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  1. #1

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    Health insurance questions (USA)

    I get my health insurance through my employer. It is considered a good benefit, although they keep raising the deductibles every year. I probably pay less than many people.

    This year my employer suddenly decided to switch from Cigna (I had Open Access Plus/PPO) to United Healthcare. My primary physician works for only Cigna and if I choose UH, I will be paying him out of network. It's not a big problem for Dr.'s visits, which are about 3 per year, but the lab work could cost me a lot more, if it's done through Cigna. Their location is very convenient to me (less than 5 miles from work). With the change in the healthcare plan, my employer has retained only the HMO option with Cigna. I always thought of HMO as a bad option, and I always went for the most expensive one (OAP high/PPO) for more freedom, but now I am being forced to go for either HMO or for an out of network (if I use UH).

    The cost difference in deductibles is not much (difference of about $10 per visit) but the out of network costs and maximums are quite different, if I need something more than routine.

    The obvious question would be- why not change the primary physician? The answer is that it has taken me many years (more than 5) to find the right physician for me, after many dissatisfying experiences. In one case the physician I liked moved out of state after just one year. I am not willing to give up a doctor that fits my needs and go through the trial and error process for the next several years.

    So the solution I am considering is using Cigna HMO. Does anyone have experience with this? How good or bad (or just OK) is it? My understanding is that with HMO I can only use a doctor/facility in state (Arizona), which is not a good thing if I am traveling and become sick or break a bone, etc. I am also concerned that many specialists (I have also found the right ones in each field that I need- so far it's been mostly for routine/annual check ups only) would refuse to accept HMO. Another disadvantage with HMO is that I will need a referral from the primary care physician, even if it's only for a routine checkup, while on my other insurance (ends June 30, 2014) I could directly contact any doctor/specialist I wanted to see.

    Some questions will get answered in the on-site meetings we will be having in the next few days, but I would like to know from people that have had first hand experience with both Cigna HMO and/or United Healthcare (PPO). UH seems to be popular with employers these days, but it doesn't necessarily mean the patients/employees like it. Basically we have no choice, but I would like to choose lesser of the two evils (and those evils may still be better than what many people face for their insurance- count my blessings).

  2. #2

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    No experience with Cigna. My aunt had her supplemental medical insurance through United Healthcare. They were a little picky about doctors being in network, but they paid for most things, and just would not pay the doctor directly, at the correct rate. I had to call them quite a few times because of dealing with her estate and their customer service folks were always very helpful to me.

    Are you sure the HMO would only have doctors in Arizona for you to see? I thought most large HMOs would have a national network of doctors. You'll have to run all the numbers for the different scenarios and decide what you're willing to pay/put up with.

  3. #3
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    You are covered for ER services anywhere in the US under any HMO. UHC has improved a lot in the past ten years, so I would likely go with their PPO, and stay in network. If you go out of network and pay say $150.00 and the usual and customary reimbursement in that area for that service is $60.00, only $60.00 goes towards the deductible. You eat the remaining $90.00.

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    I have a feeling the HMO would at least cover emergency medical treatment out of your area, but you should verify that. You should also call all of your current doctors--if you haven't already done so--to determine whether they would be in-network for the HMO. I've never had HMO coverage, but when I briefly switched out of Blue Cross/Blue Shield, I was burned by the new company's definition of reasonable-and-customary in comparison to the negotiated charges I benefited from with BC/BS. I suspect that out-of-network costs could be similar.

  5. #5

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    Couldn't you get the doctor to give you a lab order, and then choose a UHC in-network lab to do the lab work?

    I have UHC, and I do not use the radiology or lab facilities affiliated with my doctor's hospital because (even thought they're in-network) they are hugely more expensive than other facilities contracted with UHC.

    I've paid to see out-of-network docs before, and I'd do it again -- but I would make sure to do lab, radiology, and Rx in-network. Doctor visits are the cheapest part of my medical care.

    (I didn't realize CIGNA had doctors who only worked for them. I don't think we have that in Colorado.)

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    I work in insurance and prefer an HMO to a PPO, mostly because of the accountability. Your primary care physician is being compensated for coordinating your care. If your physician's practice is well organized, you shouldn't notice any difference or delay in your services. A good doctor will refer you to competent specialists and the type of insurance you have should not be a barrier to getting good care. Just make sure you're preferred hospital is in network and that your primary physician has admitting privileges there. If he does, you'll have access to the right specialists.

    As for barbk's question, physician's contract with insurance companies. Some insurers will pay extra for exclusivity in an area. United is notoriously cheap, so it doesn't surprise me that Vash's doctor would prefer to take Cigna patients.

    ETA, all HMO's cover non-routine care outside of your service area. If you're traveling and break a leg, the initial treatment is covered as long as you follow the notification rules. They assume you will get the follow up care at home, though.
    Last edited by Aceon6; 04-01-2014 at 02:11 AM.
    AceOn6, the golf loving skating fan

  7. #7

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    Quote Originally Posted by Vash01 View Post
    It's not a big problem for Dr.'s visits, which are about 3 per year, but the lab work could cost me a lot more, if it's done through Cigna
    Many doctors use multiple labs, and you can require that your work be done through an in-network lab. You may need to remind them of this each time, and tell them which lab to use. You can also get your lab work done independently, at an in-network lab. The doctor would write you a prescription for the lab work, and off you'd go.
    Use Yah Blinkah!

  8. #8
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    UHC is popular with employers because they aggressively market themselves to acquire new business. In fact, they have been known to take a loss in the beginning of a contract to secure new clients. Employers love that, and that's why you seen them hiring UHC, including my old employer. As a Benefits Manager, I brought UHC into one of my
    companies, and overall my employees liked them. With that said, Cigna's HMO is about average in the industry. Personally, my wife and I have used HMO's for 25 years, and had very little troubles with any of the carriers we have used. I even had surgery that my HMO covered at no cost. Your PPO wont do that for you, but I do understand the desire for the freedom that a PPO carries. I just never felt the freedom was worth the extra premium cost, and the copays the PPO required.

    One question you need to ask at the Open Enrollment meeting concerning the HMO is about referrals. Many HMO's now allow patients to directly refer themselves to a specialist, without having to have the primary care physician order the referral. This is available for most specialists, like ENT's, Dermatology, Podiatry, but not all. You have to follow a particular procedure to do this, but it's not hard. This is something the carrier should easily be able to answer.

    BTW, you are correct, some doctors wont take HMO insurance, for the most part because of how they get paid. Plus they don't have to answer to a medical group about the care they are providing. For example, I once had an ENT doctor refuse to perform surgery for one of my employees children because he didn't like how much he was going to get paid to perform the surgery, even though he was under contract to perform the surgery at an agreed upon price. Mind you, the child was losing more of his hearing as every day went by, yet the doctor kept wanting more money. I had to get his Medical Group to threaten him with legal action if he didn't perform the surgery immediately. This is rare, but it is example of what can happen. With that said, for the most part, using an HMO is a lot easier to use than a PPO.

    One thing you didn't mention was if you are on any medications. I only mention this because each insurer has their own formulary list, and one company may cover a drug at one price, and the next company do it differently. For example, the wife of my CEO used to get migraines, and she got a 30 day supply from old company, whereas UHC barely covered the drug and would only authorize 6 pills a month instead of the 18 she used to get. You can imagine the problems that caused! My point is, your company will have done a "disruption report" which will tell them the differences in the coverage, it's good to know in advance what to expect.

    But the bottomline is, the choice of HMO vs. PPO is very personal. Some people hate the "managed care" concept of the HMO, others like the overall lower costs that the HMO brings.

    Good luck in making this decision.

    BTW, as others have stated, don't worry about travelling out of the HMO area and getting sick or injured. All you need to do is keep receipts for anything you paid for, and file a claim when you return.

  9. #9

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    I also work in insurance, and IMHO, an HMO is restrictive, yes, but it does wonders in keeping the cost of the plan down for your employer (and ultimately you in your payroll deduction contributions) AND your out of pocket costs.

    PPOs, EPOs, etc, allow more freedom, but because out of network doctors aren't contracted with the insurance carrier, they can charge you whatever they want for services. Most out of network benefits pay based URC (Usual, Reasonable and Customary), so if you go out of network for a service, and the doctor charges you more than the URC amount, you will get balance billed and have to pay that amount on top of any copay or coinsurance. This can significantly increase your out of pocket costs if your doctor is not in network.

    A few things to keep in mind (my apologies if someone already mentioned these, I just skimmed the thread quickly), make sure any hospitals, doctors, specialists, pharmacies and labs are in-network, otherwise you're going to get smacked with a huge bill and be responsible for 100% of the charges of any out-of-network services. You can search the Find a Doctor section on Cigna's website to see what facilities and doctors in your area are in network for the HMO plan.

    Anyhoo, sorry for rambling and I hope this helps...
    "You may know what you need, but to get what you want better see that you keep what you have." ~ Stephen Sondheim

  10. #10
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    My experience with UHC in Nebraska is that UHC sucks. They aggressively negotiate provider contracts to the point that some physicians will not accept UHC clients. But that probably is regional specific. I've opted to stay with my physicians who were out of network but even they have a contract that limits what they can bill for, that was the final straw for one of my doctors who I have had for 22 years. That office would no longer keep me as a patient because of that. UHC hadn't allowed a change in costs for 8 years. Fortunately my husband's employer changed benefits from UHC to BCBS. At the same premium with more in network providers, lab, radiology, and hospital services.

  11. #11

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    I wanted to add that United Healthcare is currently in a big fight in Delaware with AI DuPont Children's hospital. The contract expired Monday at midnight. They may still be negotiating, and a lot of the families switched to other insurers, but there are still a couple thousand kids whose insurance is screwed up right now.

  12. #12

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    I'm lucky to have a choices of a number of not-for-profit insurance options. They're slightly more expensive, but less likely to screw the doctors or the insured. If you don't travel outside of your home area more than 3 months a year, a regional carrier can be a good bet.
    AceOn6, the golf loving skating fan

  13. #13

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    I got some info from our benefits office. The Cigna HMO is valid only within our county. They don't have an out of network option, so if I go outside it will be as if I don't have health insurance. They gave me a number to call and find out if my other doctors accept Cigna HMO. It does cover emergencies out of state though.

    This really sucks. I was happy with Cigna PPO. If I switch to UHC, I will have to pay out of network for my primary physician and ask him to give me a prescription for labs that are not a part of Cigna. It was very convenient for me to have everything in one building and just 3 miles from my work.

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