Anybody have advice about HMOs?

Question

My spouse and I live in the Sacramento area and are trying to chose between two HMOs offered by my work. Theres also a PPO option but we've kind of ruled that out. The two HMOs offered are Kaiser and Cigna. We just graduated from college so we're kind of lost. Anybody have any advice or experience with either of these??? Also if anyone uses either of these, are there any doctors you recommend?

Answer 1

I had a Cigna Open Access which is an HMO with no referrals needed.  It wasn't the greatest but I'd choose it over Kaiser since I could use my doctor (who was in the Cigna network).

Check the price and check an individual plan because if your employer isn't paying a good portion of the plan you may have more, cheaper options as an individual.  Regardless you should always price it to consider.

http://www.InsurancePickle.com

Answer 2

I have had Kaiser for over 30 years.  The good side is that there are no surprises.  Your coverage will tell you what the charges (co-pay) are for an office visit, emergency room, hospitalization, or prescriptions.  If you need a specialist who is not a Kaiser doctor, you can be referred by your regular doctor without a lot of paperwork and they will cover it just as if you went to a Kaiser doctor.  If you have a life-threatening condition, you can be taken to the nearest hospital, even if it's not a Kaiser facility (I KNOW from experience).  They will transfer you to a Kaiser facility as soon as you can safely (medically safe) be moved by ambulance, which they will pay for.  All the doctors, nurses, pharmacists at Kaiser are employed by Kaiser, so no questions about being covered for a visit.

The bad:  sometimes it takes a month or more to see certain specialists, or you might have to go to a different Kaiser facility up to an hour away.  Sometimes the emergency room is very crowded.

Answer 3

The problem with asking about these plans on this forum is that both companies have many different HMO plans. No one here will know which plan your work offers. If your work group is large enough the plan can be tailored just for them and will be different from all the other plans. You'll need to carefully compare the benefits of both plans and, more importantly, the exclusions with both plans to see which would suit your situation the best. Both are very good companies.

Answer 4

Each person is going to have an opinion regarding a company based on their personal experience.  You never know if they have a valid point or if the company was correct.  We are always right ourselves right, it is always their fault :o)

The way to do this is to take the plans you are looking at and break them down coverage by coverage against each other.  Every person and families needs are different.

If you are people that get sick frequently and go to the doctor regularly, then a plan with a low copay for doctor visits and a higher monthly premium may be right for you.  If you rarely go to the doctor and can afford a higher copay as little as you go, then you may want the plan with the higher copay and probably lower premium.

Look also at the deductibles needed to be met and the out patient care.  If you know you may need a procedure within the next year, then this is something to take into consideration.  If there is a chance of pregnancy in your relationship or planning on getting pregnant in the near future, this is something you may want to look at and consider as well.

Basically, look at the plans you are thinking about and compare each of the coverages and see what works best for you and your situation.  Be sure to think about the what if's and your past happens with doctor and hospital visits.

Answer 5

I had Cigna and was not happy with it.  It didn't even cover all of my baby's initial appointments and recommended vaccines and we had a hospital bill we had to pay through a credit agency.  I have heard better things about Kaiser from friends.

Answer 6

Hello Justin,

I'm in Sacramento also, and have worked in the health insurance industry for 8+ years, so I think I can provide some food for thought here.

1)  Kaiser and Cigna work differently.  With Kaiser as you may or may not know, everything is done through Kaiser facilities.  You could go meet with a physician at a facility who could prescribe a medication and then send you for an x-ray and you'd most likely be able to do those things at the same facilities that same day.  There are some people that REALLY like that model of insurance.  The one-stop shopping method appeals to them.  

Because HMO's require that you coordinate care through your Primary Care Physician, your best bet to navigate the HMO insurance plan well in Kaiser is to select a Primary Care physician and get in to see them ASAP once your insurance becomes effective.  Some people wait until they're sick to go see their PCP for the first time and then find they can't get into an appointment very easily.  New-patient appointments take longer, so they're a generally fewer of them available with a doctor in a given day or week.  

2)  Cigna HMO will have you select a PCP that's within one of the medical groups in Sacramento.  You'll pick between Sutter Medical Group, UC Davis, Mercy Medical Group, Hill Physicians, etc.  Picking the physician/medical group is important because that is what determines where you go and who you see for scheduled type services.  With a Cigna plan, if you go to the doctor and he gives you a prescription and then a referral for an x-ray, you're going to end up going to a separate pharmacy to get the RX filled, and then another facility to get the X-ray done.  This can be more time consuming because you're driving to different locations to get the services done.  

Most people have strong opinions regarding the insurance they have.  They either LOVE it or HATE it.  People with Kaiser are either big fans, or they don't like it at all.  

Your best bet is to consider what plan would work best with you, the location of the facilities (I have heard of people who live in Fair Oaks/Citrus Heights having to go all the way to Roseville to get a PCP with Kaiser).

TALK with friends and family.  Word of mouth is a great marketing tool.  If someone LOVES their Primary Care Physician, ask them why and then check and see if they're accepting new patients.  

I hope this has given you some direction and food for thought.  Please email me or respond if you want to discuss further.  

Good luck!

Kathy K

www.premiumwatchdog.com

Answer 7

I had Cigna "open access" HMO which stunk.  My son saw a doctor in a practice that was in my network #, but the doctor was in a different network # (WAS approved by Cigna but in the wrong #) & they refused to pay.  Figure that one out.  Luckily it was only a checkup, not something very expensive.

Sometimes it took them 2 months to pay doctor bills.

I don't know anything about Kaiser, but I would choose the PPO over an HMO any day of the week.  We were on a PPO before the HMO and are on one again, thankfully.

In a PPO, if you go to a doctor out of network, they still pay, a lower % of the bill but they still pay...also, you can go straight to a specialist.  If you broke your arm, you can go straight to an orthopedist, with an HMO, you have to go to your regular doctor 1st to get a referral to go to the orthopedist, what a waste of time.  If you don't do that, they don't pay.

If you go to a doctor out of network with an HMO, they don't pay ANYTHING, you have to pay it all.

The deductible usually stinks with a PPO but you know what your possible out of pocket expenses are, with an HMO you really don't know because sometimes you may think your doctor is in network when he really isn't...

In my office, the PPO option is actually cheaper than the HMO.