Are you happy with your Insurance? Need advice in California

[laura]

Hi all. I am wondering, what insurance do you have and are you satisfied with it? Especially as we PWCs have special needs...I am here in California considering switching my health insurance. But there are many choices and I'm not sure what will serve me best as a PWC.

So there's Blue Cross, Kaiser, Aetna, Healthnet, etc etc. So many choices! I currently am not satisfied with my doctor and so am open to changing. By the way, I am not getting insurance through an employer, I pay myself.

Thanks!

 

[ixchelkali]

Forget Kaiser in the greater Los Angeles area. Don't get me wrong, Kaiser is good for many things, just not for ME/CFS. Essentially no treatment, no testing, and no ME/CFS knowledgeable doctors. There are (at least) a couple of us here on PR from the L.A. area who have compared notes, and our experiences with Kaiser were pretty much the same.

I've heard that Kaiser has some ME/CFS literate doctors in the Bay area, so I think it varies by region. I heard a rumor about one knowledgeable Kaiser doctor somewhere in eastern San Diego county, but was never able to track him/her down.

If anyone has information to the contrary and knows a good Kaiser doc in the L.A. area, I'd be happy to hear about it.

What area are you in? If you're thinking about changing insurance, and if your insurance will cover pre-existing conditions, why not pick the doctor first and find out what insurance they take?

 

[laura]

Thanks for your feedback. I am indeed in the greater LA area. Bummer about Kaiser, they have good plans and I know people who like them. But none are CFSers. I'm thinking about Blue Cross PPO -- I have had bad luck with their customer service but it would allow flexibility in providers.

Or maybe I should follow your suggestion, find my doctor first, then switch to one the doctor takes. That's probably the smart thing to do. Though it's going to take some time for me to find a new doctor that I like....

 

[ixchelkali]

How about Dr Chia in Torrance? Though I hear there's a long wait to see him.

 

[WillowJ]

I second the "don't go with Kaiser" motion. I have heard of Kaiser being liked in California, and I don't know how much it's different there and here, but in the NW they use substandard testing procedures. They do have a few competent doctors but not very many.

Medical people are generally reluctant to criticise other medical people and plans, but I have heard other medical people saying they don't know how Kaiser practitioners sleep at night. I have heard a few sangiune personalities happy with Kaiser, but most people who have an actual injury or disease--even people with standard issues--are extremely unhappy and cannot get proper testing or care. I have heard lots of horror stories, and experienced a few of my own.

In my region people have exactly 3 choices for coverage (which choices vary depending whether you are on the individual or group market, but there are still 3 and one is Kaiser either way) and Kaiser is the least expensive. But we finally dumped them, figuring inferior care wasn't worth the money spent even if it was less.

you can get ratings from JD Powers, your state insurance commissioner, and other sources. Keep in mind that this may not give you all the info. For instance, the Insurance Commissioner keeps complaints about items covered under contract but not paid--and Kaiser does just fine on this. Their problems are quality of care and billing issues, not denial of coverage.

Business factors go into insurance ratings as well: http://www.ambest.com/ratings/methodology/healthmethodology.pdf

See:
http://www.consumerhealthratings.com/index.php?action=showSubCats&cat_id=10
http://health.usnews.com/health-plans
http://www.jdpower.com/healthcare

here we go: http://reportcard.ncqa.org/plan/external/PlanSearch.aspx
this one is good because it tells you how many people are happy with their doctors--you must go to "compare plans" to find this info. not all plans are listed.

 

[urbantravels]

I have Southern California Kaiser. I've had Kaiser for decades - first in Northern CA, where I lived at the time, and now in Southern CA (they are two separate organizations.) But it is Southern California you asked about, which I've had about ten years. They are excellent for straightforward medical issues, their emergency room care is great, and they are very on top of preventive care. Plus the value of not having to quibble endlessly over bills the way you do with other plans is inestimable. I've had excellent care from them in the past for a variety of issues, none of them hugely serious, and my ex-husband had surgery there.

Everything I just said goes out the window once you have CFS and are trying to get care for it. If there's a doctor in all of Southern California Kaiser who knows a damn thing about CFS, I have yet to find him or her. They almost seem to have a hive mind mentality about it - their party line is that they believe it is a real disease, but this statement is always followed by "but I don't know anything about it." They all want it to be the other guy's problem, only there is no other guy.

Only good things I have to say about being a CFS patient with Kaiser: copays on meds are cheap (I don't insist on anything exotic or non-generic); they did a VERY thorough job ruling out other conditions before I got the CFS diagnosis and it happened pretty fast (none of that taking years to get all other conditions ruled out, for me it took about four months); my premiums remain affordable (I bought an individual plan since my former employer didn't provide benefits, and the premium is amazingly affordable, and there were no shenanigans about trying to boot me when I went from really healthy to really sick); and I have a kick-ass physical therapist, who actually reads up on the literature and knows what he's doing. I had some trouble at first getting approved for physical therapy - I think they didn't want to approve it "just" for CFS - but when I complained of neck and back pain (true, and it was excruciating) I got the go-ahead. And that way I got in the door to some good overall management of my energy envelope stuff as well as the specific PT for neck, shoulders, other parts that trouble me because of what my fatigue does to my biomechanics.

I've never heard much good about other SoCal health insurers either, nor have I found a CFS doctor in SoCal that I'd care to go to. Chia in my opinion is too focused on enteroviruses.

All of this discussion may be completely moot since if you have CFS, you have a very serious pre-existing condition, and you said you have an individual plan. I believe you will find you are no longer insurable on the individual plan market. Pre-existing conditions will continue to be cause for denial of new insurance plans to individuals until 2014, unless the ACA gets gutted first, in which case "2014" becomes "never."

If your issue is that you are not happy with your doctor, you are more likely to be able to switch doctors than to switch plans. Even if you don't find a CFS expert, which are rare as hen's teeth, you may be able to find someone you like better who will work with you more effectively.

(p.s. Also be careful if you ever want to switch plans *within* your same insurer - say they offer a menu of different plans and you see one that seems more affordable or whatever. Read the fine print: sometimes you will have to re-qualify medically to change plans, just as if you were a toally new customer, and sometimes you won't, depending on the details of the plans. Kaiser actually has a chart that makes this semi-comprehensible if you look at it real hard for a while.)

 

[urbantravels]

State of California's Office of the Patient Advocate ratings of California HMOs:

http://www.opa.ca.gov/report_card/hmorating.aspx

Other kinds of health plans covered too:

http://www.opa.ca.gov/report_card/healthplans.aspx

 

[WillowJ]

They all want it to be the other guy's problem, only there is no other guy.

best quote ever

about pre-existings... it does depend on your state. My state requires people with pre-existing conditions to be insurable (your insurance may exclude that particular condition for only 6 months and only if you had no previous coverage, to discourage people from buying "insurance" only when they need care and cancelling it as soon as they don't need care anymore... but they must sell you a plan without a delay and cover everything else without a delay and, at least after 6 months, cover your pre-existing condition). This, among other regulations, is why there are only 3 insurers in my area. However, a lot of AIDS patients moved to my state when this went through and it is expensive to do business in the state.

Other states have high-risk pools for pre-existing conditions.

I'm surprised that CA does not have some sort of remedy for pre-existing conditions?

 

[urbantravels]

Ah, I see I need to update my info:

http://www.latimes.com/health/la-he-high-risk-pool-20101108,0,7199647.story

A few catches, like being ineligible for Medicare or Medicaid, and having had no insurance for six months prior to applying to the pool. Only three plans available (one is through Kaiser!) Premiums based solely on age and on region.

http://www.pcip.ca.gov/PCIP_Program/default.aspx

According to the chart, at my age and in my region, my monthly premium would be more than $100 more per month than my current Kaiser plan.

So, still not the greatest option for those who merely want to switch insurers for convenience or preference; mainly designed to bail out people who are currently uninsured and are medically uninsurable on the individual market. The part about going without insurance for 6 months first would certainly give me pause; I can't imagine wanting to do that on purpose just because I felt like changing insurers. Paying full price for all my meds alone for six months would be fairly ruinous.

 

[WillowJ]

Ah, so CA has had a high-risk pool for those with pre-existing conditions. However, it's been expensive AND people have no more choices than they do in my corner of my state. Odd that it would be both.

That's crazy that you would have to go without insurance in order to change. However, you could always check with the manufacturers of your meds--they might be willing to help out if you really needed to change insurers.

 

[urbantravels]

Not having had insurance in the prior six months is a requirement to qualify for *all* Federal high-risk pools.

http://www.hhs.gov/ociio/initiative/hi_risk_pool_facts.html

There is also still a California high-risk pool, which requires that you have been ineligible for buying other coverage for the past 12 months, but (apparently) not that you have actually not been covered for that period. You couldn't get into the California high-risk pool if you currently have coverage for which you continue to be eligible or if you just dropped your previous insurance by your own choice; you could if you've been kicked out of your previous coverage for reasons other than fraud. The monthly premiums are much higher than the Federal PCIP. Only two providers, Anthem and Kaiser. I'd pay exactly twice what I'm paying now for the cheapest provider they offer - surprise! Kaiser again! The Anthem would cost me three times what I'm paying now. Besides, Anthem is pure evil.

Again, none of these options are designed for people who just want to switch insurers; you have to be overboard already before they make any sense.

 

[urbantravels]

I prefer not to get into the politics of this here; I'm just stating what the facts currently are for those who need the information.

 

[WillowJ]

that's true... I'm sorry... I'm just frustrated because my state came up with a compromise and solution on this ages ago, and I don't understand why people are still suffering with this problem when alternatives exist.... but like you said this isn't the thread for that, so I will shut up now. peace

 

[laura]

Thank you everyone so much for your feedback!

Urbantravels, thank you for the links to ratings. And the info on Kaiser. They may not know anything, but I haven't seen that other doctors know that much, either...

Ixchelkali, I'm not familiar with Dr. Chia, what is his treatment approach?


By the way, this issue has come up for me because I now have COBRA, and so have to get insurance when that ends. And COBRA is very pricey. So sooner would be better!

As for the pre-existing condition issue, I'm probably dreaming, but I'm hoping I'll get lucky. Because I was diagnosed years ago when I lived outside of CA. And my current doctor has done a little bit of testing and whatnot for the CFS, but no major procedures or heavy duty medication prescriptions. So I'm thinking, it depends upon what he put in the chart, what went into the medical records system for my current insurance...

If I can't get an individual plan, then I dive headlong into the insurance hell that you all were discussing.

 

[urbantravels]

You yourself have to disclose your medical history when you apply for an individual health insurance plan. If you withhold anything substantial, that is still grounds for recission (cancellation of your insurance) if it's ever found out.

The state insurance commissioners and the Feds have gotten pretty good at cracking down on insurance companies that practice recission on policyholders for minor omissions in their original application claiming they're "fraud," (i.e. not putting down every little case of the sniffles you've ever had) but I think withholding a diagnosis of CFS would not go into the minor omissions category. I personally would not risk it; you might want to consult a lawyer.

I don't have time to look into the websites now myself, but there may be something on the California state websites about what happens when COBRA runs out; I think you do have options then that you might not otherwise have, even with a pre-existing condition. Check carefully, details *really* matter with this stuff.

 

[laura]

well, when you put it like that...
I don't want to do something illegal. I'm just really worried about it! To have no insurance for 6 mos, so I can apply for a high risk pool, and then pay those rates, sounds awful...

You are right, I need to look into COBRA -- I could be missing something important. Maybe there is another option.

 

[laura]

Going to post what I found out so if others need the info its here. Apparently I can continue my insurance after CalCobra ends, but I have to use up all of the CalCobra first. Then there are two options, a HIPAA plan or converting to individual insurance. They can't deny me for having a pre-existing condition. But I'm sure the premiums are high. And it seems that I can't change insurance companies.

So I'll have to wait a few years until Obamacare kicks in, and negates the pre-existing condition thing, so that I can have more insurance choices!

 

[Hope123]

The problem with most state high-risk pool insurance plans is that they are too costly for many people who need them (the chonically ill) to afford -- i.e. the insurance companies say "Ok, we'll comply with federal/ state regs saying we have to provide coverage" but none of the regs say anything about affordability. So even though on paper there are protections, the practical side of it is the folks who need care still don't get it. Rules change and states differ so people should google 'insurance commissioner' with 'your state' to get up to date info.

Secondly, be careful with omissions on your insurance form. People may not be aware of this but insurance companies have a national database (Medical Information Bureau) where they exchange info about patients so even if you omit something by intent or by accident, they will pick it up. The database is legal per the US regulations out there currently although some have argued this violates patient confidentiality.

 

[WillowJ]

or move to WA; same rates for everyone (of same age and smoking/nonsmoking status) whether you have pre-existing condition or not... probably still expensive compared to other states where they don't have this rule, but probably not as expensive as high-risk pool... also you do not need to fill out a health form in WA if you previously had insurance

 

[SaraM]

"I have heard other medical people saying they don't know how Kaiser practitioners sleep at night."

Willow, you could not describe Kaiser better than this. I have been with Nor Cal Kaiser for a couple of years and I have had a terrible experience with them. I had to see somebody outside Kaiser to get a CFS diagnosis and after doing so, my PCP at Kaiser started to mention CFS on my file. I saw him 2 weeks ago again for a check up and an ultrasound and he has not ordered them yet! I know he is not knowledgeable, I know he does not care a bit about my health, but I have to tolerate him in a way because he is supportive in some areas.