Open Enrollment Questions

21

Well, Kaiser invented the HMO but yea, it’s more common for Kaiser though some other HMOs have big complexes.

My current PPO is run by a hospital and has a medical center next door and I now get everything done in the same building again. Rhemy, PC, labs, and even when I broke my wrist the surgeon’s office was in that building and surgery in hospital was next door. :joy:

1 Like
22

Well that was a given. At least in terms of health care. And some other stuff. There are worse places, but we should do better.

2 Likes
23

Yea, if he loses coverage it triggers a special enrollment period. The only thing to consider is the difference in cost of premiums vs hitting a new deductible/out of pocket max.

24

Paging @nickybecky1 for Kaiser + pregnancy/baby experience!

2 Likes
25

Thanks to @Clare-Dragonfly for the Bat signal! I have had experience being pregnant with Kaiser, having Kaiser for years, and then also leaving Kaiser. This will probably be long but I hope it will be helpful.

I live in a region that is not CA and we have a decent Kaiser network but nothing like we would have in CA. Things I loved about Kaiser:

  • Everything is in one place and you never have to worry about what will be in network. Here Kaiser actually does contact with a hospital rather than running their own, but still they manage the costs the same. Pretty much everything is billed, insured, and everything through their website, which I LOVE. Labs are available right away, providers talk to each other, in general, I found it really super awesome
  • I needed perinatal mental health support when our kid was little and they had no specialists. They did not bat an eye at referring me out and then paying like it was in-network
  • I spent very little time navigating medical care stuff
  • We had a medical emergency and had to go to the children’s hospital near us. There was a Kaiser floor and while we were in a specialist ward, the Kaiser hospitalist (attending on the floor basically) visited us and reassured us that while the hospital and doctors treating us were not Kaiser, they were all in-network and nothing to worry about.
  • Well integrated OB/nurse midwife care meant that we could get all our care from midwives and get an OB involved only if needed (In our case, not needed). We got amazing incredible care from our midwives. Our midwife group was all awesome. There were about 6 of them. I mostly saw a couple and then was signed up to meet the others later. I ended up giving birth 3 weeks early with a midwife I’d only met at a “meet the midwife” social event but it was totally fine.
  • They also referred out to a pediatric specialist but they did make us see their specialist first and then request a 2nd opinion which was kind of a pain, especially because the KP specialist felt we probably didn’t need surgery so we put off getting the second opinion and then the pediatric specialist agreed with the initial referring doctor that surgery was needed, and by the time we got the surgery, it was obvious to us too that there was a big issue.

However, remember how I mentioned we’re not in CA? The neighborhood I live in has a Kaiser clinic with no pediatricians. We were fine with a family doctor, so no big deal. BUT that family doctor, and one of his colleagues and the lab tech and the consulting nurse each made an error that together added up to that emergency stay in the children’s hospital and my newborn nearly losing his life. This was not a Kaiser problem, it was a problem with that specific clinic, but there were no other options near us to get care other than this tiny clinic, so we changed. One of the biggest problems with the clinic was that they did not do the lab work in house and we were never told that and then they failed to order a test stat to have it sent over.

I was heartbroken to change actually and I’m still annoyed with having a site for my insurance, a site for my doctor’s medical advice, and a separate site for billing for each care provider. But being able to choose a doctor in our neighborhood was worth it and now that I’ve built up care providers all in my neighborhood, I won’t go back in this region. There were slightly more limited options for lactation support that required a bit more travel, and the midwives were at the larger regional hospital that was 20 minutes away vs 5, but that didn’t bother me at all.

If you live near enough to a large Kaiser hospital that it seems convenient, I’d do that in a heartbeat. If it’s not convenient, you might be annoyed by all the visits to the midwife/OB and eventually pediatrician. Our kiddo had some unforeseen medical issues that caused us to have a LOT of visits to the doctor, so it was really frustrating. It took us 6 months after the medical errors happened to finally decide to change insurance because we really wanted to make it work with Kaiser. If we moved to an area like CA with a strong Kaiser presence, I’d seriously consider going back into the system.

For what it’s worth, I also had a CDHP through Kaiser during my pregnancy and because my premiums were so low and my employer kicked in to the HSA, it made sense to keep it even though I went through open enrollment at the end of the 1st tri. We ended up having something of a worst case scenario with the NICU billing $93,000 for our stay but we hit our out of pocket max and it was still cost effective. But if the HMO is your cheapest option then that would make sense, it just wasn’t for us.

3 Likes
26

Hey, thanks so much for sharing! Extra hearts for you: :two_hearts::two_hearts::two_hearts::two_hearts::two_hearts: And for @Clare-Dragonfly for referral! :two_hearts::two_hearts::two_hearts:

I’m sorry to hear the medical staff’s error put your child at risk and put you through that stressful experience. Sounds like you are all doing ok now?

2 Likes
27

Thanks! We are doing okay. It could have been much worse but all is well. Or at least as well as anyone is in 2020?

I hope your decision goes well. It’s an exciting thing to be thinking about.

4 Likes
28

I also wanted to add, if you have more specific questions or an idea of something you’re worried about, I’d be happy to chat those things out. Kaiser aside I love helping people choose the right health insurance. (I know, it’s weird! And I’d rather we just could all use health care and didn’t have to do this weird dance but until that’s true I like helping people get good care!!)

4 Likes
29

Thanks! I think what I most needed was stories of good experiences to outweigh the one story I read that one time, wherein a lady didn’t get diagnosed because all the docs in her network were sending tests to the same crummy lab that was slacking. :frowning_face:

But I think I have gotten that here! And I’ve been thinking about how the HMO model seems to have features I liked about the good campus clinic I had access to, and used extensively, and found very convenient.

3 Likes
30

A conversation in another thread (I think in the parenting section) about birthing centers reminded me another con about Kaiser for pregnancy: the free labor and delivery, childcare, and breastfeeding classes were completely useless. They consisted of a PowerPoint presentation given in a big room, and really didn’t cover anything you wouldn’t have found on YouTube.

Also, they do have lactation consultants available after you go home, but when I tried to schedule an appointment, the nearest one was 2 weeks out, and I had to go all the way to the hospital to see her. In hindsight I wish I had just shelled out some money for a private one that would come to our house.

All in all, I was happy with the level of care, but did want to warn you accordingly

3 Likes
31

Thanks! That is very good to know!

1 Like
32

I went with Kaiser. Found the “Evidence of Coverage” forms well hidden in corporate site and apparently Kaiser covers more fertility treatment than other options (not IVF/ART, but diagnosis, prescriptions, etc) so that kind of cinched it. I’ve also heard a lot of good things here and offline, it’s cheaper, it seems straightforward administratively, and we have no particular attachments to any doctors/specialists. So. We will see how that is! Thanks everyone for weighing in!

Nothing too exciting in my other elections (dental, vision, life, accident), but my comapny started offering legal insurance (pays lawyer fees) and is promising pet insurance this year, which haven’t heard of businesses doing? I don’t think the pet insurance sounded well priced compared to the market, though…

3 Likes
33

My company has offered pet insurance for a few years but I’ve never tried it. I haven’t compared it to other pet insurance on the market but it just didn’t sound very useful.

1 Like
34

Pet insurance has gone through a lot of changes in the past decade. I shopped for it this past year, and I was surprised at the huge differences in coverage and price across insurance companies. So I wouldn’t be surprised if your employer chose something that is a worse offer than what you can get on the market yourself.

2 Likes
35

Does it also trigger the special enrollment period for her, though? They both work at the same place and not clear whether they each have individual coverage or are on a family plan and if so, under whom.

36

At my work at least, my spouse losing his coverage triggers an enrollment period where I can add him to my plan. If he becomes eligible for coverage, I can use that to drop him if I like.

We also have companies with different open enrollment cycles so that’s also a special enrollment period (if his open enrollment makes us want to make changes to mine or vice/versa)

37

Here’s my question: Why does anyone in the US think this is a functional system?

My husband’s open enrollment ends today. Mine starts in 2 weeks. My company just released information, so we are spending the day comparing premiums and coverage for 5 different plans, and every combination of just adult, adult+kids, and family that we can think of.

We have to look up if our doctors are in each of these 5 plans.

We have to weigh premiums vs. coverage, which vary widely among the plans.
We have to guess if I’ll need physical therapy, if I might be going to the neurosurgeon, how many therapy visits I need.

Why? That’s my question.
Why can we not have a single-payer healthcare system like developed countries do?

9 Likes
38

Because choices!

1 Like
39

Because they work in the insurance industry and make $$$.

I’m with ya. It’s a clusterf-ck.

3 Likes
40

No one does, I think?

3 Likes