If I learned anything since my diagnosis, it’s that American health plans are pretty much all the same if you don’t have any special needs. That is, we bounced around a fair bit between various HMOs and PPOs and POS’s over the years. Some had higher co-pays, others had higher deductibles. It didn’t make that much difference, and even though I have three kids, I never looked into it very carefully.
Then I got diabetes. I had to see an endocrinologist regularly. I had to see a diabetes educator and a nutritionist regularly. Since the diabetes affects everything, I had to see an ophthalmologist, allergist, gynecologist, podiatrist, and sometimes orthopedic surgeon. My life became a nightmare of pre-authorizations and referrals. Who was in my network? How much would I have to pay if they weren’t? Why does my local “Medical Group” have the right to restrict me from seeing the world-class diabetes specialists at my local university?
What I found out is summarized below. Note that this highly condensed info took me a good half-year to work out, and with every agency sending me off in another direction, getting there was a bit like taking Mr. Toad’s Wild Ride in very slow motion. (The details of your plan options may differ, of course!) And note that just as I’ve figured this all out, my husband’s company is CHANGING PLANS AGAIN!! Am I covered for Exploding Head?! Anyway, here goes:
Cheapest option, but everything goes through your primary care physician. This means you need a referral from your “family doctor” for every other doctor or treatment. A pain in the @#$!! for most diabetics, who generally only see their general practitioner at the point of diagnosis, and then move on to real diabetes care. Luckily, you can usually call in for a referral, and a single referral can often provide for a long-term treatment. Standard copays for doctor visits are just $10. BUT you are locked in to choosing providers within the local network, or Medical Group, contracted with your health care plan. This includes hospital care. You need to go to the Medical Group’s specified hospital, except for out-of-town emergencies, which are supposedly covered at 100% (in my experience, you still get billed for various treatments). The HMO is also the only plan option that offers “non-critical” medical services like education and training. (Hello, 18 M diabetics in America need this stuff!)
If you choose to go out-of-network (outside the Medical Group), you pay a percentage of the provider’s regular fees for each treatment. The stinger is that your health plan will not cover any percentage of an out-of-network service that your Medical Group claims to offer itself.
Most expensive, with a significant annual deductible, because you can see any doctor including specialists without referrals. Still, they make a distinction between “preferred” and “non-preferred” providers. Preferred have signed billing agreements with your health plan, so you as the patient pay just a 20% copay versus a 40% copay for providers who have no relationship with your plan and can charge whatever they like. With our provider, the PPO plan does not cover any “special programs” like nutritional counseling or diabetes education.
The POS (Point of Service) option doesn’t cost much more than an HMO, and lets the patient choose for each medical service whether to use HMO or PPO benefits. So you can use your HMO option, and get a referral for an in-network doctor at a $10 copay, or you can go the PPO route and see a preferred provider at 20% cost or a non-preferred provider at 40% cost. Here’s the rub: these choices have caused a great deal of billing confusion, so much so that many POS plans have been cut altogether. It’s up to YOU, as the patient, to tell your doctor which option you’re using, or they’ll probably bill you incorrectly. Naturally, you’ll want to go the HMO route if your doctor’s in the local Medical Group, because it will cost you less.
With services like counseling and diabetes education, you often have no choice really. For example, under our plan, since these services are covered only by the HMO, you’re locked in to whatever your Medical Group happens to offer (unless that group grants you an exception). No matter that a nearby university has a world-class diabetes center! If your Medical Group offers “equivalent services,” they won’t be granting any exceptions — so you get whatever they’ve got, unless you want to pay full price out of your own pocket to upgrade your care. In my case, a half-hour visit with my wonderful educator at UCSF put me back $380 without the insurance. I haven’t seen her for a year.
All the diabetics I know have had similar troubles, discovering their plan doesn’t cover some critical portion of their care.
I know I’ve said this before, but I still don’t get it: Why are US health plans so restrictive on services that have the potential to ward off the big bills? Why shouldn’t patients have the freedom to take advantage of the best educational resources in their area, even if these resources aren’t the health plan’s devoted business partners? Happily, diabetes is very manageable with good training and education. If not properly managed, diabetes complications are going to cost the health plans a hell of a lot more than university counseling sessions would (!)