Topic: HMO vs. PPO - SF Bay Area

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Posted on: Sep 24, 2010 04:09PM

Posted on: Sep 24, 2010 04:09PM

littlefeet wrote:

I need to make a fairly quick decision about insurance and whether to trade an HMO for a PPO. Most of my concerns stem from questions about what my options will be when it comes time for reconstruction. I want to be able to get a DIEP or Tram, assuming there is enough tissue, and I don't want the appeal process with an HMO to interfere with my being able to get immediate reconstruction using the procedure I want. It seems a PPO would make that more likely. If anyone has any opinions and would be willing to share their experiences, I'd be grateful. I am in the SF Bay area, currently am going through chemo at UCSF, and will be having a mastectomy in February or March. My insurance options are Blue Shield/Hill Medical Group HMO or Perscare PPO (a couple others, but I'd probably go with Perscare). Thank you,

Laura

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Sep 24, 2010 04:37PM lauri wrote:

Check with UCSF to see if they've had problems with your issue using the HMO.  The breast clinic might know, or the insurance coordinators.  I had coverage at UCSF under an out-of-state Blue Cross PPO plan but didn't have reconstruction so I can't address your specific question.

From the ashes of disaster grow the roses of success Dx 3/8/2006, ILC, Left, 6cm+, Stage IIIB, metastasized to bone, Grade 2, 11/12 nodes, ER+/PR+, HER2- Dx 11/15/2021, ILC, Stage IV, metastasized to bone Hormonal Therapy 11/27/2021 Femara (letrozole) Targeted Therapy 12/2/2021 Ibrance (palbociclib) Radiation Therapy Whole breast: Breast Surgery Mastectomy: Left Chemotherapy AC + T (Taxol) Hormonal Therapy Arimidex (anastrozole)
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Sep 24, 2010 05:33PM ibcmets wrote:

Laura,  With an HMO; you may not have the option to see a certain doctor you may want to see.  You may also have to travel further to see someone they designate.  The first place to check is with UCSF.  I go to Valley Oncology in the bay area.  They are affiliated with UCSF.  Of course even with PPO's you would be paying more if  out of network with your doctors.

Terri

6/2009 stage IV diagnosis w bone mets ,Xgeva , 2015 brain mets, liver metastasis
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Sep 24, 2010 06:43PM CoolBreeze wrote:

Interesting because I'm in the same boat. I have perscare blue shield HMO and it's been great all last year with my cancer treatment.  However, my plastic surgeon doesn't accept Hills.  Because my old PS dumped me (decided on the operating table he didn't want to do reconstructions anymore!) so  I get to make an exception and see him, but it requires paperwork and some fear that I'll end up rejected (again)  Since I've had the expander in for a year, I really want it OUT!

Other than this one thing though, every single thing has been covered 100%.  All my chemos, alal my doctors, everything.  I've gotten the same care everybody gets - just as quickly.  So, I'm not sure I want to change.  :) 

Ann's cancer blog: www.butdoctorihatepink.com .....multicentric/multifocal IDC/ILC+DCIS/LCIS/ADH Official dx? "Your breast was a mess." ~UniMastectomy/Chemo/Herceptin/Tamoxifen/Recon Almost Done! Oh wait. mets to liver 5/21/11 Now Stage IV Dx 8/17/2009, IDC, 4cm, Stage IIA, Grade 3, 0/3 nodes, ER+/PR-, HER2+
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Sep 24, 2010 07:34PM littlefeet wrote:

Thanks everyone for your responses. I hadn't thought of trying the UCSF insurance administrators, so will look into that. Sorry you went through that experience, CoolBreeze - sounds awful. I have heard good things about Dr. Foster (plastic surgeon) at UCSF, so you might consider checking there if the paperwork nightmare becomes too much wherever you are now... I'm pretty sure that my HMO will ultimately cover the DIEP based on older msgs I've read on this board, but I want to have things ready to go and not months of appeal hell when it's time for my surgery so that I can get immediate reconstruction/DIEP. I'd like to be able to take 2 months off to heal and then go back to work. I know there will be revision surgeries/appointments, but I would so much like to have the bulk of everything behind me.

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Sep 24, 2010 09:47PM CoolBreeze wrote:

I've heard good things about Foster too.  

I'm in Sacramento though, don't want to do the drive if not necessary.  My new PS also has a fine reputation so I'm comfortable - I just think of the years of revisions ahead and would like to make it easier on everybody.  I will still get to see him but they set time limits on all my treatments with him and then their office has to appeal...it's just a silly game.

Yes, it was awful - I have had the expander in a year and didn't need radiation!  I am too thin for any other kind of reconstruction so this was it.  The expander is so uncomfortable - I cannot WAIT to get it out of me.   Sometimes I think I should sue my last PS for causing me this problem.  

Ann's cancer blog: www.butdoctorihatepink.com .....multicentric/multifocal IDC/ILC+DCIS/LCIS/ADH Official dx? "Your breast was a mess." ~UniMastectomy/Chemo/Herceptin/Tamoxifen/Recon Almost Done! Oh wait. mets to liver 5/21/11 Now Stage IV Dx 8/17/2009, IDC, 4cm, Stage IIA, Grade 3, 0/3 nodes, ER+/PR-, HER2+
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Sep 25, 2010 01:36AM gale1525 wrote:

Make sure the doctors and hospital you choose take what ever insurance you want.  Doctors don't take all insurances. Even with a PPO you need to stay in network to get your best rates

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