Update #14: health insurance options, which one would you choose? (long)

[AnnieW625]

We have Kaiser HMO and are generally happy with it. We will pay $265 a month for premiums next year, $3180. Our co pays are $15 for sick visits (anthing other than a physical, pap smear, or well baby visit basically), and most drug prescriptions are between $5 and $15. We have the opportunity to switch to a PPO which has zero monthly premium, a $1,000 family deductible, and a $6,000 family maximum. So we would be saving $265 a month or essentially putting that into the FSA to help cover the costs, but I am somewhat hesitant about switching because for the better part of 10 yrs we have had HMO coverage and haven't had to pay for much at all. I have no clue what we spend in medical yearly other than the premiums, co pays, and Rxs, (which I can calculate using our online medical recods). Our HMO doesn't send out EOBs or bills unless DH goes to urgent care and he tells them to bill us instead (:shake:, he has done this twice). We have never once been able to write off medical expenses on our taxes because it is never even close to the $9000 we'd have to spend. I guess we are lucky.

Advantages to switching to PPO:
*closer pediatrician offices (that come highly recommended from friends)
*highly recommended OBs (we are done having kids though, but for female issues could be important)
*no monthly premium
*more variety for pharmacies
*simply being able to call and make your own appt., and not having to deal with a call center
$1,000 family deductable

Cons:
*unknown costs
*potential billing issues, I had issues with a different PPO I had the year I was pregnant with DD1, and had horrible billing issues.
*we could have to trek all over town to go to labs
*we would pay 20% of the costs incured from $1,001 to $6,000

Advantages to staying with HMO:
*know all of the costs up front (IE: I know that my premiums should cover most of our care for the entire year, except co pays, and Rx.)
*no billing issues
*keep the same pediatricians, and ENT specialists DD1 saw (just in case we need them for DD2)
*I like my PCP, a DO
*almost everything is under one roof (or no more than 5 miles away, the peds. offices are moving to a new clinic, closer to our house)
*no charges for hospital stays
*$15 outpatient surgery co pay
*urgent care is provided in house, and we know the drill.
*online medical records

Cons:
*clinic, and hospital are further away
*dealing with call center for appts.
*having to really state your case when you want care ASAP
*having to go to in house pharmacy (although once I have a refill I can change locations, but they still have to be in the Kaiser network)

[lmr1101]

Do you guys have regular rx? I would want to find out what those would cost on the PPO plan. (you can do that just by calling the carrier and telling them which plan your employer is considering and which drugs you are taking)
Then think about how often you are taking your kids to the dr. You should be able to find out what the dr visit copay is.

Once you know those costs you will have a much better idea if it is worth it to switch. Drugs alone might make you stay on your current plan, if you take monthly meds.

If those costs turn out to be pretty small I would highly consider switching to the PPO and putting some of the saved premium costs in the FSA. Unless there is a major expense (like a surgery) it is highly unlikely you will end up spending more than $3000 on the PPO over the year.

[AnnieW625]

Do you guys have regular rx? I would want to find out what those would cost on the PPO plan. (you can do that just by calling the carrier and telling them which plan your employer is considering and which drugs you are taking)
Then think about how often you are taking your kids to the dr. You should be able to find
out what the dr visit copay is.

Once you know those costs you will have a much better idea if it is worth it to switch. Drugs alone might make you stay on your current plan, if you take monthly meds.



we don't. I am no longer on birth control, and I just got an rx for a topical acne cream last month, and it was the first time I had used it since I got pregnant with DD1 in 2005. It costs $15 every three months or so. If we switch insurance the costs will be essentially the same.

Other than ear infection meds for the kids, and an occaisional antibiotic for either DH or myself we don't have any on going health issues or pharmacy costs.


If those costs turn out to be pretty small I would highly consider switching to the PPO and putting some of the saved premium costs in the FSA. Unless there is a major expense (like a surgery) it is highly unlikely you will end up spending more than $3000 on the PPO over the year.

See this is what I am thinking as well, but the overly cautious person thinks that with my luck we'd have something catastrophic happen and would have been better off with the HMO.

DD2 is having some selective hearing issues so I am starting to wonder about her potentially needing tubes, but it could also be nothing and her just being a tad defiant and being 2 yrs. old;).

[SnuggleBuggles]

You've always seemed to glow about Kaiser over the years on here so maybe you should stick with it? :) I have a PPO and no problems. I really don't pay much attention as everything has always been covered. It sure is nice to make my own appointments and not have a lot of red tape too.

[sariana]

If we had Kaiser as a (viable) choice, I would go with it in a heartbeat. I hate having a PPO. I say "viable" because technically we could pay for our own Kaiser coverage, but the non-group rate is too high.

I'm not sure why the call center is a negative. Being able to call just one number no matter who was suffering what is what I miss most about Kaiser.

Remember that with a PPO you never know when your plan might choose to drop your PCP from the network. A Kaiser doctor is a Kaiser doctor.

[NJ_Mom2011]

I have relatives living in Orange County, who had major health problems. They complained about the limitations re selection of specialists on the Kaiser system. They needed to see a non-Kaiser specialist, which as you probably know, is a big no-no.

So the question with your PPO option is what's the coverage for out-of-network. If it is slim to none, you might as well stick with Kaiser since both plans give a limited selection of specialists. Of course, knock on wood, this is assuming you need access to specialists.

Off topic, I am so jealous that you have Kaiser, and so wish that it was here in NJ. Even for people who hate them (which my relatives do), Kaiser indisputably has a beneficial influence as it pressures all of the other insurers to offer cheaper insurance rates.

[sariana]

When my DS needed a service not provided by Kaiser, they sent us out of network and covered it 100%. They didn't even blink. They also sent us out of county when we wanted a second opinion. And charged us only our co-pay. They covered all the visits for another issue when we wanted a second and then a third opinion. No problem.

I hear about people being denied coverage, and it always gives me pause.

[AnnieW625]

I talked to DH not too long ago, and he says that he wants to stick with Kaiser. He says if the rates go up again, closer to $300-$350/month then we'll look at switching, but he says why mess with something that isn't broken.


.......I'm not sure why the call center is a negative. Being able to call just one number no matter who was suffering what is what I miss most about Kaiser.
The Downey/Bellflower service center is pretty good actually, the Harbor one is horrible, and it has been years since I dealt with the OC area one, but for the most part I guess it would just be easier to call and get an urgent same day appt. with a pediatrician and not have to call the call center, but at least someone is always there. I did tell some white lies once though to get out of having to talk to the advice nurse before getting an appt. for DD1 because I knew she had an ear infection.


I have relatives living in Orange County, who had major health problems. They complained about the limitations re selection of specialists on the Kaiser system. They needed to see a non-Kaiser specialist, which as you probably know, is a big no-no.

So the question with your PPO option is what's the coverage for out-of-network. If it is slim to none, you might as well stick with Kaiser since both plans give a limited selection of specialists. Of course, knock on wood, this is assuming you need access to specialists.

Off topic, I am so jealous that you have Kaiser, and so wish that it was here in NJ. Even for people who hate them (which my relatives do), Kaiser indisputably has a beneficial influence as it pressures all of the other insurers to offer cheaper insurance rates.

In regards to people not getting what they want with Kaiser the first thing I learned, esp. here in So Cal was that I had to be b!tch to them on the phone and spell out exactly what I needed and why I needed it. Most of the time they have complied. The only semi frustrating thing that has happened with my care was the initial misdiagnosis of the issue the OB thought Baby 2 had (ecogenic focile, small hole in the heart that often heals before birth) vs. missing the signs for tri-18, and then waiting four weeks to get me into the perinatologist for an echo. cardiogram. Otherwise including having to go to a genetic counselor, the second perinatologist I saw, and then the whole surgery center issue the process albeit sad was pretty painless. I ended up with a great OB who I saw when I was pregnant with DD2 (he was very much hands off, no u/s, no stress, didn't make me worry about anything), and then while he didn't deliver DD2 I was super happy with the L&D nursing staff and the resident who delivered DD2. The nurses in the post L&D area of the hospital could have been a little bit better, but that was mainly a language thing as English was not their first language, and I don't know Tagalog either so there was a definite language barrier there.

In the PPO we would have to pay 40% for out of network services vs. the 20% that are agreed upon for the in network.

I do love Kaiser's Not for Profit practices. I was absolutely floored when I watched The Business of Being Born (Ricki Lake's birthing documentary) and there was absolutely NO mention of Kaiser in it because even though they use medical midwives they have them available when you want them and my experience was that even the OBs are very low intervention vs. what is was like delivering at the hospital where I had DD1 at where one of the first questions I was asked is if I wanted an epidural.


When my DS needed a service not provided by Kaiser, they sent us out of network and covered it 100%. They didn't even blink. They also sent us out of county when we wanted a second opinion. And charged us only our co-pay. They covered all the visits for another issue when we wanted a second and then a third opinion. No problem.

I hear about people being denied coverage, and it always gives me pause.

When I had to have my D&E surgery all I had to pay was $75 in co pays for the non network surgery center, and about $40 or $50 in meds from a non Kaiser pharmacy (that I never got reimbursed for because I didn't file the paperwork). Kaiser covered the entire $17,000+ bill. With a PPO that would have cost me $3400, plus whatever I was paying for monthly premiums, this new no monthly premium plan PPO is new. So not the end of the world esp. if you are putting your monthly premium into an HSA, but $75 is definitely easier to swallow.

[o_mom]

A couple of questions... When you say it is a $6000 maximum, is that your maximum out of pocket? Does that include the deductible or not (so $6000 total or $1000 ded + $6000).

You later said that you pay 20% from $1000-6000, but usually the max is your max out of pocket, so you pay 20% until you have paid $6000, which would actually be about $25k in expenses (if it is really $5000 more than the deductible). Do you know which it is?

I guess I would look at it this way:

With the PPO, you would have to have more than $11,900 in expenses before the HMO would be cheaper. It is likely a little more than that once you factor in copays. $1000 deductible plus $2180 in coinsurance (which is 20% of 10,900) just to equal the premiums of the Kaiser plan.

Worst case, you pay $2820 more if you max out your PPO coverage - again, likely slightly less than that because of the copays on Kaiser.

Best case, you don't even meet your deductible and save $2180 in your HSA to roll over to the next year.

After the first year or two, as long as you don't have a large expense, you will likely have enough in your HSA to cover even the worst case scenario and can lower the amount you are putting in. If you do go that route, I would plan to put all your premium dollars in the HSA the first year. That way you are no worse off in your paychecks, but you can build the account for future years.

When we switched, our calculations worked slightly differently in that our worst case scenario was that even if we maxed out the HSA, we would not pay any more than with our copay-based plan - the premiums were that much more. With essentially no risk, we were good with switching. If you think a $2800 loss would be too much, then it might not be for you.

[Aishe]

See this is what I am thinking as well, but the overly cautious person thinks that with my luck we'd have something catastrophic happen and would have been better off with the HMO.

I have the opposite mindset about this: I think that if something catastrophic happens you will be very happy to have a PPO. That way you can go to Irvine or Cedars or wherever the best specialists happen to be. I know a couple people who received cancer diagnoses while on HMOs (Kaiser and non-Kaiser) and it was positively nightmarish trying to get the right treatment. One friend had an extremely rare and aggressive cancer and her HMO wanted to send her to a general surgeon for treatment. It was unbelievable.

Just food for thought. I know health insurance is always a tough decision.

[AnnieW625]

I have the opposite mindset about this: I think that if something catastrophic happens you will be very happy to have a PPO. That way you can go to Irvine or Cedars or wherever the best specialists happen to be. I know a couple people who received cancer diagnoses while on HMOs (Kaiser and non-Kaiser) and it was positively nightmarish trying to get the right treatment. One friend had an extremely rare and aggressive cancer and her HMO wanted to send her to a general surgeon for treatment. It was unbelievable.

Just food for thought. I know health insurance is always a tough decision.

Cedars is not an option. I am not sure which Irvine hospital you are talking about, but I would not go to UCI, and I have more options closer to home including LB Memorial. I could go to Hoag if I wanted, but then I'd be on the hook for up to $12K of the cost vs. the $6,000 for most other hospitals in my area, most of which are pretty well regarded.

My mom's best friend is a breast cancer survivor and she has Kaiser in Nor Cal. She had one of the top Kaiser Breast Cancer surgeons do her double masectomy. She has been cancer free now for almost 6 yrs. .

There are good and bad stories everywhere.

[niccig]

Best case, you don't even meet your deductible and save $2180 in your HSA to roll over to the next year.

After the first year or two, as long as you don't have a large expense, you will likely have enough in your HSA to cover even the worst case scenario and can lower the amount you are putting in. If you do go that route, I would plan to put all your premium dollars in the HSA the first year. That way you are no worse off in your paychecks, but you can build the account for future years.


I think Annie said a FSA and those don't roll over to next year, it's a use it or lose it. But you could put the premium amount into a savings account and create your own private HSA, so have the funds for any health emergency.

You need to add up how much your medical costs you. We don't go to the Dr for amount of $3000 (you're premiums a year). We never hit our deductible amount, which is $1000 a family. We have annual exam each, I see my endocrinologist a couple times a year. DH went to urgent care the other week but that is first time in years we've gone there. So in your situation, I would be coming out about 2K ahead.

[o_mom]

I think Annie said a FSA and those don't roll over to next year, it's a use it or lose it. But you could put the premium amount into a savings account and create your own private HSA, so have the funds for any health emergency.

You need to add up how much your medical costs you. We don't go to the Dr for amount of $3000 (you're premiums a year). We never hit our deductible amount, which is $1000 a family. We have annual exam each, I see my endocrinologist a couple times a year. DH went to urgent care the other week but that is first time in years we've gone there. So in your situation, I would be coming out about 2K ahead.

Ah, OK. I missed that. I would then only contribute to the FSA the amount I thought I would use. Then, save the difference in premiums outside of the FSA to start building a health fund in case you would need it. It's not as good tax-wise, which makes it less attractive, but would still overall be a savings in a 'good' year. A few good years and you could have enough to stop funding it at that level.

I will say that the first few years of our high-deductible plan, we were like you Nicci. However, this year, we met the deductible by April 1st. You really never know what is going to happen so if you (general you) can't afford to pay the max OOP, it may not be the right plan. In this case, the max difference would be $3k, so I would only switch if I knew I could cover that if it came down to it.

[AnnieW625]

Well DH and decided to do the low cost PPO. We looked at the costs and decided to go for it. We will be putting $150 a month into the FSA ($1800) so we know we will have the deductible plus a little more so we are covered (3/4 of us will most likely need glasses as well). We will be putting $200 more into the DCA account as well (so wcs we can pull out that money as long as we have put that month's money into it), and will be putting the extra $150 a month into the savings account. We have until 6-30-14 to get the money out of the FSA so we have some leeway, but all purchases must be made in 2013. Nice thing about the FSA is that we can get the money out to pay the bills as soon a Jan. 30th so if we happen to have a month where we have $500 in charges but have only paid $200 into it we don't need to wait until we have $500 to get the $500, kwim?

Thanks again for all of your help, and opinions. And O_Mom, sorry I completely missed your first post yesterday, but Nicci answered your questions correctly. The max out of pocket a family has to pay is $6,000 per calendar year (as long as you go to a tier 1 hospital, if you go to a more expensive tier 2 hospital then your max oop automatically jumps to $12k).

[ha98ed14]

Well, we have Kaiser and I've been happy with them. Thankfully we've always been pretty healthy and don't need to seek treatment outside of the "network." I know a lot of people are afraid that they won't be able to see the best specialists because they don't work for Kaiser, so I wanted to share this story.

DD was born with a very rare internal birth defect. You could not see it on the outside, but it could have had serious consequences if not addressed by a year old, and it required major abdominal surgery to correct. (They found it on the 20 week ultrasound.) So, as we are being counseled about the surgery process, they tell us that because we are in OC, and there is no in-house Kaiser pediatric surgery team, that they contract out to the pediatric surgery group at CHOC. The CHOC docs come to the Kaiser hospital and Anaheim and do the surgery. I look ask around and them up and they get glowing reviews, etc.

So at the pre-op appointment, the primary surgeon gives us the full details of what will happen to DD. The plan was to cut her from sternum to the top of her pubic bone in order to gain access to the abdomen. I was of course freaking out about her having surgery at all, but it made it so much harder to imagine the scar that would be there later. But whatever, you do what you have to do. So on the day of the surgery, we show up at the hospital at 5 AM, they administer the pre-op medication (starts with a T, but I cannot remember the name), DD is knocked out. The plan was for the CHOC surgeon, his assisting surgeon (two partners in same CHOC practice) and a pediatric anesthesiologist. So the anesthesiologist is there, the assisting surgeon is there, but the primary surgeon is not there. They call his home, his office, his cell. No one can raise him. The secretary at his office cannot find him, no answer on his cell phone, his wife does not even know where he is. (Or so they tell me.) Seriously, they thought he'd had a car wreck or something equally tragic. We were there waiting for over 3 hours. Finally the assisting surgeon decides not to proceed because they would have to re-sedate DD. (They hadn't given the general yet.) So they put her in recovery and someone from the Kaiser office comes down to talk to us.

I was upset, but I didn't realize what a big deal this was. Apparently it is unheard of for a surgeon not to call unless they really have been in a car wreck. Well, turns out this guy decided to go to San Francisco with his... mistress? but we do not find that out until later. So the Kaiser director is apologizing up and down, says this has never happened before. Finally they give us our options: 1) reschedule with another doctor in the practice group and stay at CHOC to have the surgery done or 2) go to the big Kaiser hospital on Sunset Blvd in L.A. and have the team of in-house Kaiser pediatric surgeons do the surgery. We choose Kaiser Sunset (which is ironically across the street from CHOLA) because the idea of doing business with this CHOC Team scares the %^&* out of me. I can't get past the feeling of incompetence on their part.

So for two months, I drag DD to L.A. to go through the whole pre-op appointment sequence again. We go there the day of the surgery and it is the primary ped surgeon, the intern, the resident and two medical students plus a pediatric anesthesiologist. (Obviously the medical students are just watching.) They do the surgery, which takes 2 hours longer than then said, but whatever. We go into see DD in recovery and there is no incision. Seriously. All there are are three sutures, one across her navel and two other "dots" on her stomach. I was floored. When the attending and resident rounded on her the next morning, I asked them why there was not one long incision down the middle of her abdomen, they said, "Yeah, it's new to try to do it laproscopically on infants, but we thought we could do it. We wanted her to be able to wear a bikini someday." I told him that was not what the CHOC team was going to do. He said that the Kaiser surge team did it because it was a teaching hospital. I am not sure what that meant because I am sure CHOC is a teaching hospital too, but my point is that here was this team of lowly Kaiser physicians who I was choosing over the premiere CHOC team, and they did a better job. At the post-op appointment I asked the primary surgeon about it and he tells me that there are kids from OC who come to Kaiser Sunset to see the ped surge team because this CHOC team messed up. Who knows if that is true or just a little rivalry among surgeons, but it was true in our case!

DD spent 3 days in the PICU and another 4 days on the peds floor. She had an NG tube, a pic line and every other tube and wire coming out of her, but the nurses were awesome, so nice and supportive. We paid $300 for what had to be thousands of dollars in medical care. It probably would have bankrupted us if we'd had a 20% co-pay. I was and am so grateful to Kaiser. And I pray I never have a healthcare need that they cannot meet in house!

[AnnieW625]

Thanks HA for your input. I am very glad that CHLA is a tier 1 hospital if our girls need any serious surgeries when they are children because Miller at LB Memorial is not (and neither is CHOC) and therefore if we went to LB Memorial we'd be stick with a $12k oop max vs. the $6k at CHLA. Our other option is Los Alamitis so as long as it isn't something super serious we should be fine.

[sariana]

You must be relieved to have made a decision.

[Tondi G]

Well, we have Kaiser and I've been happy with them. Thankfully we've always been pretty healthy and don't need to seek treatment outside of the "network." I know a lot of people are afraid that they won't be able to see the best specialists because they don't work for Kaiser, so I wanted to share this story.

DD was born with a very rare internal birth defect. You could not see it on the outside, but it could have had serious consequences if not addressed by a year old, and it required major abdominal surgery to correct. (They found it on the 20 week ultrasound.) So, as we are being counseled about the surgery process, they tell us that because we are in OC, and there is no in-house Kaiser pediatric surgery team, that they contract out to the pediatric surgery group at CHOC. The CHOC docs come to the Kaiser hospital and Anaheim and do the surgery. I look ask around and them up and they get glowing reviews, etc.

So at the pre-op appointment, the primary surgeon gives us the full details of what will happen to DD. The plan was to cut her from sternum to the top of her pubic bone in order to gain access to the abdomen. I was of course freaking out about her having surgery at all, but it made it so much harder to imagine the scar that would be there later. But whatever, you do what you have to do. So on the day of the surgery, we show up at the hospital at 5 AM, they administer the pre-op medication (starts with a T, but I cannot remember the name), DD is knocked out. The plan was for the CHOC surgeon, his assisting surgeon (two partners in same CHOC practice) and a pediatric anesthesiologist. So the anesthesiologist is there, the assisting surgeon is there, but the primary surgeon is not there. They call his home, his office, his cell. No one can raise him. The secretary at his office cannot find him, no answer on his cell phone, his wife does not even know where he is. (Or so they tell me.) Seriously, they thought he'd had a car wreck or something equally tragic. We were there waiting for over 3 hours. Finally the assisting surgeon decides not to proceed because they would have to re-sedate DD. (They hadn't given the general yet.) So they put her in recovery and someone from the Kaiser office comes down to talk to us.

I was upset, but I didn't realize what a big deal this was. Apparently it is unheard of for a surgeon not to call unless they really have been in a car wreck. Well, turns out this guy decided to go to San Francisco with his... mistress? but we do not find that out until later. So the Kaiser director is apologizing up and down, says this has never happened before. Finally they give us our options: 1) reschedule with another doctor in the practice group and stay at CHOC to have the surgery done or 2) go to the big Kaiser hospital on Sunset Blvd in L.A. and have the team of in-house Kaiser pediatric surgeons do the surgery. We choose Kaiser Sunset (which is ironically across the street from CHOLA) because the idea of doing business with this CHOC Team scares the %^&* out of me. I can't get past the feeling of incompetence on their part.

So for two months, I drag DD to L.A. to go through the whole pre-op appointment sequence again. We go there the day of the surgery and it is the primary ped surgeon, the intern, the resident and two medical students plus a pediatric anesthesiologist. (Obviously the medical students are just watching.) They do the surgery, which takes 2 hours longer than then said, but whatever. We go into see DD in recovery and there is no incision. Seriously. All there are are three sutures, one across her navel and two other "dots" on her stomach. I was floored. When the attending and resident rounded on her the next morning, I asked them why there was not one long incision down the middle of her abdomen, they said, "Yeah, it's new to try to do it laproscopically on infants, but we thought we could do it. We wanted her to be able to wear a bikini someday." I told him that was not what the CHOC team was going to do. He said that the Kaiser surge team did it because it was a teaching hospital. I am not sure what that meant because I am sure CHOC is a teaching hospital too, but my point is that here was this team of lowly Kaiser physicians who I was choosing over the premiere CHOC team, and they did a better job. At the post-op appointment I asked the primary surgeon about it and he tells me that there are kids from OC who come to Kaiser Sunset to see the ped surge team because this CHOC team messed up. Who knows if that is true or just a little rivalry among surgeons, but it was true in our case!

DD spent 3 days in the PICU and another 4 days on the peds floor. She had an NG tube, a pic line and every other tube and wire coming out of her, but the nurses were awesome, so nice and supportive. We paid $300 for what had to be thousands of dollars in medical care. It probably would have bankrupted us if we'd had a 20% co-pay. I was and am so grateful to Kaiser. And I pray I never have a healthcare need that they cannot meet in house!

Thank You for sharing this story. I have heard some very wonderful things about Kaiser and some not so great things about Kaiser ... I always found myself overlooking Kaiser as a medical insurance option. We had some unfortunate events that lead to huge medical bills in the past and we essentially depleted our savings account to pay down those bills because of the percentage we had to pay with our PPO insurance. It is great to be able to call any doctor and see whomever you want to ... but in the case of accidents and ER visits and surgeries PPO's can be VERY expensive.

I'm thrilled for you and your DD that she ended up at Kaiser Sunset with their team of doctors. It was a case of being at the right place at the right time huh! All that craziness with the CHOC doctor happened for a reason!

[bisous]

Annie what a brave new world, lol.

We have Kaiser and LOVE it. BUT DS1 has a very expensive preexisting condition that is very affordable thanks to Kaiser. Without that issue, PPOs would be more appealing. Every family has different needs.

Definitely keep us updated on how the PPO works out for you!

[bisous]

HA98ed14,

What an amazing story. I'm glad things worked out so well. I'm also super impressed with Kaiser sunset! DS1 sees a pediatric endo there. We're going tomorrow!

[AnnieW625]

You must be relieved to have made a decision.

yes it felt good to be done considering I had limited time to make a decision. If I didn't have all of the good doctor recs. I have from friends I don't think I would have even considered switching.


Annie what a brave new world, lol.

We have Kaiser and LOVE it. BUT DS1 has a very expensive preexisting condition that is very affordable thanks to Kaiser. Without that issue, PPOs would be more appealing. Every family has different needs.

Definitely keep us updated on how the PPO works out for you!

I had HMO or PPO insurance growing up and never really had many complaints except when my pediatrician I loved moved to Kaiser when I was 14 yrs. old and my parents wouldn't switch because it was more expensive, and they wanted local (non Kaiser hospital was 2 miles from the house, and Kaiser hospital was 25) I didn't like his replacement much (he wasn't very sympathetic to teenage girls). Thankfully he only lasted a year or two or we switched to a PPO and care wise all I needed was a dermatologist so I didn't need a referral.

If it weren't for there being no monthly premium at all then we would not have even considered it. That was a big selling point for us. The PPO I had when DD1 was born (which is still offered) has a monthly premium attached so it is the same price as Kaiser. To me that is no brainer if you are healthy then go with Kaiser if your only other PPO option has a monthly premium attached to it.

WCS if we hate it we'll be back at Kaiser in a year, but for the most part I hope things go smoothly and this works out for us.

[Globetrotter]

Here's the thing - there is good and bad everywhere, but the "bad" Kaiser docs are associated with Kaiser and you tend to hear the bad stories.

I had Kaiser for a long time and it was alright. They are fabulous with preventive care and screenings and education. It is impersonal compared to a smaller office and sometimes I felt like a number. I liked the coordination of care between departments, which is certainly easier when it's under one roof, plus most services are in one place. You have to learn how to work the system and get in sooner (say how anxious you are, for ex.).

The downside is that you are greatly restricted in your options if you want a second opinion or if you want to see Dr. X outside of the network. I imagine you may not always be able to take advantage of new treatment options if Kaiser docs don't offer them (though don't assume they are necessarily worse). I switched to a PPO because choice is important to me and we could afford it, and in fact I upgraded to a POS Choice open access, so I can see any specialist I want without referrals. My main reason for switching was the terrible care I received at one of the Kaiser hospitals during my L and D, and given my location I would have to go there for subsequent deliveries. No way was I going there again!! Since then, they have changed their policies and have become nursing friendly and less interventionist, but at that time twelve years ago, it was pretty awful.

Now, in an ironic twist, most docs in my town refuse to accept my POS insurance (Aetna) so I have had to switch docs! Fortunately, my PCP is an angel. She told me she signed the contract with Aetna ($2 less per office visit) because she loves her patients and enjoys seeing them - she also sees a lot of medicare/medi-cal (medicaid), and I'm betting her colleagues are increasingly rejecting them.

OP, glad you made your decision! Since you like the medical group model, you may be able to find a large group that functions like an HMO with all services under one roof (but depending on your insurance, you should have the option to go elsewhere if you like). In the Bay Area we have Palo Alto Medical Foundation.

ETA: Cost is generally a big selling point for Kaiser.

[codex57]

You can have good and bad at Kaiser and PPO.

Couple of quick stories.

Bad non-Kaiser story: UC San Francisco. One of the premier teaching hospitals in the world. MIL finally gets the head gastro guy as her doc instead of dealing with incompetent residents (literally; my wife told one her decision would send MIL into the ER but the resident did it anyways and MIL did go to ER, so they retaliated by describing DW in the notes and playing hide the chart whenever DW went with MIL to appointments). Needs liver surgery for cancer. Plenty of ultrasounds and stuff beforehand showing the cancer and stuff. Get call day of surgery. They can't find the cancer. Ask if we're sure it's the liver (why ask us, you have all her med recs). Somehow, they wandered to the lung and found a possible cancer bit there. WTF? MIL dies a short while later cuz cancer has spread too far to stop. Moral of story: just cuz a doc is book smart/research smart, doesn't mean they know how to practice medicine. Even the heads of departments. Practicing medicine on people and writing in journals are two very different skills.

Bad Kaiser story: kid has pain. Kaiser PCP won't allow a MRI. Kid goes to multiple other providers, including some Kaiser ones. All, and I mean all, tell her she needs a MRI. PCP still refuses and since the PCP is the gatekeeper, no MRI. Kid ends up paralyzed cuz PCP refused to authorize MRI and an eventual referral to specialist. It's less of a problem in NorCal, but the way the SoCal Kaiser Medical Group is run (partnership vs the NorCal corp model), it's a partnership. THat means the PCP gets their pay docked or upped depending on how many higher cost procedures or referrals they authorize a month. Leads to greedy bastards like this PCP and horrific results for the patients. I have the name of the legal case if you want the details.

If you think you're having a problem with your medical provider/health plan, PM me. Sorry, I only can help in California.

[ha98ed14]

It's less of a problem in NorCal, but the way the SoCal Kaiser Medical Group is run (partnership vs the NorCal corp model), it's a partnership. THat means the PCP gets their pay docked or upped depending on how many higher cost procedures or referrals they authorize a month. Leads to greedy bastards like this PCP and horrific results for the patients. I have the name of the legal case if you want the details.


Where are you getting this information? I had a very frank conversation with DD's pediatrician once about the benefits/draw backs of being with Kaiser v. his own private practice. He chose Kaiser in part because he is salaried. There's no pay change depending on what his patients need. He sees patients. Kaiser pays him the same amount every pay period. The end.

[KrisM]

Make sure you don't put too much in the FSA, since it's gone if you don't use it. We have a PPO and have well-visits that are 100% covered. Many years, we only spend $500 out of pocket, as we tend to be healthy and don't take any ongoing prescriptions. Two years ago, we spent $3500 or so, as DH was really sick for a week. Four years ago, we spent about $3500 when DS2 was born. So far this year, we've not used our $300 in the FSA.

[AnnieW625]

.......OP, glad you made your decision! Since you like the medical group model, you may be able to find a large group that functions like an HMO with all services under one roof (but depending on your insurance, you should have the option to go elsewhere if you like). In the Bay Area we have Palo Alto Medical Foundation.

ETA: Cost is generally a big selling point for Kaiser.


......It's less of a problem in NorCal, but the way the SoCal Kaiser Medical Group is run (partnership vs the NorCal corp model), it's a partnership. THat means the PCP gets their pay docked or upped depending on how many higher cost procedures or referrals they authorize a month. Leads to greedy bastards like this PCP and horrific results for the patients. I have the name of the legal case if you want the details.


Where are you getting this information? I had a very frank conversation with DD's pediatrician once about the benefits/draw backs of being with Kaiser v. his own private practice. He chose Kaiser in part because he is salaried. There's no pay change depending on what his patients need. He sees patients. Kaiser pays him the same amount every pay period. The end.

HA, have you ever had Kaiser in Nor Cal? There is just something different about it. For whatever reason I remember it running a bit more smoothly and there was less red tape. I don't remember having to talk to the nurse advice line anytime I was sick and needed a same day appt.; who knows maybe I just got lucky. I was only a memeber in Nor Cal for 18 months and I didn't have many health issues so I was good, but I got way more warm fuzzies from it than I initially did in So Cal.

The Permanente Medical Group of Kaiser is a different company than the Southern California Permanente Medical Group. When I moved here from Nor Cal I had to have my medical records sent to the new Kaiser just like I would if I other non Kaiser insurance. I could no longer use the same medical record number, and I no longer had access to my online medical record. Even though it was the same company it was like I was new to a whole other culture of medical insurance I wasn't used to. I really have had a positive experience with Kaiser and am glad we gave it a second shot (2008 to current), but a lot of that has to do with me being proactive about my care. IMHO if you aren't going to be proactive then Kaiser might not be the best fit.


Make sure you don't put too much in the FSA, since it's gone if you don't use it. We have a PPO and have well-visits that are 100% covered. Many years, we only spend $500 out of pocket, as we tend to be healthy and don't take any ongoing prescriptions. Two years ago, we spent $3500 or so, as DH was really sick for a week. Four years ago, we spent about $3500 when DS2 was born. So far this year, we've not used our $300 in the FSA.

That is why I am playing it safe this year and only doing $1800, but I don't want to short change it too much just in case we end up having to pay all of that $1000 deductable. This past year we did $300 and that was one pair of glasses and DD1's eye exam. I then used that reimbursement to buy DD2's glasses. WCS at the end of next year if we still have money then everyone will get a spare pair of glasses. DH has already said that he wants prescription sunglasses so he'll finally get a pair of those. We have a pretty wide range of stuff we can submit for including all prescriptions (as long as we have a copy of the receipt) so I will do that as well. It turns out I can also submit for dental fees and I pay $180 to $240 a year for dental visits because I go every 3 to 4 months.

[codex57]

Where are you getting this information? I had a very frank conversation with DD's pediatrician once about the benefits/draw backs of being with Kaiser v. his own private practice. He chose Kaiser in part because he is salaried. There's no pay change depending on what his patients need. He sees patients. Kaiser pays him the same amount every pay period. The end.

If you really wanna know, PM me. I try to not put personal info out on the web.

[BayGirl2]

I haven't read all the responses, just the first page. But I have Kaiser in NorCal and we've chatted about it in the past so thought I'd weigh in. I would definitely stay with Kaiser. I left Kaiser when I changed jobs and before I married DH and that was my least-preventative-cared year of my adult life. It took me months even to find a Dr and get an appt, and then it was at a clinic that catered to low income with barely any customer service. Then I ended up with billing issues bc I saw a non-PPO doc at a clinic that had PPO docs, but they had rescheduled me with the wrong person. The entire saga was just not worth even getting a pap smear. If I needed something like a test, shot, or prescription I had to run all over town.

I can't fathom going through a PPO system with 2 kids, because even my relatively healthy kids have had a couple ear infections and a tonsillectomy plus regular checkups. I just don't have the time to deal with the logistics and paperwork. And I know with Kaiser if DS's eardrum ruptures on Sat morning before we leave for vacation I can call urgent care and go to a clinic that day. (Happened last month, Oakland was booked so we went to Hayward, had a prescription in hours and he was healthy by the time we reached LA.)

For me a couple hundred dollars a year is totally worth the included preventative care and convenience, and I'm happy with all my Dr's.
If something catastrophic were to happen to any of us I'd feel more comfortable with Kaiser's coordination of care and E-records, and I'd fight the battle for specialists if I felt I needed to.

ETA: Just saw you decided (see I should read the whole thread). I do understand Kaiser NorCal and Socal are slightly different and my experience is with NorCal. Also we have a local office that runs more like a family practice so its even more personal, that was not the case when Oakland was my PCP location. Good luck with your choice!

[daisymommy]

Where are you getting this information? I had a very frank conversation with DD's pediatrician once about the benefits/draw backs of being with Kaiser v. his own private practice. He chose Kaiser in part because he is salaried. There's no pay change depending on what his patients need. He sees patients. Kaiser pays him the same amount every pay period. The end.

That's exactly what it says in my Kaiser membership handbook as well.