Kaiser Permanente versus BCBS

[rute boye]

Several years ago my wife, who was insured by BCBS, had a burst appendix and obviously had to go to the nearest hospital ASAP. The bill was something like $8000, which BCBS refused to pay because the hospital & surgeon were not preferred providers. (In fact, the surgeon on duty at the hospital happened to work for Kaiser.) She ended up having to pay the bill out-of-pocket. She subsequently switched from BCBS to Kaiser and, for the reasons described by MsEvie64 above, has loved it ever since.

[BT Lover]

Originally Posted by rute boye

Several years ago my wife, who was insured by BCBS, had a burst appendix and obviously had to go to the nearest hospital ASAP. The bill was something like $8000, which BCBS refused to pay because the hospital & surgeon were not preferred providers. (In fact, the surgeon on duty at the hospital happened to work for Kaiser.) She ended up having to pay the bill out-of-pocket. She subsequently switched from BCBS to Kaiser and, for the reasons described by MsEvie64 above, has loved it ever since.

That sounds like it would have to be under an HMO plan which the majority of BCBS plans are PPO, so that doesn't make any sense to me. Now, with Kaiser you would have had to have pre-approval. We never had to get pre-approval for hospital visits with BCBS and even now with UHC, but obviously, they do reimburse based on in network or outside of it. For emergency care, they typically reimburse all of it regardless. So, it sounds like there are some facts missing from this story.

[airjay75]

Originally Posted by BT Lover

That sounds like it would have to be under an HMO plan which the majority of BCBS plans are PPO, so that doesn't make any sense to me. Now, with Kaiser you would have had to have pre-approval. We never had to get pre-approval for hospital visits with BCBS and even now with UHC, but obviously, they do reimburse based on in network or outside of it. For emergency care, they typically reimburse all of it regardless. So, it sounds like there are some facts missing from this story.

To me, it sounds like a BCBS plan where you only have in-network benefits. For example, if you are a federal employee, I believe there are two nation-wide BCBS PPO plans - one that pays both in-network and out-network benefits, and one that pays only in-network benefits. Of course, there is a pretty significant premium savings by going with the in-network only plan.

[rute boye]

Originally Posted by airjay75

To me, it sounds like a BCBS plan where you only have in-network benefits. For example, if you are a federal employee, I believe there are two nation-wide BCBS PPO plans - one that pays both in-network and out-network benefits, and one that pays only in-network benefits. Of course, there is a pretty significant premium savings by going with the in-network only plan.

Airjay describes the out-of-network appendectomy situation exactly. My wife's BCBS plan was one for federal retirees.

Several years prior to the appendictomy incident I was traveling and had to check into an out-of-network hospital far from home for an emergency and ended up staying several days in the hospital. Total bill was over $6,000. Kaiser required appropriate documentation, which I provided them, after which Kaiser paid the out-of-network hospital in full (except for a $20 co-pay on my part.)

[BT Lover]

Originally Posted by rute boye

Airjay describes the out-of-network appendectomy situation exactly. My wife's BCBS plan was one for federal retirees.

Several years prior to the appendictomy incident I was traveling and had to check into an out-of-network hospital far from home for an emergency and ended up staying several days in the hospital. Total bill was over $6,000. Kaiser required appropriate documentation, which I provided them, after which Kaiser paid the out-of-network hospital in full (except for a $20 co-pay on my part.)

That makes sense then. I have heard that government plans have a lot more restrictions. It is good to clarify that, because it sounds like most of us who are or have been with BCBS have plans other than the government ones. I loved my PPO plan with them. But, to be honest, I have never had a PPO plan that didn't work out well.

[airjay75]

Originally Posted by BT Lover

That makes sense then. I have heard that government plans have a lot more restrictions. It is good to clarify that, because it sounds like most of us who are or have been with BCBS have plans other than the government ones. I loved my PPO plan with them. But, to be honest, I have never had a PPO plan that didn't work out well.

Just to be clear, federal employees (and retirees, I believe) have a choice - they can pay higher premiums and have BCBS that provides benefits both in and out of the network or they can opt for lower premiums and have only BCBS with benefits inside the network. There are actually a lot of other health plans they can choose from as well including Kaiser, Consumer Directed Health Plans, High Deductible Health Plans, HMOs, and various others. Really, probably too many choices for the average employee, but I suppose I'd rather have too many choices than too few.