Personal Finance (Not Investing) • Cancel my health insurance?

Are all of the health insurance companies more or less the same or are there some that provide particularly good/broad coverage, excellent service, and don't give you the run-around when it's time for them to pay? I don't need small health expenses covered but if something big comes up I want to feel confident that I'll be covered according to my own choices.

I don't have any way of knowing now which doctors I would want to be in-network in case of a health catastrophe so maybe I need excellent out-of-network coverage.

Insurance companies are very different in terms of coverage and network. I use an HMO, Kaiser Permanente Northern California, which is both an insurance company and a closed network of providers. I never have to submit a claim, which is very convenient. I just pay the copay at point of service. There is no issue of getting reimbursed. There is no out-of-network coverage, though, except for emergencies when traveling outside the area that Kaiser serves. In this case, you do have to pay upfront and submit a claim for reimbursement. I have had emergencies both in other states and abroad and they were all covered eventually. I never got a an insurance denial, but it took a while to get the check (many months).

I like certainty. I don't like having emotional phone calls with call center reps. I wonder if I would be happier with something like Kaiser which does exist in my area. It sounds like they do what they say they do and if you don't like it you can pay the outside doctor yourself. From experience and from what I can gather from this thread, there is a lot of uncertainty associated with being covered by the conventional insurance companies and I've heard that having Kaiser at the center of things helps things to run much more smoothly and predictably.

If I switch to Kaiser I will be 100% covered (minus copay) no-questions-asked within their closed network which is large enough to cover me for anything that might happen?

Do I get anything like negotiated rates outside of the network?

As I went through the ACA selection process back in November, the first thing that came me some comfort is the annual max out of pocket. This plus monthly premiums pretty much sets the maximum per year I'd have to pay if something catastrophic comes along. All plans I was considering were in a surprisingly narrow range. This was the certainty I needed to know that a catastrophic event would not likely derail our retirement, even if it went on for a few years.

I then started to narrow down my plan choices
- Wanted to make sure our primary docs were in network
- Wanted to make sure that as many of the specialist docs we've had over the years (the ones we like that is) were in network
- I then went through a list of common specialties for which we've never had need, but I wanted to see how many providers are in network within a reasonable driving range
- Nice to have would have been HSA eligible, but only a couple of plans were and they were inferior in pretty much every other way I cared about.

I ultimately also went with certainty. The plan we decided on is sponsored by one of the largest medical groups in the area. And yet, provider choices don't consist solely of ones that are part of that medical group. In terms of coverage, it checked all of our boxes. It's a so-called zero deductible plan where there is no deductible for health care, but there is a deductible for prescriptions. Even then, the lowest 2 tiers are covered before the deductible is reached. It's an EPO plan and my primary physician is not a gatekeeper to specialists.

From a practical standpoint, I know what my copays are for just about everything before I make a visit. It's now getting to be late Feb, and we've already had several doc visits and prescriptions.
- We both had covid, but were able to get video-doc who are part of the practice as our primary docs. The copay was exactly as our plan documentation stated. The antiviral we were prescribed would have been subject to the prescription deductible, but the manufacturer had a discount resulting in a $0 cost for us.
- I had my annual physical.
- I saw a new specialist recently. Again, the copay was exactly as our plan description stated. I was given a prescription, but the prescription is not on our formulary. Again, the manufacturer had a discount resulting in a relatively low out of pocket cost for me. In this case, I didn't have to do anything - the pharmacy took care of it automatically at their end.

We had the option to continue COBRA for 1 more year, so comparing ACA plans to that was appropriate. The network was hands-down larger than any ACA plan - as in nationwide vs statewide at best and, more commonly, a handful of counties. It was also HSA eligible. It came down to cost, at the end of the day. COBRA premiums would have been about 2X what the ACA plan is that we chose, when premium tax credits were considered. Compared to my portion of the premiums for the same plan when I was still working, the ACA plan is about 2X what that was.

So far, we're happy with our choice.

Cheers.

Statistics: Posted by dcabler — Thu Feb 22, 2024 5:02 am — Replies 93 — Views 10177

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