Insurance questions for the gurus of the board please
I would recommend doing a 1 year cost analysis. Try to estimate your medical costs for the next 12 months...you can include a gallbladder surgery, the special needs visits/surgeries, your labs,possible mris/scans for the pain, physical therapy for the pain, plus a little wiggle room.
After that, cut and dry--which one is going to cost more over 12 months? The HMO is going to run you about $10k. Does that include labs, hospital visits, radiology, physical therapy?
You can factor in the headache factor, too. You're gonna need referrals to all these specialists from your pcp...and if your pcp sucks balls, you are gonna be out even more $$ for the anger management you're gonna need.
I've had to see a gynecologist, a urogynecologist, a gastroenterologist, a physical therapist, an endocrinologist, a reproductive endocrinologist, my WL surgeon, and a colo-rectal surgeon this year. That's 8 specialists. I think I might have shot myself in the face by now if I didn't have a PPO. But then again, I have 100% coverage after my deductible, so I might be singing another tune if I only had 80% vs having the headache of a referral but having 100% cvg.
Aaaand if you choose the wrong plan, I guess try to find comfort in the fact that you can change it in a year or less.
Good luck and congrats.
And as someone that works in a doctor's office, thanks for knowing what 80% cvg entails. Most people think they pay their copay and that's it. Drives me nuts.
After that, cut and dry--which one is going to cost more over 12 months? The HMO is going to run you about $10k. Does that include labs, hospital visits, radiology, physical therapy?
You can factor in the headache factor, too. You're gonna need referrals to all these specialists from your pcp...and if your pcp sucks balls, you are gonna be out even more $$ for the anger management you're gonna need.
I've had to see a gynecologist, a urogynecologist, a gastroenterologist, a physical therapist, an endocrinologist, a reproductive endocrinologist, my WL surgeon, and a colo-rectal surgeon this year. That's 8 specialists. I think I might have shot myself in the face by now if I didn't have a PPO. But then again, I have 100% coverage after my deductible, so I might be singing another tune if I only had 80% vs having the headache of a referral but having 100% cvg.
Aaaand if you choose the wrong plan, I guess try to find comfort in the fact that you can change it in a year or less.
Good luck and congrats.
And as someone that works in a doctor's office, thanks for knowing what 80% cvg entails. Most people think they pay their copay and that's it. Drives me nuts.
5'9.5" | HW: 368 | SW: 353 | CW: 155 +/- 5 lbs | Angel to 
Check the rules on the Aetna ones, if you go out of network, even with their PPO and especially with their HMO products, you pay 100%.
BTW, you weren't in the Obama insurance before. Texas has always had a High Risk Insurance Pool for peope without insurance. It is managed by BCBS and the other commercial plans pay BCBS for managing it so it is completely self funded. Texas has the version that the Obama risk pool plans for other states are modeling after.
Your best bet, without looking at the plans, which I would do for you if you would like, would be to stick with the one that currently covers your fiance's disabled chiled. You can get a plan too to make sure that 100% is then covered, but don't drop a plan that currently covers him. The reason I say that is because the lifetime max has not yet taken affect and won't for a couple of years. You would not want to burn up a lifetime max on some expensive surgeries on your plans now and him not be covered later.
One question if you don't mind my being nosy. If the child is disabled have they checked to see if he can get SSI coverage? That would pay for all the surgeries. If your fiance makes too much to qualify by income (and that could very well be the case), Texas has an optional program that would still provide secondary medicaid coverage so you would have no out of pocket. This program is realtively new, started in the last year or two by the Texas legislature. It offers medicaid secondary coverage to his insurance so he is not faced with dedicutibles, copayments or out of pocket expenses, the State picks that up.
If you would like info on that I have some in my office I can send you or you can look online for Texas Medicaid Opt-In plan. Since his insurance is bare bones, high costs they could very well qualify but I can't guarantee that. I am just giving you some information that might be useful.
BTW, you weren't in the Obama insurance before. Texas has always had a High Risk Insurance Pool for peope without insurance. It is managed by BCBS and the other commercial plans pay BCBS for managing it so it is completely self funded. Texas has the version that the Obama risk pool plans for other states are modeling after.
Your best bet, without looking at the plans, which I would do for you if you would like, would be to stick with the one that currently covers your fiance's disabled chiled. You can get a plan too to make sure that 100% is then covered, but don't drop a plan that currently covers him. The reason I say that is because the lifetime max has not yet taken affect and won't for a couple of years. You would not want to burn up a lifetime max on some expensive surgeries on your plans now and him not be covered later.
One question if you don't mind my being nosy. If the child is disabled have they checked to see if he can get SSI coverage? That would pay for all the surgeries. If your fiance makes too much to qualify by income (and that could very well be the case), Texas has an optional program that would still provide secondary medicaid coverage so you would have no out of pocket. This program is realtively new, started in the last year or two by the Texas legislature. It offers medicaid secondary coverage to his insurance so he is not faced with dedicutibles, copayments or out of pocket expenses, the State picks that up.
If you would like info on that I have some in my office I can send you or you can look online for Texas Medicaid Opt-In plan. Since his insurance is bare bones, high costs they could very well qualify but I can't guarantee that. I am just giving you some information that might be useful.
Ms. Cal Culator
on 5/8/11 1:55 am - Tuvalu
on 5/8/11 1:55 am - Tuvalu
On May 8, 2011 at 6:48 AM Pacific Time, Tina.D wrote:
Check the rules on the Aetna ones, if you go out of network, even with their PPO and especially with their HMO products, you pay 100%. BTW, you weren't in the Obama insurance before. Texas has always had a High Risk Insurance Pool for peope without insurance. It is managed by BCBS and the other commercial plans pay BCBS for managing it so it is completely self funded. Texas has the version that the Obama risk pool plans for other states are modeling after.
Your best bet, without looking at the plans, which I would do for you if you would like, would be to stick with the one that currently covers your fiance's disabled chiled. You can get a plan too to make sure that 100% is then covered, but don't drop a plan that currently covers him. The reason I say that is because the lifetime max has not yet taken affect and won't for a couple of years. You would not want to burn up a lifetime max on some expensive surgeries on your plans now and him not be covered later.
One question if you don't mind my being nosy. If the child is disabled have they checked to see if he can get SSI coverage? That would pay for all the surgeries. If your fiance makes too much to qualify by income (and that could very well be the case), Texas has an optional program that would still provide secondary medicaid coverage so you would have no out of pocket. This program is realtively new, started in the last year or two by the Texas legislature. It offers medicaid secondary coverage to his insurance so he is not faced with dedicutibles, copayments or out of pocket expenses, the State picks that up.
If you would like info on that I have some in my office I can send you or you can look online for Texas Medicaid Opt-In plan. Since his insurance is bare bones, high costs they could very well qualify but I can't guarantee that. I am just giving you some information that might be useful.
Okay...this post right here? On THIS stuff you obviously know a LOT. (Maybe because you have a lot of experience dealing with insurance? I don't know.) I'm just saying that I never go into "challenge mode" when the poster is obviously well-informed on the topic at hand.
Thanks for sharing.
(deactivated member)
on 5/8/11 10:55 pm
on 5/8/11 10:55 pm
Keep in mind many HMOs no longer require the referral for specialists, making them far less annoying IMO.
That being said - the only way I would go with an HMO is by checking out the in network situation. You are tied to the network - so if it's not robust - you could find yourself and your soon to be stepson in trouble.
Labs, etc should be no big deal in either scenario, other than the deductible for the PPO.
Good luck.
That being said - the only way I would go with an HMO is by checking out the in network situation. You are tied to the network - so if it's not robust - you could find yourself and your soon to be stepson in trouble.
Labs, etc should be no big deal in either scenario, other than the deductible for the PPO.
Good luck.
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