Should I buy a PPO insurance plan in addition to my Kaiser coverage?

October 13, 2015 4:01 PM

I have Kaiser insurance through my mom's employer (I'm 23), but due to the fact that I'm trans and have psychiatric illnesses I'm really unsatisfied with the care that I get through Kaiser. Let's put it this way: I'm totally at my wit's end. More and more I'm thinking it might be a good idea to buy a PPO plan (Blue Shield, et al) through Covered California this enrollment period. Could you help me suss out some of the issues at play here? Snowflake details within.

Hi,

I'm 23 and currently getting coverage through my mom's employer through Kaiser in Los Angeles. I'm currently unemployed and don't predict I'll be employed in the next year. I like Kaiser for a lot of reasons, but certain things are really barriers to me getting help for certain things. For example: I'm trans and in all of my shopping around for a good Primary Care Physician (PCP) I've only found one that I think is halfway decent and doesn't treat me with hostility, fetishistic interest, or disdain. But it takes me three months to get an appointment with her every time because she's so busy.

Or: I have major depression, anxiety, and an un-diagnosed eating disorder, but it's impossible for me to find a therapist that I think is competent because it takes me 2 months to get an appointment, I often don't think they're competent enough to deal with my problems, and then I'm SOL. And forget psychiatric care. I've been on a waitlist for two months for a doctor that was recommended to me by my PCP. Is he any good? Who knows. If he isn't any good, what am I going to do? Who knows, I'm SOL.

Or: I'm getting completely jerked around by the staff who handles gatekeeping for trans healthcare (I'm trying to get bottom surgery), and since it's Kaiser, I'm kind of SOL. They're ordering me to see one of their therapists for an unspecified amount of time (again, if I don't like the therapist, I'm SOL), because of what they think are unresolved issues I have around my body due to childhood abuse. This is after I've told them that I've worked through these issues of abuse with a therapist at the LGBT center and that I don't think this is a contributing factor to me wanting to get bottom surgery. But, since it's Kaiser, I have to play their game and see an unknown therapist. SOL.

I'm thinking I'd be better off if I just shell out the cash for a Blue Shield or Anthem plan through Covered California at the beginning of next month so that I actually have some freedom in navigating these problems. It's getting to the point where I'm avoiding going to the doctor or seeing specialists because I never know how long I'll have to wait if they treat me poorly (which totally happens) or aren't competent.

This is a critical point in my life because I finally have the time and space to address these persistent health concerns, but I feel like my current insurance configuration is a major barrier in doing so. I know Medical is an option, but I'd almost rather spend more money right now because I think I'll be a really high user of my insurance. Let's assume money isn't an issue. Do you have any recommendations for me?

posted by lilies.lilies to Health & Fitness (12 answers total)

...major depression, anxiety, and an un-diagnosed eating disorder, but it's impossible for me to find a therapist that I think is competent because it takes me 2 months to get an appointment, I often don't think they're competent enough to deal with my problems, and then I'm SOL...

I can't speak to the trans or psychiatry issues, but for basic talk therapy, I have Kaiser Northern California and got therapy appointments very quickly. Hopefully others with Kaiser in LA can speak up. They immediately sent me out-of-network, which allowed me to get someone super-quickly. I could choose from a large pool of therapists in the region. I got a few duds, but then I found someone with 20+ years of experience who is as good as any therapist I've had so far. I kind of cheated -- requesting three names at once, called all of them, set up multiple appointments, and called back to Kaiser to change my authorization from one to the next in between appointments -- which allowed me to quickly move past the duds to someone I really like.
posted by salvia at 4:16 PM on October 13, 2015 [1 favorite]

My experience with Northern CA Blue Shield Bronze Plan was that I was unable to contact a human at any point in the process and was not able to access a doctor at all. On the other hand, my experience with Kaiser NorCal was excellent, though I did have to make a formal complaint to speed up accessing some services (9 months of waiting for surgery turned into 3 months.) Did you try complaining? Appropriate trans services via your insurance are your legal right in California, and sometimes you have to be very assertive about that.

Also, have you tried looking for sliding scale therapy via a GLBTetc center? Since you are young and unemployed, there may be sliding scale youth services offering therapy (often via MFT interns needing hours for licensure) that don't bill or even discuss your insurance.
posted by blnkfrnk at 4:18 PM on October 13, 2015 [1 favorite]

I am pretty sure that you would not be eligible for the subsidies that make the Covered California plans so affordable if you are eligible for your mom's group plan. Without subsidies the Covered California plans are pricey.

Have you tried contacting the people at Kaiser's Northern California/Oakland Trans clinic? Many people I know seem to have pretty good, culturally competent experiences there, and perhaps they can offer you help navigating trans stuff within the Kaiser system even though you're in a different part of CA.
posted by needs more cowbell at 4:19 PM on October 13, 2015

Sorry to provide a Jam Tomorrow kind of answer, but hopefully, once it launches, MyTransHealth may help with the issues in finding good PCPs and therapists.
posted by zamboni at 4:20 PM on October 13, 2015 [1 favorite]

Response by poster: @salvia: I'd love to be able to access out-of-network services, but this is something I was told they wouldn't do as long as they had openings in Psychology within network.

@blnkfrnk: I can try calling the nurse coordinator for trans healthcare, but last I talked to them they made it clear I had to go see a therapist (not of my choosing) for an unspecified amount of time before they would even add me to the waitlist for bottom surgery. Yes, I'm currently on the wait list for the LGBT center therapy, not sure when I'll be taken off of it.
posted by lilies.lilies at 4:24 PM on October 13, 2015

My wife and I really like our Blue Shield Gold 80 PPO over the Anthem HMO we had before. No trans issues and we don't use a lot of therapy-based mental health services, so I can't speak to those. We don't get subsidies, but we hit the out-of-pocket cap, and I was surprised at how affordable the superior service was when compared to the cost of HMO.
posted by infinitewindow at 4:27 PM on October 13, 2015

Having a PPO does mean you get to choose your doctors (from a list of in-network in-plan doctors), but it isn't necessarily easier to get appointments especially as a new patient. You'll have some long wait times just like Kaiser. Some don't take new patients too. I'm not trying to discourage you - just saying the grass may not be that much greener.
posted by cecic at 9:26 PM on October 13, 2015

Kaiser can very greatly from location to location, I've been told.
posted by persona au gratin at 11:56 PM on October 14, 2015

Just another heads-up of the grass-may-not-be-greener variety: whatever insurance you have, you may have to jump through some hoops to get bottom surgery approved, including getting a sign-off from a therapist.
posted by merejane at 8:54 AM on October 15, 2015

Response by poster: @persona au gratin: This is what I'm hearing too. It sounds like NorCal is a lot easier for trans women friends I have.

@merejane: Yes, there will definitely be loopholes. It's just at Kaiser I don't have choice about which surgeon I use, and I'm also at the mercy of the nurse coordinator, because my case is being held up for what I think is a bullshit reason. At least if I had a PPO I could just see a different therapist if someone didn't write me a letter.
posted by lilies.lilies at 2:09 PM on October 15, 2015

Is there a local advocacy group you could ask for advice and recommendations before you dump Kaiser? I ask because everyone I know with Blue Shield &c. has to wait months for appointments, beg for referrals, and all kinds of other crap. Granted Oakland Kaiser seems like one of the best, but I never have the problems with Kaiser that other friends do with their not-Kaiser insurance.
posted by oneirodynia at 2:19 PM on October 15, 2015

@salvia: I'd love to be able to access out-of-network services, but this is something I was told they wouldn't do as long as they had openings in Psychology within network.

Well, a two month wait doesn't really constitute "openings" in my book. Try again, emphasizing some of your more acute symptoms? Kaiser got sued not too long ago and is upgrading access to therapy services as a result, so things might still be in flux.

Another thing to consider is whether paying out of pocket might be simply cheaper than the cost of a plan and the deductibles and co-payments. I found sliding scale therapy for $65; my Kaiser co-pay is $30. So a monthly plan cost of $145 would be a losing proposition for me. But I realize you're trying to access a whole suite of services, not just weekly therapy.
posted by salvia at 4:29 PM on October 16, 2015