Help me understand (& maybe purchase) health care
September 13, 2010 2:50 PM   Subscribe

I'm purchasing health insurance for myself and my partner. I've never had health insurance before, and am more than a little intimidated by the process. Bonus: I live in the Bay Area and one of my choices is Stanford's Cardinal Care. Help/suggestions/advice please!

I'm a thirty year old female living in Oakland, CA (nonsmoker, no kids, hypothyroidism as my only preexisting condition). I'll be purchasing insurance for my partner as well (he's a 28 year old male, also nonsmoker, no preexisting conditions). We're both fairly low-income--so cost is certainly a concern--but I'll be receiving a health insurance stipend of about $300/month if I choose not to purchase Cardinal Care (I can keep the difference if I buy cheaper insurance).

I've never had health insurance before (the reason I'm buying it now is that I'm starting an academic fellowship at Stanford, which requires it), so this whole process is kind of intimidating. Health-wise, I tend to spend money on dental work (lots!) and almost nothing else but for annual pap smears and twice-annual bloodwork to check that my thyroid meds are doing their job (though I recognized enough of myself in the epic ADD thread of yore to make me wonder if I should investigate that a little further, so that might be a future consideration). My partner has even fewer health needs than I do besides getting his teeth cleaned annually and getting new glasses every year or two. But he does a lot of physically strenuous labor, so it probably makes sense for him to be covered, too, since I can afford it right now (though I guess I don't have to buy him insurance).

Right now I'm considering:
* The fact that I'll be able to use Stanford's student health services and pharmacy regardless of which insurance option I choose. ("Vaden Health Center services include primary care, counseling and psychological services, radiology, lab, pharmacy, physical therapy and nutrition.") I imagine I'll be able to take care of almost everything through the student health services the day or two per week I'm on campus, though obviously this won't help my partner (or be useful to either of us in a "hit by a bus" situation).
* Cardinal Care (through HealthNet of California) from Stanford has a $200 annual deductible (wow), a $20 copay for treatment at Stanford University Medical Center or Menlo Medical Clinic with a referral from the Stanford health services, and a 20% copay for services at those hospitals without a referral. At first glance this seems like the best option, but for only me it'll cost exactly the amount of the stipend; it'd cost another $202/month to cover my partner (yikes), and may not be as flexible since I won't be living in Palo Alto.
* Kaiser's "Deductible 50/5000" plan (50 refers to the copay amount & 5000 refers to the deductible) which says "$50 copay for preventive care (not subject to deductible) and offices visits (subject to deductible)." It would cost $211/month for both of us.
* Kaiser's "Deductible 0/1500 with HSA" which would cost $344 for both of us.
* But, honestly, both those Kaiser plans feel fairly arbitrary. Ugh.

What exactly is preventative care if it's NOT an office visit (re the 50/5000 plan)? Some of the Kaiser plans I'm choosing from "offer a copay for preventative care and certain other services" before the deductible; what are those "certain other services"? What's the point of having a health savings account, since I doubt I'll be able to put a significant amount in it? If the plan says office visits are "no charge after deductible" but the deductible's $5000 (or even $2700), and I'm sure I won't spend anywhere near that over the course of the year, is there any point to my buying anything besides the very cheapest plan? What else should I know about/be aware of/pay attention to? What have your experiences with Kaiser (or other companies) been? Any suggestions for particular plans I should consider (or avoid)? I apologize for the tl;dr-ness of this, but this is stressing me out and I realize I don't even know where to start in thinking about such a large expense that, well, I probably won't get much benefit from, barring a "worst case scenario"/hit by a bus situation!
posted by anonymous to Health & Fitness (12 answers total) 5 users marked this as a favorite
Is there anyone at Stanford you could talk to about the insurance question? Most of the time I've gotten the best info from coworkers since they are other users of the plans you'll be getting. You should also call and see exactly what student health services covers.

Also dental insurance is usually totally seperate from health insurance. You should find out if you get dental insurance.

The health savings acct lets you take money out of your pay pres tax to use for approved expenses not covered by insurance. If you don't use it up by the plan year end you lose the money. It's good if you have regular set expenses you know aren't covered by insurance. Like you could claim copays from drs visits and prescriptions.
posted by oneear at 4:11 PM on September 13, 2010

I live in Oakland and have purchased individual health insurance here; I'm currently insured with Kaiser.

If you want First World healthcare, you're not going to find anything on the market that comes close to the Stanford plan. That's a great deal.

Kaiser is big and impersonal, but have a decent reputation for quality care. They're a nonprofit, and I feel less certain that they'll try to deny benefits on a technicality than with a for-profit insurer.

You save $1,600 annually on premiums for the more austere of the two plans you're considering, so basically the cheaper plan is a better deal for a "normal" year at the level of health care you and your partner are typically consuming (well below either plan's deductible -- meaning you'll pay for everything out of pocket in a typical year, regardless of which you choose). Both plans will kick in and cover a catastrophe; it's up to you to weigh whether the difference in premium is worth it to purchase the $4,500 lower deductible.
posted by gum at 4:16 PM on September 13, 2010

To answer some of your questions about terminology:

*Not all office visits are preventative care; generally, preventative care is the stuff that you do when you are still healthy (screening for cancer, getting immunizations, your annual well-woman physical, your once-every-five-years comprehensive physical where they take your blood and check your overall health). Any office visit to take care of an illness or injury is not preventative, and so you'd be paying totally out-of-pocket for that until you hit your deductible--then you'd continue paying a part of it afterward, up to your maximum annual out-of-pocket limit. That's probably less of an issue for you, because you can access student health services for a lot of the primary care stuff, but potentially a bigger issue for your boyfriend.

*There's probably little point in your having an health savings account, because those are mostly used to shelter income from taxes. If you're low-income and you're a student, I'm guessing your marginal tax rate is so low it's not worth pursuing HSAs or FSAs. I'd ignore these, honestly, in your situation.

*I have Kaiser (not in California) and I like it a lot. They have a pretty advanced medical records system, bunch of all-the-time urgent care centers open after regular business hours and on weekends, and their medical centers are big enough that my experience has been I can call up with urgent stuff (like say a UTI) and get in right away. However, given that most of your primary care would be done through Stanford, I think you're losing a lot of good stuff about Kaiser that makes putting up with the irritating stuff (they're hesitant to prescribe or treat quickly when watchful waiting is an option, if you are stricken with a rare disease you're going to see a Kaiser doc and not the world-famous specialist down the road, etc).

*More generally, there are three big dimensions on which health insurance varies:

--the benefit package (what is covered and what is not covered, is there any lifetime limit to my benefits),
--the cost-sharing (how much do I have to pay under different situations, what is the most I would ever have to pay in a year if I was really sick),
--the premium (what I pay per month)

The premium is very sensitive to benefit package (fewer services, lower premium) and cost sharing (higher deductible and copays, lower premium). If you want low monthly costs you can "buy down" the premium--in essence, accepting more risk yourself--by either increasing your cost sharing (moderately risky) or shrinking your benefit package (pretty risky once you get past things you are certain not to need like maternity care or fertility treatment). The Kaiser plans you are looking at are cheaper both because you will pay a lot more if you actually use services, and also because it covers a lot less--most notably, it doesn't cover prescription drugs, which is a pretty big coverage gap.

Honestly, if it were me (and I'm just an internet stranger, so take this for what it's worth), I'd go with Cardinal Care. My reasoning would be as follows:

1. Since you get primary care through Stanford, your major reason for having insurance is for moderately- to extremely-expensive medical problems. (Note that student health services doesn't cover surgery or hospitalization, and there's a whole host of things that can befall otherwise-healthy 28-year-olds that would cost thousands of dollars. Appendicitis, food poisoning so bad you need to be admitted to a hospital for an IV, breaking an ankle... and that's not counting true catastrophes like being in a bad car accident or getting cancer.) Because of this, I'd be inclined to focus *less* on the out-of-pocket for an office visit and *more* on maximum annual out-of-pocket. For Cardinal, it's $500 per year. For the two Kaiser plans you linked to, it's more along the lines of $7,500 (for each of you, not together). That's a pretty significant difference. Would you be able to remain in school if you needed to come up with $7,500? Or would that be the sort of bill that is too big for you to cover with an emergency fund? I'm guessing it might swamp you; the reason to get insurance is to protect against this exact situation. Medical bills don't have to be cancer-sized to totally fuck you.

2. For your boyfriend: same as above, except primary care and prescription drugs aren't free through Stanford for him. If he is injured, even a minor injury, can you afford to pay several hundred dollars to get him fixed before insurance kicks in anything? Even after you hit the deductible, the cost-sharing is pretty steep until you hit maximum out-of-pocket for the year--you'd be on the hook for 20 percent of the cost of inpatient hospital care, which can get really, really, really pricey. Prescription drugs aren't covered at all, which is a pretty significant gap for your boyfriend in a catastrophic situation--an increasing number of treatments for cancer are covered under the category of prescription drugs (like Avastin). I'd be really wary of going without prescription coverage for him at all.

3. Lastly, the fact that you (and all other subscribers) are getting "free" primary care, prescriptions, and lab/xray is priced into Cardinal Care--I'm guessing that (along with the fact that students are generally a younger and healthier population) is what is driving a surprisingly** low premium cost for what is a pretty extensive benefit package (mental health benefits, maternity benefits, etc). If you go with Kaiser, you won't be using those benefits through your insurance, but you will in effect be paying for them since they are covered for everyone else in the risk pool.

**In fact, paying $200 per month per person for this type of coverage is... unusual, extremely so, unless your employer is subsidizing a huge part of it without you realizing it. It's a good enough deal that personally I'd be really hesitant to pass it up for my partner if I could swing it financially every month.
posted by iminurmefi at 4:18 PM on September 13, 2010

Kaiser has a lot of clinics -- vaccination, classes, etc. -- that aren't a strictly one-doctor, one-patient type thing. Perhaps that's it? Kaiser has folks who are thrilled to talk to you if they think they can sign you up. I liked the convenience of the electronic health records, nurse lines, infrastructure, no-paperwork of Kaiser. I disliked that their first line nurse practitioners and primary care docs seemed really... underwhelming in quality (although I loved my specialists).

Check your paperwork, but health savings accounts sometimes cover things like copays, medicines, glasses, Tylenol and Sudafed from Walgreens, etc. If you're good about doing mail-in rebates elsewhere in your life, you'll love it. If you're a "why bother", you may leave money sitting on the table.
posted by Gucky at 4:18 PM on September 13, 2010

[disclaimer: I'm just a guy with health insurance for my family in MN]

What exactly is preventative care if it's NOT an office visit (re the 50/5000 plan)?

"preventative care" is routine stuff that you do as a matter of course.

I have a high-deductible plan with an HSA. If I just decide to go to the doctor tomorrow for some specific complaint [My knee hurts, or what have you] that visit is a standard office visit and I pay out of my HSA. My insurance won't cover it until I hit the deductible.

My annual physical [and those of my kids and spouse], however, is covered regardless of my deductible. That's preventative care. Your pap smear and so forth would probably fall under that umbrella. I can't speak to the thyroid testing. That'd be a question for the Kaiser folks.

Some of the Kaiser plans I'm choosing from "offer a copay for preventative care and certain other services" before the deductible; what are those "certain other services"?

This, again, is a question for the Kaiser folks, and it should all be spelled out in detail somewhere, but based on that website you linked, the services with co-pays after deductible are:

Periodic Health Exam $50 Copay (deductible waived)
Periodic OB-GYN Exam $50 Copay (deductible waived)
Well Baby Care $30 Copay (deductible waived)

That group is "preventative care"

Office Visit for Primary Doctor $50 Copay after deductible
Office Visit for Specialist $50 Copay after deductible
Emergency Room $150 Copay after deductible
Outpatient Lab/X-Ray $10 Copay after deductible
Mental Health Coverage $50 Copay Individual Visit / $25 Copay Group Visit, 20 Visits per year (after deductible)

That group is "certain other services".

What's the point of having a health savings account, since I doubt I'll be able to put a significant amount in it?

One thing is that the money you put in there stays with you and accumulates over time. When I first switched to a high-deductible plan with HSA, it turned out that the annual HMO premium [rather like your Kaiser 0/5000 plan] was equal to high-deductible-plan + deductible [which is what went into my HSA]. Assuming we went to the doctor as much as we did the previous year, it was a wash. If we spent less, the excess left in our HSA carried over to the next year.

Note that an HSA is NOT the sort of medical-expense account that is forfeited at the end of the year [at least not here in MN], as oneear mentions.
posted by chazlarson at 4:19 PM on September 13, 2010

Full disclosure: I work at Stanford.

In terms of quality of care, Stanford Hospital's practitioners do not do general care well. The specialists in the hospital are fantastic, and most of the hospital's resources go to support the big ticket items-- surgery, cardiology, oncology. Because of this, the quality of the Family Practice and Stanford Medical Group (General practitioners) is not that great. But if you have a big emergency or chronic condition, Stanford is a great place to be treated. You can get decent care from Kaiser, and you're right, I doubt you'd spend $5000 in a year on non-preventative care unless there was a big emergency.

If you're essentially using the services at Vaden (which is separate from the hospital and is fairly decent, from what little I've heard) for general/preventative care (physicals, paps, screening tests, etc.), you'd probably only need coverage for emergencies, so I would go with the cheapest you can get, which is the high-deductible Kaiser plan, but that's just my opinion. YMMV, and imminurmefi makes a good point about whether you would have $7500 to cover emergencies should they happen. But if you're getting $300, and it costs $211 for the cheapest plan, you could put the extra into savings.

Pointedly ask your fellowship coordinator who you should talk to in benefits about this-- these are exactly the questions they are meant to answer. I honestly found that the best info I got was from co-workers, so definitely talk to former fellows if you can find them (they may have gotten hired on full time in the department).
posted by sarahnade at 4:40 PM on September 13, 2010

Do NOT use Kaiser. I repeat: NO KAISER. Seriously. I have heard so many horror stories about their care. My father is a physician in San Francisco and his attitude is "it's easier for Kaiser if you die." In fact today he was telling me that a friend of his passed, and I asked what happened, and he said "well it's not entirely clear...he went to Kaiser's ER know."

The other thing that pisses me off about them from a business standpoint is that their whole thing is to be an HMO/hospital/docs office/pharmacy combo, but the various Kaiser regions don't even share records or coverage! My friend who has Kaiser Northern California couldn't get treatment at Kaiser in LA.

I don't know much about Stanford as general care, but they do have great specialists if something major happens (cancer, etc).

Do check if dental (and vision, if you wear glasses) are covered in the plans you're looking at. Usually they're separate. Most health plans cover *medical* eye stuff (like if your eye is injured) - some cover a vision exam every year or two.
posted by radioamy at 6:38 PM on September 13, 2010

I have no idea how Stanford works, but in my experience university clinics will bill your insurance just like any other provider. University clinics are nice in that they're student-focused and convenient, but they're not free.
posted by miyabo at 6:44 PM on September 13, 2010

I've been going through a similar process right now. My husband just started graduate school, and we've decided to pay a ton so that I can get on his group plan--honestly, $200/month to get him covered is relative bupkis. If it makes you feel any better, it's going to cost me about $400/month for health coverage on my husband's plan (!). However, the deductible differences are huge between a $5000 deductible (which was approximately what we were looking at for me, too) and a $200 deductible. Would you have $5000 to pay all at once if there were a medical emergency? That might seem unlikely, but I spent one afternoon in an emergency room last year because of suspected appendicitis, and it cost my insurance company nine thousand dollars. Unlikely? Sure, but there are no guarantees on this sort of thing. Other questions you might want to look into: is there any coinsurance built into this? What's the out of pocket maximum? Also consider what you would do if you got pregnant. None of the insurance I could buy had any sort of maternity coverage*. Finally, you should know that the paperwork you're going to have to presumably fill out (though underwriting might be different in CA) is labyrinthine. I started the process of applying only to find that the insurance company wanted dates and treatment information for every time I went to the doctor for sinusitus, breast cysts, and acne going back a decade. I'm in the process of getting those records just for informational purposes, but it sure did make me nervous about getting denied for pre-existing conditions.

Anyway, good luck with your choice. I know it's not an easy one.

*A few of them let you purchase maternity coverage at $120 a month--but wouldn't let you use it for 10 months, and then maxed out at $1200. I'm still not sure what the godammed point of that is.
posted by PhoBWanKenobi at 6:45 PM on September 13, 2010

I super-skimmed, so disregard if this is useless, but in a similar situation, I came up with five semi-likely scenarios (pregnancy, a horrible backcountry accident requiring a helicopter and several operations on a broken leg until ultimately they amputate, appendicitis, broken jaw during a crime, youthful onset of MS or some other chronic scenario, and any of the above while out of state and in another country). Pick things you think could happen and compare the expected costs to you. This gave me clarity while comparing plans.
posted by salvia at 8:54 PM on September 13, 2010 [1 favorite]

And to build on what PhoBWanKenobi said--not only is there a huge difference between a $200 deductible and a $5,000 deductible, but you don't stop paying for medical care after you hit a deductible. The deductible is the "floor" of what you'd have to pay before insurance kicks in at all; after you hit it, in most cases you're still responsible for something like 20% of the cost until you hit your out-of-pocket maximum for the year (the "ceiling" of what you'll pay).

Too many people seem to focus on the deductible--either because they misunderstand what it is or because they can't imagine having a medical emergency that would exceed it--and if I could give one piece of advice to everyone buying insurance it's that you need to focus just as much (or more!) on the annual out-of-pocket maximum. That's the amount that you are potentially on the hook for for a single medical event if something happens, NOT the deductible.
posted by iminurmefi at 5:42 AM on September 14, 2010 [1 favorite]

I have a good friend who is a grad student at Stanford. She also receives a (small) stipend from her department to purchase health care, but Stanford health care is hella expensive there AND they charge by the quarter, I believe (not by the month). She has had surgery through the hospital, and then had to have the work re-done. She constantly complains (as a grad student on a really low budget) about having to pay for her Stanford health care. I'm not saying that you should choose Kaiser; what I'm saying is ask around and see what others think of it.

As for Kaiser: I was turned down by Kaiser of SoCal for a pre-existing condition. You may not be able to get coverage from them as an individual with a pre-existing condition; double-check this before you turn down the Stanford insurance.
posted by librarylis at 8:52 PM on September 14, 2010

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