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Health Insurance


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  • Health Insurance

    [Health Insurance]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 04-27-02 13:13

    Dear members and visitors,

    In addition to my work with the HCMA, I have been a human resource manager for 16 years. In my work in human resources have dealt with thousands of different health insurance options, plans, schemes and various state and federal programs. I am sending out this posting with some words of wisdom regarding choosing health insurance plans.

    While in most employment situations HMO's (health care maintenance organizations) appeared to be the most cost efficient programs requiring the least amount of paperwork, they are not. In an HMO you are required to get referrals to every specialist visit. This means in many cases he would have to go to a general physician in order to get approval to go to a cardiologist. This causes delays in treatment, frustration, and unnecessary paperwork. HMOs are extremely difficult to negotiate with if there is in need to go to a specialty center or to a specialist. It is simply a numbers game to most of these companies they fail to look at complex diagnoses and this creates extreme difficulties to the patient. The end cost of HMO tends to be much higher then PPO's or POS plans because so many things are denied, therefore it comes out of your pocket.

    PPO's (preferred provider organizations) allow you access directly to specialists without the need of a referral. These programs have in most cases easier access to specialty centers or specialists and require far less paperwork. PPOs normally cost a little more than an HMO, in my experience the cost differences is well worth it. When you're in a PPO and you stay within the network there's no out-of-pocket expenses other than a copayment per visit. Also in my experience, PPOs are far easier to negotiate with an HMO's.

    POS (point of service) programs depending upon your state of residents these plans mean different things. Some POS plans allow you to choose any provider again within the network, some require referrals others do not. Those plans requiring referrals really see more like HMOs, does not requiring referrals work more like PPOs. Costs on POS's very depending upon structure.

    Then of course we have your traditional indemnity plan. Indemnity plans are what we all had 15 -20 years ago. This is the plan or you had out-of-pocket deductible of $500 per person ( for example) and it was 80/20 split, the plan paid 80 percent you paid 20 percent of the balance of the bill. These plans are still available and in most cases there are no networks and therefore allow you to go to whatever doctor you choose to.

    Overall what we need to remember is that insurance is not a right, it is in fact a privilege. When you choose a health-care plan you must do so as a true consumer of health-care. You must think of what your needs are going to be best and worst-case scenarios. If you choose a health-care plan that is inexpensive in all likelihood you're going to find gaps in coverage. These gaps come out of your pocket. So think long and hard about choices.

    While you're making these choices I ask you to remember one other items, physician availability. In the past one to two years many physicians have dropped out of networks and HMO's and PPOs because of fee negotiations. I am in a very interesting position where I can see the negotiation factor for both the perspective of the patient and the physician. The physicians have been asked to take lower payment for almost every procedure they perform meanwhile malpractice insurance rates are skyrocketing and patients are demanding the highest quality of health-care ever known in United States of America. While technology and advances in medicine are wonderful things you must ask yourself, who is paying for this?

    I leave you with this thought when you make your choice for your health insurance plans, are you making the best decision for your future?

    This posting does not require response back to me.

    Best wishes,

    Lisa Salberg




    [Re: Health Insurance]

    Author: Sarah Beckley (---.dialup.mindspring.com)

    Date: 04-27-02 23:06

    Dear All,

    I want to second Lisa's motion and also point out that in 1997, the Wall Street Journal published a story about a study done on cardiac patients (mostly CHF, MI, etc.) mortality in HMOs vs. PPOs. All things being equal, cardiac patients in the HMOs had a higher mortality rate than those in PPOs. I will try and find the original story for anyone who wants.

    Also, my personal experience of being in the hospital while in an HMO vs. in a PPO were NIGHT AND DAY. HMO: nightmare!!! PPO: not too bad (I was in the hospital, after all!). The main problem was that there was only 1 doctor there who was in my HMO (from the entire electrophysiology department of 6 or 7), so he had to sign all my orders. However, I NEVER met the man. Ever. Never saw him. And every single order he wrote was wrong and some of them could have killed me. I ended up staying an extra 4 days b/c of his f'ups. Even the prescriptions he had written for me at the end were wrong (doses that didn't exist, etc.).

    Another important thing to take advantage of are medical spending accounts. You can set aside some money from your pay check pre-taxes (they'll deduct it from your check) that you can use to pay for your out-of-pocket expenses. Almost every plan has an out-of-pocket cap --say $2,000. So if you are hospitalized, even if your share is supposed to be $5K or 10K according to the straight math, you never pay more than 2K in one year. The stinky part of MSAs is that you have to spend it all in one calendar year (at least the one's I've seen). Or you don't get the money back. So if you KNOW you are going to spend 500 or a 1000 or whatever, you save money by using an MSA. Just make sure to use it.

    Take care



    [Re: Health Insurance]

    Author: Matthew Jesaitis (---.disney.com)

    Date: 05-03-02 14:23


    I thought that since the general perception of HMOs is not such a good one, I'd give some positive opinions from my own experiences. Like many others, I chose an HMO plan for cost reasons. I use CIGNA HMO. Maybe it's because I live in a city with great hospitals and physicians, Orlando, FL, that I have such good coverage. I have never been turned down for any test/procedure requested.

    The only "problem" I ever had with my HMO was in the beginning, when like you stated, I had to make an appointment with my primary care physician in order to get a referral for my cardiologist. I was in a bad state of CHF. When I finally saw my primary physician I was immediately admitted to the hospital. At that time, my physician talked with CIGNA and they decided that from that moment on, if I had any problems I could go directly to my cardiologist. Problem solved.

    Another benefit was a "Well Aware" program that CIGNA has in which they provided me with a scale and BP monitor at home for 6 months so that I could check my weight and BP on a daily basis. The readings were automatically sent to them via phone line. A nurse at CIGNA would call me if I missed a couple days or if the readings were not so hot to ensure I was OK. They would also call my doctor if the readings were bad. This program got me into the habit of checking every day.

    Another reason this HMO may be so good is because of my employer, a small company called Disney where benefits are pretty excellent. Although I sometimes worry about my future health, I don't have any fears about my HMO. I hope it was OK for me to name them, but I assumed it would be OK since it is positive feedback.

    Best wishes to all. Matt Jesaitis
    NOTE: This is a post from the previous forum message board.