Health Insurance- Help Me Understand How It Works Here?

Updated on November 12, 2009
S.M. asks from Los Angeles, CA
14 answers

Hi there

My husband and I have just moved from the UK and we are trying to make sense of health insurance packages so we can choose a package for next year- we have to decide by end of week to secure coverage for next year.It is quite hard making sense of all the different options and whilst the company my H works for obviously pays towards them it seems we have to pay a significant chunk, not only each month but if we need treatment up to the first $3000 as well each year.

Now one of the packages is offered by kaiser hmo foundation health plan of california and what we can't understand is that this package is less per month and yet the deductables seem less than the more expensive packages. Now clearly we must be misunderstanding something as the cheapest one cannot be the best one or no one would bother with the expensive packages.

ANyway i just wondered what people who have young families do-is there a particular health insurance company that is more popular- i guess with a baby on the way I anticipate i may need the doctor for baby more often than i need the doctor.

What we cannot understand is how people who are on low income manage to get health care- it is so different to the uk where we pay a tax on our salaries then all health care is free for everyone- very few bother with private coverage.
Anyway any advice will be useful- trying to find our way through it and pick the best plan for the three of us.


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So What Happened?

Thank you so much for taking the time to help me- all those responses are really helpful. I am reading through them again to really try to comprehend how it works and forwadring to them to my poor husband who has to decide by the end of the day as he is off as we move house over thye next two days- and the deadline is looming.

It seems that if you are not fussy about which doctor you visit the hmo s are fine- to be honest neither of us visit the doctor regularly but of course with a baby we do not know what the baby's needs will be. It seems kaiser are equivalent to the NHS in the way that you just go tpo one doctor and then wait to be referred to a specialist so this is what we are used to in the UK and of course this would mean that sometimes you had to wait over a week to even get an appointment with that doctor and a specialist referal could be 3 in principle the HMO seems fine and the ppo seems more like the private health care some people opt for in the UK as they want state of the art hospitals and doctors they know of. I am pretty pragmatic and am happy to see a trained doctor-we are on the more expensive ppo that expires at the end of the year now and of course we just picked any obst anyway as we have no idea of knowing who is recommended being new to the US. The hospital we are going to is the local one and just seems like a regular hospital so maybe these ppos are going to be somehow 'wasted' on us as we are just after basic care and a doc for the baby. I guess as you get older the ppos become more attractive maybe as you need more health care possibly and of course no one knows what is going to happen with their health.

I really am shocked( despite having seen Micheal Moore's SICKO before we came how kind of capitalist the health system is here- it is just one big business and that has got to lead to unethical shenanigans going on.How poor families on low middle incomes manage if their company does not foot some of thebill, i can only imagine. It must be so stressful for them as it is the one thing you really cannot economise on if something goes wrong, you need the care.

Thanks again- i really appreciate all of your input.

Thanks stephanie- i will keep researching. To be honest in the UK- you would never speak to a doctor- you call the reception and they try to fit you in- rarely do you see the doc on the day you call unless you deem it an emergency so I am thinking everyone who uses the NHS is on the kaiser in the UK.
It is reassuring that people have ood things to say about kaiser as the company seemed to present the ppo as the real option, like no one would be interested in the hmo- yet when we look at it it seems the ppos are more expensive in every possible way.
Maybe we try a hmo the first year and we can always change the following year if it is not satisfactory.

Thanks all-you are much clearer in explaining it all than all the paperwork we got!!


Thanks- I have had far more positive endorsments of kaiser over the last few days so we have ecided to go with them- the hmos all seem to involve you paying more if you need to go to hospital which does not make sense when you pay more per month.
My other half went 3 years without even visiting a doctor and I am not a regular user if i can avoid it so the idea of being able to choose a doctor is kind of an indulgence we can afford not to have. It is really just about ensuring the baby has reasonable access- seems like kaiser system is really like what we are used to on the national health service in uk- which we now realise was amazing- free health care for all- no matter who you are or what your income level. I hope the US administration can change the health system tomake sure all people have access without having a big monthly bill-paying for health care outside of taxes just seems a bit medieval.

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answers from Los Angeles on

I've had Kaiser for the past 38 years and am very happy with it! I don't know how I could have raised my kids without it - they had very good "well baby" services and we had the world's best pediatrician! I have found them to be very pro-active and try to prevent larger problems down the line. Good luck!

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answers from Los Angeles on

Hi S.,
You have some very thorough responses here. I'll keep mine brief. We have seen friends with Kaiser HMO plans go into the hospital and come out in worse condition than when they entered. That happened a number of years ago so perhaps it has changed, but it taught me a huge lesson - to always go with a PPO, regardless of the extra cost. I know it's confusing and expensive. Best of luck to you in deciding.



answers from Los Angeles on

One more thing I wanted to add in Kaiser's favor (I've been with them for almost 40 years, and have raised a 23-year-old daughter with them), is that they are available at all hours by phone or by taking your child in. My daughter had strep throat on Christmas Day, and it was easy to get in and see a doctor. We have also had good experiences with getting an MRI for her to rule out brain problems with migraines, as well as getting therapy and medications that have helped her through difficulties. Each doctor has to be checked out individually, but good care is available. Good luck.



answers from Los Angeles on

Hi S.:

Good luck on this important decision. I know it's not an easy one. Even for those of us born/raised here, the healthcare system is not easy to navigate and can be quite confusing. (As a matter of fact, our government is grappling with the decision right now as well).

In my case, the choice was easy. My husbad's company offers us an HMO (Kaiser) at no additional cost to us (it is included in his union dues). I have had Kaiser since my first child was born and he's 12 years old now. We now have 3 children, the youngest two being 9 and 6, and they were all born in Kaiser hospitals, and their pediatrician (whom I just adore!) is a Kaiser doctor. My eldest son was diagnosed with Epilepsy when he was 8 and while we did have to get a referral for the neurologist, the process was very speedy and efficient. We love our neurologist! My daughter who is 6 has a benign tumor that grows in her mouth and has had to be removed twice now, (she is current scheduled for a CAT scan to see if it has returned a third time, unfortunately) so she sees an oral surgeon/maxillofacial specialist, as well as a pediatric oncologist and of course we had to get referrals for these as well. Again the process was speedy and extremely efficient.

Frankly for us, it is a cost issue....we can go with a PPO paying a lot for the monthly cost, as well as deductibles, co-pays, etc. none of which exists for us with Kaiser. However, even if I had a choice (and money was no object) I would stay with Kaiser as I just love our (my husband and my) doctors and the kids pediatricians and other specialists we have to see. (As you can see, we REALLY use our benefits!!)

I know that Kaiser had trouble in the past, but for 12 years, it has been WONDERFUL to us and I am happy and proud to recommend them to you.

Good luck with the decision and God bless your little bundle from heaven!




answers from Los Angeles on

HMOs will be less out of pocket expense to you, but you do not have much control over your care. You have to choose a primary care physician and get referrals to specialist (except for OBGYNs which you can self refer to). I recently switched to a PPO and it is a lot more money for us because things that used to be covered 100% under the HMO are now only covered 80% and we are going to all the same doctors! My daughter was in the hospital once and the bill was $17,000 and we only owed a $500 co-pay. Now we would owe 20%. But there is an out of pocket maximum each year so check into that.

Basically you get a lot more flexibility with a PPO because you can go to any doctor in the network without a referral. PPOs also tend to cover more medications (which has been helpful for us) and more procedures.



answers from Los Angeles on

I can't even imagine what's going through your head as you contemplate this important decision...especially as an expectant mother. First, health insurance is very expensive. Different employers offer different options and pay different amounts toward the premiums, but all in all it's expensive. I hope I can help with some understanding as it's also very complex.

Insurance usually comes in the form of an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization).

HMO's typically are less expensive. They operate in that you select a primary care physician or medical group. For doctor visits you must see your primary provider or group. You can only see a specialist once you've been referred by your primary. Kaiser is an HMO. You visit their offices, see their doctors, get referred to their specialists, and have babies in their hospitals. They have had a bad reputation in years past, but I've heard wonderful things about them over the past decade.

PPO's give you the freedom to choose any doctor you desire and, in most cases, without a referral. Insurance will often pay more (80%-100%) toward your visits if you choose a "Preferred Provider", which means a doctor/group that has a contract with the insurance company and agrees to their terms. You can usually see doctors out of network, but will most like have to pay more out of pocket (50% or more).

Then, there are a lot of things to consider on top of that. Co-pays, which would be how much you have to pay each time you visit a doctor. Deductibles, which is how much you have to pay overall before insurance kicks in and starts paying for your visits. Emergency coverage, especially if you are traveling. Alternative care coverage (i.e. chiropractic, mental health, etc.).

Personally, my family has a PPO and I love it except for the expense of it. A couple of decades ago HMO's got a bad reputation...long story. At that time I switched to a PPO and built wonderful relations with many doctors, primaries and specialists. Now that HMO's have a better reputation, I'm not willing to give up my doctors. I love my OB/Gyn, my allergist, my pediatrician, and others that I have a history with. Plus, I love going straight to a specialists without seeing a primary first. For example, just last week I took my son to a podiatrist to treat a wart on his foot. My daughter had one once and the pediatrician could not attend to it because of its nature and referred me to a podiatrist. This time I went straight to the podiatrist and did not even bother with the pediatrician. As a result, it saves me money because I only have to pay 1 co-pay instead of 2.

Kaiser at one time had one of the worst reputations and they're still recovering from that. So, you'll sometimes hear negative feedback regarding them. But, overall I've heard wonderful things about Kaiser in recent years. If I had no history with anyone, I probably would choose that insurance option. But, if picking your own doctor to meet your needs is important to you , then I would investigate the PPO's.

A good source of information could also be provided by your company's Human Resources department. Someone there should be able to take the time to go through and explain your actual options so you can more easily understand it. Regardless, I hope that my information was helpful as I'm far from being an expert. I wish you luck in your decision.



answers from Los Angeles on

I was with Kaiser from birth to about 5 years ago (only because employer didn't offer it) and yes there were issues for years but they are so so much better these days. I have a pre-existing condition and was in the hospital a number of times and it was always a pretty good experience. I HATED switching to "regular" insurance. Such a huge hassle. And now that I am unemployed (laid off) I am going back to Kaiser and my husband and son as well. My parent's have always been with Kaiser and also my inlaws. And yes, as one woman suggested, many lower income families do belong to kaiser but my family has always lived in Manhattan Beach and my in-laws in Orange County and it was never an issue for us.
Good luck. Insurance "sucks"! :) But we just can't go without it. I sure hope our government makes some improvements!!!



answers from Los Angeles on

Hello S.. This is confusing for those of us who HAVEN'T lived in the UK!! LOL!! :) Choosing an insurance company is a chore, and one that shouldn't be taken lightly. I think the type of coverage you decide on depends on the needs of your family. Does your family have frequent doctor visits? Is there a pre-existing condition anywhere? Frequent ER visits? Any physical therapy (long term)? Stuff like that will (should) affect your decision, because each plan is different and some cater to people who are like me - and go twice a year for a pap, and that's about it. I rarely used my insurance when I had it. If you frequently use it, or anticipate frequently using it, then I suggest one with a lower deductible, if that is offered. I also wanted to let you know that for MANY years I had an unfavorable opinion of Kaiser. I never dealt with them personally, but I always felt that was the insurance for the "undesirables" (as my dad would say) and I wasn't interested in it. Anyway, this past year when my son was born, he was added to his father's insurance which just so happens to be Kaiser. I had a fit about it, and am still pissed off about how they handled the circumcision situation, BUT.... other than that.. I have been extremely happy with them, and the facility I go to is very clean and tidy, not at all like what I expected. BEST of luck to you on this :)


answers from Los Angeles on

Hi S., I know I'm a bit late but I want to add my 2 cents worth. I have had Kaiser for most of my life, about 45+ years. I would not change. Currently my husband and I pay for our own medical insurance (and yes, it is expensive)but as long as we can manage it we'll stick with Kaiser.

You can build relationships with the doctors there. If you have a problem with one (and there are a few), just complain. Kaiser is very customer service oriented and they will do everything possible to make it right for you. My doctors almost always call back within 24 hours if not sooner plus I am able to email them. OBGYN does not require a referal.

I really like the fact that everything is right there in one place, the labs, doctors, specialists, hospital, emergency and urgent care. You can always get in to see a doctor the same day if you call in the AM. And there is always urgent care in the evenings, weekends and holidays.

Kaiser now offers a multitude of plan options (something I get to chose as the plan administrator for my husbands business) which include deductible plans, HMO/deductible and straight HMO plans, all with differing co-pays.

About 10 years ago my father needed surgery for esophigeal cancer. Kaiser didn't have a specialist so they brought in a doctor from UCLA to perform it at Kaiser facilities. There are some very experienced doctors in every imaginable department.

The only thing I didn't like was after delivering my babies they have "rooming in". After 52 hours of labor and a C-section all I wanted to do is sleep and let them feed the baby. lol

I think for the medical attention you need you will be very pleased with Kaiser.



answers from Los Angeles on

Just keep in mind that with Kaiser you can't call your doctor directly. You call a call center and they take the message and forward it to your doctor. The turnaround time for a return call, my friends with Kaiser tell me is very poor. Since you are having a baby you might want to be able to call your pediatrician's office right away and have your calls returned right away--just a thought.



answers from Los Angeles on

Hi S. -
It looks like you've already made your decision, however I wanted to give you my experience with Kaiser in hopes that it's helpful. I have had them for about 4 years through a chronic medical condition and a pregnancy. I do have to tell you that the doctors make the difference! I have had a few horrible experiences, however for the most part I have been extremely satisfied with Kaiser. When I was looking for a new job one of the stipulations I was looking for was that they had Kaiser.
Aside from the obvious financial incentives of Kaiser, I have been really happy with the service/care I have received.
Yes, you must choose a primary doctor, however I have found it very easy to get the specialty care that I have needed. I have been using a referral I got 3 years ago to continue with my specialty care.
As far as the comments that you can't communicate directly with your doctor - well if you call in you do leave a message for them to get back to you which I have done on occasion, however have always received a call back on the same day. However, you also have the option to e-mail your doctor. Once you have seen a doctor they are added to your e-mail list and you can e-mail them securely from your online account. I have one doctor that I am in regular communication with all of the time and she always responds same day (sometimes in as little as 30 minutes!)
So as I mentioned earlier it's all about the doctor you see. In my bad experiences I have not been happy with the doctor I've seen. Once it was my primary care doctor - I was able to easily switch doctors. Another time it was a specialist - I was able to be referred to someone else. Most of my experiences have been good experiences. For my daughter, her pediatrician is worth his weight in gold! He skipped his lunch break one day to see my daughter and re-evaluate the diagnosis we had received in urgent care the night before because I wasn't comfortable with what they said. My specialist - as I said she is in constant communication with me and responds very quickly to any questions I have. She also keeps me up to date on advances made in the field that might be helpful to me. I feel like I have a one on one doctor.
So my recommendation to you would be to go with Kaiser and if you are unhappy with the service you receive at any point, find another doctor because the great ones to exist!!



answers from Los Angeles on

Hi S.,

I have Kaiser and it is good coverage. It is less expensive because it is an HMO (which are self governed and are like "one stop shopping") and all types of doctors are associated with it but you can only pick a doctor from their directory. You can only go to their hospitals. If you need prescriptions, you fill them at a Kaiser pharmacy. With a PPO plan it costs more but you can generally pick any doctor you like from anywhere as long as they take the insurance that you have. You can fill prescriptions at Walgreens, Target etc. Also you may have a choice of different hospitals as long as the doctor you have chosen has privileges there.

There are pros and cons to both but I have always gotten good care with Kaiser. If you don't already have a doctor that you want to see that is outside of the Kaiser plan then they are well worth looking into.

I know it is confusing but I hope this helps.




answers from Los Angeles on

i've lived here my whole life and even i don't understand it.
just know that HMO means that you won't have the flexibility of choosing your doctors. You have to go to your primary doctor for everything and they will refer you to a specialist.i think that includes needing a referral to an an ob/gyn. And just because you go to your primary doctor, it doesn't automatically mean that you are qualified for a referral. It's to your doctor's discretion.

If you have a PPO plan, you do pay more in your salary, but your co-pay may be less and you have the flexibility to go to any provider/specialist that takes insurance (plenty to choose from) at any time, without having to first meet with your family/primary doctor for a referral.

I'm sorry that that's really all that I know. Regarding this $3000 yo mentioned, i don't really understand it myself.

My family currently have Anthem Blue Cross PPO. And my annual deductible is $200/250 (Not even sure what that means myself; supposedly it's an amount you have to spend out of pocket/up front(?) for each year - not a part of co-pays). I know that there are those who have to spend $1000. I can't imagine...But some years we pay it and other years we don't - some doctors never asked...i guess it just depends on who I go to). My co-pay is $20 per visit.



answers from Los Angeles on

Hi S., if you can afford it, I recommend avoiding HMOs.
Usually they're the cheapest but the care you get is rigidly controlled (meaning, a smaller choice of doctors, and the care they can provide you is more rigidly controlled. I have had a few negative experiences with HMOs). A PPO system will give you more flexibility to choose a doctor you like and to easily see a specialist if needed.

Here we are really limited to the insurance companies our employers provide, unfortunately, so I wouldn't say one type of plan or company is more popular per se. Some employers will pay more per month for your insurance (so you pay less) or provide a better selection of plans.

Here's a link describing some of the pros and cons of different types of plans:

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