's even worse when they could something improperly.

I will say that overtime my experience with the PPO has gotten better. I really hope yours does too.
Print the post Back To Top
No. of Recommendations: 2
Did you ask about the negotiated rate for your insurance or were you given their standard billing cost?



I also miss Kaiser. I had to change to Blue Cross because my husband was going to lose Cobra and was in the middle of radiation treatment. with Cobra, co-pays, and uncovered expenses, we paid 13K in medical bills that year.
Print the post Back To Top
No. of Recommendations: 1
Kaiser's main campus is a block from my apartment (this was wonderful since I don't drive). I pass it on my walk to the bus stop. *sigh*

I'm glad to hear the world of PPOs improved over time for you.

shire
Print the post Back To Top
No. of Recommendations: 0
No, I didn't know there was such a thing as a negotiated rate for my insurance company. Good to know! Thanks for the tip.
Print the post Back To Top
No. of Recommendations: 0
Post Script I currently have 2k in my E-fund.
Print the post Back To Top
No. of Recommendations: 0
I'm so sorry you lost your preferred--and convenient--doctors and easy to use insurance plan. You might go to your benefits office and request that Kaiser be reinstated as an option for next year (or is your company small enough that they offer only one health insurance option?).
Print the post Back To Top
No. of Recommendations: 1
No, I didn't know there was such a thing as a negotiated rate for my insurance company. Good to know! Thanks for the tip.

Always send all medical bills through your insurance. For in-plan providers, the amount will be reduced to the negotiated rate. The difference could be minor but is frequently significant.

The initial bill for my husband's hospital stay was over $30K. The insurance rate was around $11K. The difference for an office visit with our primary care doctor isn't very large.
Print the post Back To Top
No. of Recommendations: 1
My employer decides which plans or plan they are going to offer their employees.
Print the post Back To Top
No. of Recommendations: 3
shirehobbit,

You wrote, I'm glad to hear the world of PPOs improved over time for you.

I've had negative experiences with HMOs. My preference has been to select a PPO when available and costs are similar. The last time I was covered by an HMO was in the '90s. PPOs present their own types of headaches, but I won't be going back to an HMO unless there is a significant savings to me personally.

- Joel
Print the post Back To Top
No. of Recommendations: 5
shirehobbit,

You wrote, No, I didn't know there was such a thing as a negotiated rate for my insurance company. Good to know! Thanks for the tip.

Tip #2: The provider often doesn't know the negotiated rate. They usually go through a 3rd party service that negotiates for them and they may not be able tell you the negotiated rate. If you really need to know the cost, the provider should be able to submit what I believe is called a "pre-certification request" to the insurance company for the procedure. The insurance company will send you and the provider a letter authorizing the procedure and an estimate.

Of course you can only do this with procedures that can be planned for in advance. In those cases, I highly recommend you make sure you understand if there will be other service providers involved. If so, you have the right to require them to be in-network. Sometimes it can take some poking and prodding to make this happen; but it usually saves on the complaints and recriminations afterwards.

- Joel
Print the post Back To Top
No. of Recommendations: 1
My employer decides which plans or plan they are going to offer their employees.

I know. But employee feedback may make a difference, especially if there are a number of people who complain about the loss of the Kaiser option.

It was my mother's job as office manager and eventually Asst VP to choose the company health insurance at the small company where she worked (~30 people so no dedicated HR person). As a worker bee who lived just within her means, she always went for the most generous option her bosses would allow. But her argument to them was based on maintaining high employee morale; and reducing employee turnover, training costs, and absenteeism due to having to change doctors or spend time searching for cheaper medical care. The bosses found her arguments persuasive, but that was in the 60ss-90s.
Print the post Back To Top
No. of Recommendations: 1
I've had negative experiences with HMOs

Like so many things, there's a spectrum of quality. I believe Harvard-Pilgrim, Tufts, and Kaiser are considered the best HMOs. I was quite happy with Harvard Plan back in the 80s/90s--the no=paperwork and no-surprises aspects were a big plus.
Print the post Back To Top
No. of Recommendations: 0
We let them know that we weren't happy with the change.

They had some valid reasons, one of them being that this HMO isn't offered in all the areas we they have employees. They wanted one that is.
Print the post Back To Top
No. of Recommendations: 2
So my new PCP refers me to an ortho and sports medicine clinic. I look them up and learn they are not in network. But I thought PPOs meant you have more choices than a HMO. Yes, but they are not all affordable choices.

Most PPO have their own websites where you can look up specialists to see if they are in-network or out-of-network. Your PCP probably doesn't know what other doctor's offices are in-network for your insurance plan. With a PPO, going to an in-network doctor means there will be lower co-pays (after any deductible is paid) than going to an out-of-network doctor.

I personally prefer a PPO because I see a lot of specialists, and I find it easier to be able to get an appointment without needing a HMO-referral each time I have an appointment. If I need a new doctor (for instance my internist moved out of the area so I needed to find a new internist) I usually ask a doctor I'm already seeing for the names of 3 doctors they would recommend. That way I can look them up with my health insurance's website to see which of them accept my insurance and whether they're in-network.

I don't know the size of your company, but there's no ACA against companies still offering an HMO choice. So you could always give your HR department feedback that you miss having an HMO choice - maybe they'll consider offering that again in the future.
Print the post Back To Top
No. of Recommendations: 2
The real problem with going somewhere out of network is that you don't have protection against balance billing.

Let's say you go to an in network provider who would charge $1000 for a procedure. Your insurer might have a contract to pay $200 for it. The contract also typically provides that the in network provider must accept that $200 for the whole thing and can't charge you for the balance (the $800). So - from your standpoint as a patient - it's all good. This even works if you are still in your deductible. Let's say you had a $500 deductible. All the in net work provider could get from you would be the $200 that the insurer would have paid if you weren't still in your deductible.

Now, let's say you go to an out of network provider who would charge $1000 for a procedure. Your insurer has no contract with that provider. However, your insurer will only pay what it considers a reasonable amount. That would typically be something like the $200 it would pay to an in network provider. So your insurer (assuming you have met your deductible) sends $200 to the out of network provider. But, the out of network provider (having no contract with your insurer) will then balance bill you for $800. You might be able to negotiate something lower or might not.

So - if it was me - I would not be going to the out of network clinic that your PCP referred you to. Find out who would be in network for the specialty in question and have your PCP refer you to someone in network.
Print the post Back To Top
No. of Recommendations: 0
The real problem with going somewhere out of network is that you don't have protection against balance billing.

Out-of-network balance billing has to be watched because the ACA still doesn't put annual caps on that. But just like everything, whether out-of-network is a plus or minus depends on one's own healthcare needs. Like I'm not going to go out of network for my neurology needs, because right now I only see a neurologist annual for medication for migraine headaches and I feel I'm a fairly standard/mild case for migraine treatment. But when considering a heart surgeon, I want access to as many choices as possible, so I can find the best doctor for my particular situation since it's not a standard case - even if that means I could utlimately pay more for final services.
Print the post Back To Top
No. of Recommendations: 0
I agree that sometimes going out of network is the best choice. My kids see one provider who is out of network but we know in advance what the charges will be and the lower reimbursement is OK.

I've also known people who used out of network physicians working out in advance what the actual charge will be.
Print the post Back To Top
No. of Recommendations: 0
The real problem with going somewhere out of network is that you don't have protection against balance billing.
And often it's hard to find this out. When I had major surgery a few years ago turned out the anesthesiologist and several labs were out of network (although hospital was not). I ended up paying about $13K out of pocket when theoretically it should have been $6K max.
Print the post Back To Top
Advertisement