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Kaiser HMO plans in CoveredCA
Old 01-02-2016, 08:31 PM   #1
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Kaiser HMO plans in CoveredCA

I enrolled in an Anthem Blue Cross plan which had the lowest premiums.

But now I'm having misgivings. Their in network is limited. So while $4500 deducible and $6500 out of pocket max sound good, these are for in-network providers only.

The out of network amounts are double.

So for instance, for urgent care, I have to go to a clinic 7 miles away through cross-town traffic and they have limited hours, 7 AM to 5 PM, M-F. Only one MD on staff.

I'm not sure what happens in an emergency. I call 911 (or someone does) and I get taken probably to one of the big hospitals and they're not in network as far as I can tell.

Then I had problems sorting through their in-network doctors, trying to get an idea of whom to choose. Of course back in the day, I just went to whichever doctor they appointed me at one of the large clinics around here. I was for instance handed over after doctor retirements. Now I've Googled some of the doctors and not sure that's a useful exercise, though I'm wary of that a lot of doctors went to medical school overseas, at some institution most people here never heard of. I thought the AMA limited credentialing doctors trained overseas.

The Kaiser Bronze HMO plans are about $50 more a month, one an HSA plan. When you go through the CoveredCA search and line up plans side by side, the terminology is perplexing.

For instance the Anthem plan has an Individual deductible while Kaiser HMO (non HSA) is "Not Applicable." But then further below there is a Medical Deducible and Brand Drug deductible of $6000 and $500 respectively. The Anthem is Not Applicable for these categories.

Interestingly, the Out of Pocket Max for these two categories are Not Applicable for Kaiser.

Primary Care, Specialist visits are 40% Coinsurance after deductible for Anthem and "$70 Copay before deductible." OK what happens after the deductible is met for Kaiser, would it be free?

The drug benefit might be good if you have a lot of prescriptions, 100% after deductible which would presumably be $500 for the drug deductible. For Anthem, it's 40% but there is no separate drug deductible so it would be part of the $4500 or $9000 deductible bucket.

Emergency Care is 40% vs. 100% and Urgent Care is 40% vs. $70 Copay before deductible.

The other thing is there's a relatively new Kaiser facility just 2-3 miles from me. But I had Kaiser coverage growing up and remember ridiculously long waiting times. I usually went in for urgent or emergency care reasons so I suspect that would still be the case, because their clinics are probably packed all the time.

My folks chose Kaiser for Medicare Advantage and they report good experiences with getting appointments and so forth.

But I guess one's experience with Kaiser may depend on the facility and the doctors at a particular facility.

Price-wise, for $600 more a year in premiums, the potential for lower out of pocket costs seems to be there.
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Old 01-02-2016, 09:04 PM   #2
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I have Bronze HSA HMO with Kaiser in southern CA.

Kaiser is closed network - so unless it's an emergency - you go to a Kaiser facility and see a Kaiser employee. In the case of an emergency - you go to the closest ER. If you are out of the Kaiser area - you call the 1-800 number and they'll tell you what facility they have arrangements with. Unless it's an emergency - in which case you go to the closest ER. I've done this in Palm Springs (sent to a specific urgent clinic), Santa Barbara (sent to Cottage Hospital), and Las Vegas (sent to Sunrise (?) hospital).

For the HDHP - you pay the copay at the front desk when you have an appt. (For my plan it's $55). They will bill you for the balance. It's a higher figure for the ER. They look at your out of pocket & deductible and, if not met yet, will bill you for the negotiated rate. You *DO* get the advantage of member rates...

Once the deductible is met - in theory you still pay the copay ($55), until the max OOP is met.

Even with our incredibly bad luck with sports injuries this year we benefited from the member/negotiated rates and barely met the deductible.
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Old 01-02-2016, 09:30 PM   #3
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OK that sounds different than the ones offered up here.

The Kaiser Bronze HMO has $70 copays for the first 3 visits. After that it's not spelled out but presumably you pay a higher bill until your deductible is met.

So if you're paying $55 a visit and theres no limit on the number of visits at that rate until you meet the deductible, that may be good for heavy use. But the Bronze plans in general are only suppose to insure 60% of the costs up to the out of pocket max?

Kaiser also has an HMO HSA plan and there, the benefits do look more like the Anthem plan, 40% after meeting the deductible.

I'd hate to go to an ER room because of the wait time but if you're transported because 911 was called, I guess that would be the closest hospital.

Hmm an 800 number for non Kaiser in network facilities?
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Old 01-02-2016, 10:54 PM   #4
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You have to go 7 miles to an urgent care facility? There are millions of people who have to drive a heck of a lot farther than that to get any medical care of any kind. 7 miles isnt very far.
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Old 01-02-2016, 11:05 PM   #5
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Well there are hospitals less than half the distance.
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Old 01-02-2016, 11:22 PM   #6
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Quote:
Originally Posted by rodi View Post
I have Bronze HSA HMO with Kaiser in southern CA.

Kaiser is closed network - so unless it's an emergency - you go to a Kaiser facility and see a Kaiser employee. In the case of an emergency - you go to the closest ER. If you are out of the Kaiser area - you call the 1-800 number and they'll tell you what facility they have arrangements with. Unless it's an emergency - in which case you go to the closest ER. I've done this in Palm Springs (sent to a specific urgent clinic), Santa Barbara (sent to Cottage Hospital), and Las Vegas (sent to Sunrise (?) hospital).

For the HDHP - you pay the copay at the front desk when you have an appt. (For my plan it's $55). They will bill you for the balance. It's a higher figure for the ER. They look at your out of pocket & deductible and, if not met yet, will bill you for the negotiated rate. You *DO* get the advantage of member rates...

Once the deductible is met - in theory you still pay the copay ($55), until the max OOP is met.

Even with our incredibly bad luck with sports injuries this year we benefited from the member/negotiated rates and barely met the deductible.

We have this same plan with Kaiser, also in SoCal, new for 2015.

We'd had Anthem for 2014 and had difficulties finding doctors, both up in NorCal (our long-time doctors would not take it so we paid out of pocket) and after our mid year move back to SoCal, where we also ran into problems finding doctors.

For 2015 we went with Kaiser and have been pleasantly surprised at the whole system. Very timely appointments, well organized.




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Old 01-03-2016, 09:07 AM   #7
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explanade -- I also find this very confusing, and I've had Kaiser coverage for 50 years. ACA has made what was previously a simple system a whole lot more complex.

Here are a couple of links that I found helpful to understand the difference between copay, deductible, coinsurance, HSA and what counts towards which limit.

Our deductible HMO plans
HSA-qualified
Questions and Answers
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Old 01-03-2016, 09:47 AM   #8
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explanade - the plan I described was a HDHP w/ HSA.
They have a few other bronze plans that are closer to what you describe. Please note - the deductible is indeed high - for myself and 2 sons it's 9K - which as of the bill we got yesterday - we've met for 2015. Yikes. Kaiser is the third most popular provider on CoveredCA (as of 2014) and in 2012 (pre-ACA) the largest provider in CA (stats that included employer provided insurance.) But it's definitely a different model - doctors and providers are employees of Kaiser taking ONLY Kaiser insured - rather than the traditional model where there are in-network doctors who "accept" reimbursement rates from several insurers. I've had long discussions with our pediatrician - she prefers working for Kaiser for the work/life balance. She lives in my neighborhood (which is upper middle class) but drives a mercedes. She is given a balance between clinic hours and her area of passion - neo-natal work at the Kaiser hospital. She says the best part is she has absolutely no involvement in billing/payments/etc... she just practices medicine.
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Old 01-03-2016, 01:21 PM   #9
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Yeah I'll have to keep in mind for next year.

I've already paid the Anthem premium for January.

Still have time to possibly change it but I'm traveling this month and most of next.

Fortunately I haven't needed much medical services, though I failed to take advantage of the preventive care benefit in 2015 -- just never got around to it.
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