[mjl1124]

I have finally passed the 3-month trial period at my current job, and am now able to sign up for health insurance coverage. I was wondering what plans people have chosen from what their work place offers, and for what reasons.

Since I work at a small firm, I only have a choice between 2 plans from Anthem Blue Cross: HMO 100% (with $10 office visits) and Premier PPO (with $20 office visits). From what I can understand, the only difference between the two is that with PPO I can choose any physician I like, but will have to pay much higher costs if he/she is not in-network. It seems that Anthem penalizes you very heavily for not choosing within their provider network, from paying higher office visit costs, paying about 60% of your medical costs if your doctor is not in-network, and an annual deductible (which you don't have to pay if you have HMO). All of which makes choosing PPO not an appealing choice. Currently, I think I am going to go with HMO, but can anybody tell me the pros and cons of HMO and PPO, so I can make a more informed decision? The 8-page pamphlets I got on the two plans are not very helpful, and do not answer all my questions.

Specifically, my questions are:
1. Are trips to the optometrist covered by HMO or PPO? This is a burning question that I cannot figure out! I know that dental coverage is separate from medical coverage, since it is a separate category on the application I have to fill out, but is vision coverage included in medical coverage? Or does it vary with different employers' available plans?
2. How long would I have to wait from turning in my application to being covered?
3. Are all conditions covered right when I am able to get coverage, or is there a distinction between pre-existing and sudden illnesses?
4. What exactly is a deductible?

If anyone happens to have Anthem Blue Cross, or better yet, either HMO 100% of Premier PPO, that would be great too!

[watcher]

-vision is usually not covered in your health plan. there are seperate plans for vision. i've only had experience with VSP when covering vision. you might want to ask your employer about it.

-coverage starts whenever your contract states it. i've had times when coverage didn't start until i signed the contract. other times i had coverage start before i even signed anything. they just wrote the coverage date to a previous date, and allowed me to get reimbursed for previous expenses. you should ask your company HR for the specific date of coverage that will be specified in your contract.

-as soon as you sign on, you get covered for everything from then on out. there may be restrictions, but they're not usually discriminated by pre-existing conditions, but specific cases when insurance cannot apply.

that said, i signed onto ppo because i don't have a personal physician i go to all the time. HMO's are better if you don't travel much and have your own physician that's in-network. i like the flexibility of a PPO, especially when i get checked and get referenced to other specialists for certain conditions and those doctors happen to be out of network. but it really depends on your personal preferences.

[sasuke-kun]

1. it all depends on the plan. for some, optometrists should be covered by your plan under medical up to a certain amount, there usually isnt a separate coverage for it. for HMO, you most likely wont need a referral to go to one. but for others, you may only get a discount card which isnt insurance but may save you something.

3. insurance companies can deny you coverage if you have a certain pre-existing conditions for private insurance. for employer insurance, there are time limits where they will and wont cover your condition.

4. a deductible is an amount that YOU have to pay before the insurance starts to cover your expenses. kind of similar to car insurance. lets say you get into an accident with $1000 worth of damage and you have a $500 deductible, you have to pay the first $500 before your car insurance starts to kick in. but it can be tricky with health insurance. for alot of PPOs, you have a deductible that you must reach before they cover for office visits, etc. usually after the deductible is met, you still have to pay a copay or coinsurance (typically 20%).

i signed up for HMO because i rarely see an doctor and if i did, i would only have to pay a flat copay with no deductible. my employer's PPO is a 20% coinsurance so it could be any amount on top of a $400 deductible.

[questions987]

I work for the father of HMOs so I can kinda help you on a few of these things.

Deductable: The amount of minium amount of money you'll have to pay before the insurance company will fully cover you. For Kaiser it ranges from 1500 to 2500 per year before they fully cover you.

For instance, if you choose the Deductable plan at Kaiser you have a 55.00 co-pay until you reach your deductable and then it becomes 20. The only issue with that is very few people actually meet the Deductable min. Usually younger, more healthy people will opt for it - because it's less expensive monthly and you don't need as much medical coverage - considering that most younger people really only need the annual or semi-annual check up.

Pros and Cons of both. I had a PPO growing up and I now have an HMO. There's really not much of a difference, I'm not sure how you're specific HMO will work but for my company HMOs have proven to be easier to deal with. With my PPO when the doctor made a referral to a specialist, I still had to get insurance approval to go (I've heard that you have to do the same with HMOs, though). I do know that for my company all you need is a referral, sometimes even that is questionable and you can just go stright to the specialist. I've heard that HMOs are more difficult deal with, but I do know the whole idea behind the HMO is that your medical and your insurance are run by the same company so it should make the billing issues A LOT easier.

I would consider - how often do you think you'd need to go see the doctor, and do you have enough put aside for emergency expenditures? The PPO plan is probably cheaper monthly but if you have a family to cover you might want to do HMO.
A lot goes into the consideration -
Does your company cover all of it/do you have a monthly fee? If yes - do you have a family to cover?
Do you have health issues that will need lots of visits?
Can you afford the monthly fee for both or could you use the extra cash?
And if you choose the cheaper plan: do you have enough put aside to deal with incidentals because until you meet the min deducatible - it'll be expensive.

As for vision: I would check on that - some companies cover it, sometimes it's an extra fee that you can actually add on. Both PPO and HMOs pretty much fully cover vision. My PPO was an annual 300.00 for glasses and my HMO gives me 175 every two years.

Start of coverage: It usually varies by contract. October tends to be open enrollment and that means coverage starts January 1st. Because you're a new hire, coverage will usually start the 1st day of the following month after contract is signed. That allows the insurance company/your company to process the paperwork for deductions and coverage card and everything.

Unlike purchasing private health insurance: by law when you have medical coverage you are covered for ALL health issues, prior, current, future, etc. So they can't use the whole "this happened before we got you" deal - its part of hte coverage. The only time prior/current health issues apply is if you apply for private health insurance - they have a right to refuse coverage.

Special note: Open enrollment for most companies is October, so you can choose the plan that best suits your lifestyle now and change it again your next open enrollment period if you need to. I will warn you to turn in your paperwork within 30 days, as a new employee, many companies will just automatically cover you with the cheapest plan if you don't respond within 30 days (and most of the time, it's the one plan you don't want).

I would go to HR and ask HR about the cost - they obviously can't answer coverage issues, but they can put you in contact with the insurance rep that can answer any coverage issues/questions you might have. Your HR person obviously also has coverage through the company so they should also know about the various coverages and can tell you their own experiance.

Personally - I'm forced to go HMO but I don't pay a dime for my coverage at all - my company pays 100% of the cost because it is an HMO. PPO was great while I had it but towards the end I hated the PPO with a vengance and have found that my HMO has always been good to me and I've never had any coverage/billing issues. But I do know a lot of people do (I know we're treated differently when we're employees) and that HMOs are generally hated for a reason so I would def. do a side by side comparison with the cost. I'd also google the two plans with the company and see what the pros and cons are of that specific company. I know you can google my company and see where patients have issues.

Either way, it's going to expensive, with all of the regulations now, insurance in general is super expensive and the because of the regulations, it's hard to sort your way through the system. I would recommend that either way you go - you always have the number to customer service handy, document times/days/person you speak to when you have to call and keep every single visit receipt that you get.

Hope that helps!

[watcher]

^ OP should listen to questions. haha... she works in that industry. my post was based on my own personal experience