Health Plan Options: High deductible? PPO?

[thenmama]

It's almost open enrollment and given our medical expenses we've decided to re-evaluate our plan options this year, instead of automatically re-enrolling in the HMO. Wondering if the plans that are more costly up front might actually be better for us in the long run. Has anyone else done this? If so, any tips on plan shopping and/or feedback on other plan types? I know a lot of it will be plan-specific but still interested to know how such changes have worked out for others. Also would really (really, really) appreciate any heads up you may have on things to watch out for when comparing plans, pitfalls to avoid, etc.

 

Thanks all!

[lfran]

What I learned to my surprise was that as a Blue Cross subscriber, I got the "member" rate even when I hadn't met my deductible. So a doctor that was PPO but not HMO would charge me $300 if I was HMO only but if I went to him under the PPO plan, I got the negotiated rate of, say, $120. This is even if I hadn't met my deductible.

 

I spent 20 years with an HMO and this year am in a combined HMO/PPO plan. For next year, I am choosing to go to a very high deductible plan with a much lower premium, because the premium savings pretty much matches the deductible and I can put money aside in a health savings account to pay for it, with further tax savings.

 

Another HUGE benefit for me vis a vis HMO and PPO is that I can self-refer to ANY specialty with the PPO plan. The HMO does not serve as a gatekeeper.

 

If I choose to go to someone who is completely out of network, but he or she will send labs to an in-network lab (Labcorp or quest, or even metametrix now), I get the negotiated price that Blue Cross has with the lab. HUGE savings over when I was paying out-of-pocket costs for non-HMO doctor's labs.

 

But, watch out for presciption plan costs, which can be pretty variable and not cover all meds. If you know which meds you are likely to need, you can call and ask their cost for those.

 

Leaving my HMO was a large cost savings for me, but we were using a lot of non-HMO docs. There is a lot more paperwork if you use out-of-network docs though.

 

It's almost open enrollment and given our medical expenses we've decided to re-evaluate our plan options this year, instead of automatically re-enrolling in the HMO. Wondering if the plans that are more costly up front might actually be better for us in the long run. Has anyone else done this? If so, any tips on plan shopping and/or feedback on other plan types? I know a lot of it will be plan-specific but still interested to know how such changes have worked out for others. Also would really (really, really) appreciate any heads up you may have on things to watch out for when comparing plans, pitfalls to avoid, etc.

 

Thanks all!

[nicklemama]

We have a high deductible BCBS PPO. It works like a regular 80/20 BCBS policy. We can go anywhere to anyone who accepts BCBS in the US. The family deductible is $2500. The out of pocket max is $5300 for the plan yr. We switched to this from an HMO during open enrollment right after DS was diagnosed w/ PANDAS. We've never looked back. The HMO would have covered very little and only if my ped would write for the referral. I could only get 8 days worth of azith and 10 days of augmentin at a time. Now, I can get 30 days of anything at a time.

 

DS has a biomed doctor who does not accept insurance but he files for us and we get 60% back from insurance. I have a doctor that does not accept insurance but gives me the paperwork to file and I get 60% back from those visits, as well. Those also count toward our deductible and out of pocket max.

 

We've taken DS out of state to PANDAS docs and they were covered. IVIG was covered out of state.

 

We have no prescription plan, per se. Our prescription costs go towards deductible and out of pocket max. We do pay the negotiated agreement cost from participating pharmacies.

 

Try and gather all the info you can on what it covers. Each policy is different. My Dh's employer self insures, so they set the rules rather than the insurance company.

 

We hit the out of pocket max last yr in May after IVIG. We paid no other costs for health care accepting our insurance for the rest of the year. We hit our deductible this yr in April but haven't gotten to the out of pocket max yet.

 

We set up a Health Savings Account. Dh's employer put $500 in it last yr. This yr it will be $750 and we contributed quite a bit to it. Its pretax and rolls over if you don't use it all in the plan yr. You can use it for any medical cost, including glasses, braces, dental, etc...

 

This policy actually has lower monthly costs than choosing the HMO offered by his employer.

 

The most critical part is reading as much of the info and fine print as you can. We had no idea IVIG would be covered. We did it, paid up front and were reimbursed.

[MomWithOCDSon]

When I changed jobs about a year ago, I came to a company that offered me a number of options: an HMO or a PPO with three levels of coverage, two of which were "high deductible" plans for which, once you met the deductible, all your costs are essentially fully covered, and there are no copays for preventative care visits even before the deductible is met.

 

I created a spreadsheet to compare the costs; to my surprise, the plan identified as a "high deductible buy-up" turned out to be the most financially advantageous as, with prescription costs alone, we would meet the deductible within the first six months of the year, and then everything after that became "freebie." Now, of course, that presupposes that the insurance coverage network is pretty wide and includes your key providers, which ours thankfully does.

 

Good luck!

[pr40]

We are also trying to change from an HMO. Our options include POS and EBPA. I don't quite understand the difference btw the two. Does anyone have experience with these?

What I think I get is that EBPA has the annual maximum which is under $6000, but then I am not sure if we can go to any dr and if they cover 100% of the cost drs charge us or 100% of the customary and expected price?

[mompaisley]

I made up a chart on Excel, comparing plans and guess-timating our doctors visits, procedures and meds. It's still a gamble, but you might get a better sense comparing the plans in an actual possible scenario.

[airial95]

At open enrollment time each year, we also use a spreadsheet to evaluate options. We compare the options at my company as well as compare them to what is offered by my husbands

 

We use the previous year's medical costs as the estimate for the following year - we're almost 3 years into our PANDAS journey, so it's proven to be fairly reliable.