What Kind Of Health Coverage Do You Have? PPO? HMO? Medicare?

[TomCADem]

There is a lot of talk about health coverage, health insurance, cadillac plans, etc. However, what kind of coverage do DUers have, if any? Also, at most places I've worked, I've had a choice of several types of plans with the main choice being between an HMO (typically cheaper) and a PPO (typically more expensive). What I wonder is what are the experiences of other DUers? What kind of coverage do we all have, and did we have a choice, or was it on a take it or leave it basis?

Here is a guide to the acronyms:

HMO - If you are enrolled in a health maintenance organization (HMO) you will need to receive most or all of your health care from a network provider. HMOs require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care.

Your PCP will serve as your personal doctor to provide all of your basic healthcare services. PCPs include internal medicine physicians, family physicians, and in some HMOs, gynecologists who provide basic healthcare for women. For your children, you can select a pediatrician or a family physician to be their PCP.

If you need care from a physician specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with a referral. If you do not have a referral or you choose to go to a doctor outside of your HMO's network, you will most likely have to pay all or most of the cost for that care

PPO - Like an HMO, a preferred provider organization (PPO) is a managed healthcare system. However, there are several important differences between HMOs and PPOs.

A PPO is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a PCP and you do not need referrals to see other providers in the network.

If you receive your care from a doctor in the preferred network you will only be responsible for your annual deductable (a feature of some PPOs) and a copayment for your visit. If you get health services from a doctor or hospital that is not in the preferred network (known as going "out-of-network") you will pay a higher amount. And, you will need to pay the doctor directly and file a claim with the PPO to get reimbursed.

POS - A Point of Service (POS) plan is a type of managed healthcare system that combines characteristics of the HMO and the PPO. Like an HMO, you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside the network for healthcare, POS coverage functions more like a PPO. You will likely be subject to a deductible (around $300 for an individual or $600 for a family), and your co-payment will be a substantial percentage of the physician's charges (usually 30-40%).

Edited to add Medicare.

Second edit to add Medicaid and VA

[PacerLJ35]

1. I'm military...so I have Tricare

It's actually pretty decent if you can deal with the red tape.

[SmileyRose]

2. kaiser

I can't say enough good things about my experiences with them.

[TomCADem]

5. I know Folks Who Swear By Kaiser, But I Heard Horror Stories About HMOs...

But in California, I do see large Kaiser complexes all around. It is one of the cheaper options offered by most employers I've had, so perhaps I should check them out again.

[SmileyRose]

13. I have it in Metro Atlanta

I am given informed choices. I am diabetic. Kaiser will pay for a 5mg glypizide pill I can cut in half because most people they treat need 5mg. I need 2.5 and they can't get it as cheaply. So - I can cut my pills in half or I can pay a little more for my meds for the convenience.

I can take free or low cost nutrition classes in the same building I see the doctor. I get discounts on those fancy athletic insoles that make it easier to get my 10,000 steps a day in. I can stop by without an appointment and ask someone to check my blood pressure, or calibrate my blood sugar monitor. I can call my health coach, an RN at an 800 number for advice of any kind 24/7.

I don't get every damn thing I want. Instead I am given the tools to keep my own butt out of the emergency room and in the primary care doctor's office as little as possible.

Now, having said all that, we've had a couple of mis-steps with my husband. I'm not slamming him, not at all, but he's a rather simple fellow. I normally take him to doctor appointment but was unable to do so this one time, and he had one heck of what I thought was a cold. An after hours care nurse did not send him home with all the right things and did not put clearly in writing what he was supposed to do. With his cognitive and communication challenges, he did all the wrong things and was not able to tell me what he did, nor what he was supposed to do. I had to take him to the ER that night and he spent the next 9 months fighting for life. Mind you, it was Kaiser doctors who saved him and they did an incredible job. The only mis-step was that one nurse, on that one day, who was in a different office that she usually is, and mishandled my husband's case. It was a human error and not a systemic one. Nearly cost my husband his life. For those who are not well able to take a front seat regarding medical care, even a great HMO like Kaiser may present a problem.

[murphyj87]

3. I'm Canadian..

so I have single payer, and far better health care than what most Americans have(after working in the US for seven years and actually using US health care).

[TomCADem]

10. John McCain and Mitch McConnell - "America is the best in the world."

Here is an early story in Slate discussing why it is so hard to gather the votes needed for health care reform when you have folks spouting BS like this:

http://www.slate.com/id/2226793/

"Nothing makes me more angry," said Sen. Mitch McConnell at a health care town hall in Kansas City today, "… than the suggestion that America does not already have the finest health care in the world." Sen. John McCain, appearing alongside him, agreed: "The quality of health care in America is the best in the world." Contrast that with what health care journalist T.R. Reid writes in his new book comparing various global health care systems: "Today, any U.S. politician who dared to make that claim … would be hooted out of the room." Reid clearly has yet to visit Kansas City.

[murphyj87]

19. Where do the GOP get health care?

http://www.huffingtonpost.com/2009/09/02/gopers-decrying-socialize_n_275196.html

[lazarus]

4. Aetna PPO

It's better than the HMO offerings at my wife's work. We're just waiting for Tricare in a few years.

[Lydia Leftcoast]

6. What about us self-employed people?

I used to have Kaiser in Oregon, which I liked pretty well, but they don't operate in Minnesota, where self-employed people can choose between Tweedledum and Tweedledee and Tweedledoo, i.e. three allegedly non-profit companies that all charge the nearly the same for the same products. For all of them, you have to have a high deductible unless you're pretty affluent, or else the premiums will be unaffordable. They all tout health savings accounts, but these charge MORE than the regular policies AND require you to put about $200 a month aside as well.

[dugaresa]

7. I have an HRA combined with an HMO which is a high deductible plan

and that was the "best choice". I am not looking forward to this year's health care nightmare.

[CaliforniaPeggy]

8. I finally got old enough for Medicare!

[1]

9. i got the NO.

i got NO health coverage.

perhaps you should include that option in your poll...

[dflprincess]

11. I have a POS plan - but not in the sense you meant here

Actually the cutsey name that give it is "Consumer Driven"

High deductible and annual out of pocket. Deductible, including prescriptions is $1,200 with a max out of pocket of $3,700 for covered expenses. It has some elements of a PPO, but it also uses a "health savings account". Some preventative tests are covered even when the deductible has not been met.

In theory it's a plan that's suppose to make a person think twice before they run to a doctor for any little reason. In reality it's a plan that does its best to discourage anyone from seeing a doctor until symptoms can't be ignored. There is evidence that, in the long run, plans like this cost everyone more money because the "insured" wait to see care until a condition is more serious. But, like many American business, my employer can't plan past the end of the next quarter so they're happy to save a few bucks in the short term.... The irony being, I work for a "wellness company".

[sandnsea]

12. Subsidized Insurance PPO.

So I didn't choose. And what about Medicaid and VA?

[TomCADem]

14. Added Medicaid and VA

Way too many acronyms.

[Mojambo]

15. No coverage.

Coming up on the ten year mark with no medical/dental.

I fully expect parts to start falling off any day now.

[frazzled]

16. We switched from the PPO to the HMO (Cigna)

We were paying higher premiums for the PPO, which in the beginning we gladly elected to do (we'd had bad experiences with an HMO plan in Massachusetts). But the deductibles started to go up, too. And my husband's doctor started ordering all these crazy-ass tests for him. He said an EKG showed he had a slightly enlarged left heart chamber and that there could be pulmonary hypertension. We were freaked, of course. He sent him first to check that there were no blood clots in his legs. This sounded reasonable. (Though I kept questioning why he wasn't sending my husband to the fucking cardiologist). That test showed him clean as a whistle. So then he started bugging him to do a sleep apnea test. We started getting suspicious. He was calling my husband at home to do it. Okay, finally he went to spend the night doing it: and the staff just stood there and laughed at him. Apparently, one look at my reed-thin husband was enough to tell them this wasn't really the right test for him. Then the doctor started to bug him about getting an MRI. We were bored with the whole thing by this point.

Okay, so as you can guess, these first two tests ate up our entire year's deductible. It was the end of the year, and this was the only medical services we'd had (besides the original physical that detected the heart problem). And we thought, you know what? This isn't a great financial deal for us. Let's try the HMO instead. It had lower premiums, no deductibles, and 100% of services paid in network. And lo and behold, this same doctor was in the network.

Next time my husband had a follow-up EKG, and guess what ... that left ventricle didn't appear to be enlarged anymore. No more tests. Was this related to the fact that he was now insured through the HMO and not the PPO? It's hard not to think so.

We haven't had any problems with the HMO version of the insurance yet. And we're happy to be paying less.

[cbdo2007]

18. "reed-thin" males can definitely have sleep apnea

I've got it and would definitely fall under the category of "reed thin". Perhaps you are the ones who are misinformed if you thought sleep apnea could be diagnosed just by looking at the patient.

[frazzled]

22. Well, he didn't

And most apnea patients are large:

Individuals with sleep apnea are frequently overweight and have large necks (collar size over 17 inches in males or 16 inches in females). The most common symptom of sleep apnea is heavy snoring that may occur after pauses in the breathing pattern. Typically, the first person who notices this is the bed partner or other individual in the household. Other symptoms of sleep apnea include falling asleep at inappropriate times, such as at work, while driving, sitting in a chair, or watching T.V. (although the latter may be indicative of the wasteland that is on the tube!). You may also notice morning headaches, memory difficulties, low energy, agitation, shortness of breath, or leg swelling. Frequently, individuals with sleep apnea will have high blood pressure that is either exacerbated or precipitated by their sleep apnea.

Now, of all these symptoms, my husband had only one: he snores (what man doesn't? Though I wouldn't call it heavy; just annoying.). He has a 14 1/2 collar size (so small we have had to order shirts from England, because no one sells them here anymore). He has neither morning headaches nor memory difficulties, has enough energy to sustain a 25-mile bike ride every morning before going to work, no shortness of breath or leg swelling. And his blood pressure has always been, and was at the time of the test, extremely low. He wasn't a good candidate. Now, I don't blame the doctor for sending him for the test--pulmonary hypertension can be related in some cases to sleep apnea. But it was a really long shot. And one that didn't even come close to panning out. I think he ordered it because he COULD.

These are the kinds of unnecessary tests that are part of why our health care costs are so high. I'm still trying to figure out why, when I was attending my ailing (and soon to pass away) 94-year-old mother-in-law in the hospital, who was being treated for a serious infection, they ordered up an EKG. I accompanied her for this test. And we were in such a stressful, end-of-life situation, it didn't occur to me to ask why they would want to perform such a test on a woman who had a clear DNR placed on her. If something had been wrong with her heart, nothing would have been done. But Medicaid paid for it. Maybe there was a good reason, I don't know. But I can't imagine what it was. Instead of staying in the hospital with all this mishegas, I wish we had had her back in the nursing home in hospice care.

[cbdo2007]

23. Hey....I believe you. I'm just saying that the people at the sleep study place were

highly irresponsible if they laughed at your husband just because he didn't look like someone who has sleep apnea based on their generalization.

The people at my sleep study told me that the spouse is usually the person who wants their spouse to get tested first because they'll notice, not only snoring but them waking up every few seconds practically choking on their "breath".

[Pithlet]

24. My father is thin and has it too n/t

[Oregone]

17. Recently switched from Idiocracy Care (uninsured plan) to Canada Care

[cbdo2007]

20. I've never understood the appeal of the PPO over the HMO.

The HMO costs much, much less for the same care. Sure you have copayments for each visit rather than a deductible but unless you have a very low deductible of like $500 you're probably never going to reach the deductible. Also, after you have paid the full deductible you still have a copayment for the most part, it's called coinsurance and is probably close to what your copay would have been anyways.

[TZ]

29. Because if you are chronically ill

The PPO is much much easier to deal with. I go to a specialist every month. I don't have to justify going to that specialist to my carrier. And believe it or not, I think in the long run it's been cheaper for me to have a PPO. In other words if you need routine care an HMO is cheaper but for anything chronic..,

[Jamastiene]

21. In my area, it is called "Self Pay."

That is, literally, what they call it. It means you do not have health insurance and have to pay with your own money if you need to see any kind of doctor, dentist, etc.

[grahamhgreen]

25. Kaiser. Atlanta. Non-profit.

[quiller4]

26. My spouse and I buy our own insurance, We are retirees not

old enough for Medicare. Our LifeWise Wise Essentials plan doesn't fit neatly into any of the categories you set forth.

We aren't required to pick a physician in a network. After we meet our deductible, we still pay 15-20%. Our providers bill our insurance and then we get an insurance statement telling us what they have paid our provider and what our share is. Our insurance contracts for substantial discounts and there is a sizable provider write-off on all bills. We aren't required to have a primary care physician and I don't. I see a nurse practitioner, cardiologist and an endocrinologist.

The only time we see a real cost differential for going out of network is when it comes to prescriptions. In network, my total monthly drug cost is $18 for my statin, beta blocker and thyroid medication. Out of network the same drugs would cost me more than $30.

Preventive screenings like mammograms and endoscopies are not subject to deductible though we pay a 15% co-pay. Flu and pneumonia vaccinations are not subject to deductible nor do we have a co-pay.

[TheKentuckian]

27. I've been on hope and pray since an old employer put me on an early version

of the Senate plan and costed me out of useable service so at the time I was lucky to be able to drop it. Since then I had an employer jack around a year til I quit in the face of a 30% cut, I finally got a form the day before I left and was kept temp to hire until the bottom fell out at the next stop so I've been hoping and praying nothing goes wrong for close to three years.

I guess I could say SELF. I did pull a molar from my own head a few weeks back, it was quite pleasent.

[Bitwit1234]

28. I am extremely lucky

I have medicare first. Then I have BC/BS PPO. I have this pick up insurance thru retirement from a state agency. I have prescription also thru my retirement, 5 dollars for a 45 day supply. If I buy the same prescription from WalMart it is 4 dollars. I have Mental Health and Glasses thru BC/BS and dental under the state with a separate policy for 8 dollars a month. BUT I am so damn mad every time I see people talking against a good Health Care Bill. I think of all the people who need treatment and can't get it because they don't have insurance. It is a crime. I argue with my relatives every day, they come up with this BS that it doesn't say in the constitution that people are entitled to health insurance and we shouldn't have it. I ask them then to explain why we have social security, do they want to give that up, THE CONSTITUTION DOESN'T SAY THAT'S A RIGHT. Don't they have Medicare, THE CONSTITUTION DOESN'T SAY THAT'S A RIGHT. Would they like to give that up. Of course, you know they have no answer. All their talking points come straight from the goon loon squad at Fox.

[TomCADem]

30. Most Surprising Result Is Folks Choosing PPO Over Other Options

Conversely, I am surprised at the relatively low number of people who had a coverage type because it was the only type offered by their employers. There go my preconceptions.