Choosing a Health Insurance Plan

Except for the past 12 months, for most of our marriage, one or both of us have been employed by a large health system that provided decent HMO insurance.  We had a set copay for a visit to our Primary Care Physician and a slightly higher copay for specialists (and it required a referral).  We also had a set copay for an Urgent Care Visit and a copay for Emergency Room Visits.  Lab and radiology work was generally covered 100% (I can't recall ever paying anything for any lab work or radiology).

Then last June, my husband was "laid off" (it was termed laid off but there was no plan to have him return so really it was terminated).  We were blessed with a specified term of severance and we chose a COBRA option of that termination.

Then one year ago this week, my husband started a new job and we had to totally switch gears with our health insurance, including switching our care to the major competitor for his previous employer.  This has been a hard switch and we delayed switching physicians as long as we could.  We still miss our previous physicians, espeically our pediatrician and ENT/audiologists.  When we selected our healthplan, we selected the more expensive plan because it was closest to what we were used to AND was cheaper than what we'd been paying.  The hardest adjustment has been switching from an HMO mindset (all those set co-pays) to a PPO setting (with the benefit of being able to see a specialist without a referral - we don't even have to select a specific Primary Care Physician; we can change who we see at anytime without notifying anyone).

Just a 2 months later, we were having to re-select our insurance plan for the 2010 year as our new employer was adding a 3rd option for Healthcare.  The Premium PPO would be $236/month for our family.  The Value PPO was set at $95/month.  And then the new Consumer PPO plan would be FREE!  Oh how wonderful to think that we could not pay a monthly premium for health insurance!!

Fortunately, I LOVE LOVE LOVE spreadsheets and math.  I sat down and came up with a couple likely scenarios.  Love gets kidney stones every few years and it had been several years so odds were it could happen in 2010.  Princess Naked Toes is very adventurous so it was extremely likely in 2010 that she would end up in the ER or Urgent Care for some incident during an adventure.  My personal experience with my former PCP (who I had a love/hate relationship with) was that if I was sick or had a problem needing to be seen fairly quickly, he would be completely booked for a month out so I'd have to go to Urgent Care.  I estimated costs for those 3 likelihoods and then plugged in how much it would cost us under each of those three PPO plans.  Based on those numbers (our tendency to choose the Better over the Good and not buying the most expensive items), we selected the Value PPO.

In mid-July (2010), my husband started experiencing some severe pains which he self-diagnosed as a kidney stone.  After several weeks of painful days/nights followed by okay days, he was in enough pain that I was able to convince him to see a Urologist and we were blessed to find someone to see him in the office that day rather than an ER visit.  Under the Value PPO, we have a copay for office visits verses 80% after deductible for ER services.

That was a Monday.  He ended up having a CT Scan that afternoon, confirming a kidney stone that still had a LONG way to go to work it's way out.  Based on the stone's position and size, it was decided to do a lithotripsy that Friday.  Let me just say that I WAY under-estimated the costs for a kidney stone.

So today, I sat down with all of our claims information for 2010 and created a wonderful spreadsheet comparing how much we've paid this year to how much we would have had to pay with both the Premium plan and the Consumer Plan.  Now, I went ahead and calculated all 2010 monthly premiums into our costs so basically it's assuming, we have no more medical expenses.  So far, there is only a difference of $800 between the 3 plans with the Value Plan (the one we chose) having the lowest costs to us!! 

I've decided to keep the spreadsheet up to date with any future 2010 claims so that as we get to select for 2011, we'll be very educated on potential healthcare expenses in 2011 for each plan.  Of course, monthly premiums and coverages may change so I'll have to change the spreadsheet accordingly, but I already have the base numbers ready to go.

As you prepare to select your own insurance plan coverage, I strongly encourage you to come up with what is reasonable for your family to experience during that coverage period.  Include annual well-child exams, immunizations, glasses, a replacement hearing aid for the one that your family loses over the summer (oops - forgot to put that in our spreadsheet but I'll use the excuse that we haven't purchased the replacement yet), an ER visit for your own adventurous child, and maybe even an urgent care visit for the potential bike accident of your bike-riding spouse.  The hardest part is estimating costs and a call to the local hospital may not be helpful because they'll won't know the specifics.  So estimate HIGH.

Good luck!