Topic: Kaiser Insurance- San Diego: good, bad or ugly?

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: May 21, 2011 11:45PM

Posted on: May 21, 2011 11:45PM

soccermom wrote:

Looks like I'm going to have to switch insurance again and the only option available through my employer is Kaiser. Anyone have reports on Kaiser they could share with me? I am 7 1/2 years post DX. Just getting yearly mammo/ultasound, surgeon and onc consult and MRI of good breast every other year. I was Her 2 + and had AC/T then one year of Herceptin. I have implant reconstruction with augment/lift on the "good" side. Otherwise no major health problems other than fairly severe arthritis in my big toe due to an old injury and feel some arthritis creeping into my feet. Had lymphedema for first few years post TX but that has mostly subsided.

The premiums are mostly covered by my employer and there is a choice between the $30. copay/no deductible or the $30. copay with 1500. deductible. 

Any info greatly appreciated and I have to decide by Weds. at the latest. 

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 22, 2011 12:16AM Joanne58 wrote:

First, congrats on your 7 1/2 yrs post dx!  It's nice hearing from women who are doing well after Herceptin, too.  Sorry about the arthritis, but glad the LE has subsided. 

I'm getting tx at Kaiser, Baldwin Park, and am very happy.  There is no way we could have afforded my cancer dx had we stayed on our previous PPO.  We're self employed, and Kaiser offered us the best plan for our family of 4.  You're lucky to have an employer pay the premiums--a HUGE savings!  I love seeing my lab/office visit results on line the day I received them.  Emailing Dr.s has been great, too.  And Kaiser's automated system calls to remind you of EVERY appt. without fail.  My family's 2 1/2 years with Kaiser has been a very positive experience.

Best wishes in your decision, and I hope you find the kind of Dr.s you're looking for within Kaiser San Diego.

"There is beauty all around when there's love at home." --John H. McNaughton Dx 9/7/2010, IDC, Left, 1cm, Stage IIA, Grade 2, 1/3 nodes, ER+/PR+, HER2+, Surgery 9/16/2010 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 10/28/2010 AC Targeted Therapy 1/21/2011 Herceptin (trastuzumab) Radiation Therapy 3/23/2011 Hormonal Therapy 4/27/2011 Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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May 22, 2011 12:41AM soccermom wrote:

Thank you, Joanne- It really is reassuring to hear that! I'm feeling better about the whole thing already. I'm realizing that my employer group plan actually is a pretty good deal, just need to adjust to the whole idea. Don't really have much choice. Were you on Kaiser before your DX? Someone said on my other thread that if you have an individual plan they will drop you if you get sick? But other people said that is illegal, so that was a confusing issue about the individual plans.

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 22, 2011 01:19AM Joanne58 wrote:

I was with Kaiser more than a year before my dx. My husband was diabetic before we joined and I had a rare eye disease of my corneas that I was afraid couldn't be treated at Kaiser. We were accepted with these illnesses and not "dropped" after we joined, due to my BC.

Funny coincidence--my favorite eye surgeon is at Sharp!  I drove to San Diego for years, just to see him, and worried the most about losing him when we switched to Kaiser.  The good news is he connected me with a Dr. he knew really well at Kaiser Riverside who handled cases just like mine.  It's been a blessing, for sure. I'm PMing you about something else. 

Glad you're feeling better about the upcoming change.  I just hope your experience will be like mine.  My folks are in Anaheim Kaiser program and have had years of great med. tx, too.  I grew up hearing negative things about Kaiser and never imagined enrolling with them.  So much has changed, dramatically in the last 15 years for the better, and Kaiser's self-contained system seems to work quite well.  I know Dr.s who are on lists, waiting to work for Kaiser.  I just hope it doesn't collapse from stresses and overloading of health-care reform.  We got a letter re increased premiums a few months ago.  One of the main reasons given was "health care reform" Undecided

"There is beauty all around when there's love at home." --John H. McNaughton Dx 9/7/2010, IDC, Left, 1cm, Stage IIA, Grade 2, 1/3 nodes, ER+/PR+, HER2+, Surgery 9/16/2010 Mastectomy: Left; Prophylactic mastectomy: Right Chemotherapy 10/28/2010 AC Targeted Therapy 1/21/2011 Herceptin (trastuzumab) Radiation Therapy 3/23/2011 Hormonal Therapy 4/27/2011 Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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May 22, 2011 02:40AM soccermom wrote:

haha I love how all the insurance companies now have a great built-in excuse for raising premiums: "health care reform"-- that's exactly what Sharp said on my old plan that we just phased out when they jacked their premium up 20 %!! somehow I don't tend to believe that one...

anyhow my day of research on breast cancer.org on this topic has been very productive-- thank you so much! 

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 22, 2011 10:40AM soccermom wrote:

also if anyone can recommend the best oncologist and breast surgeon and mammography center in the San Diego area Kaiser system that would be super helpful--

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 22, 2011 08:38PM revkat wrote:

I have to credit Kaiser for finding my tumor. I was under 50 with dense breasts, and after having my first mammo at age 45 (outside Kaiser) which resulted in an ultrasound follow-up, I realized mammos were always going to be complicated for me and I never wanted to have another. But Kaiser is all about preventative medicine. First, they sent me letters saying I could get a free gift if I came and had a mammo. Then, they called and asked "When can we schedule you for a mammo next week. Appointments are available every day from 8am to 8pm." (They did the same thing when I got behind on pap smears too.) How can you refuse that? My tumor was discovered on the mammo and I had the biopsy and was seeing a surgeon 10 days after I went in for the mammo. 

I have been happy with my care, however, I have also been proactive. When I said I wanted TC not AC+T because evidence coming out of UCLA was showing A wasn't effective for ER+ bc, I got it. It took a couple of visits of pleading for a cyp2d6 test to see how well I was metabolizing tamoxifen, but my onco did give in. Kaiser does do things by "evidence based medicine" which means you may not get what you want, but you also won't get stuff that hasn't been shown to work. (I do sometimes wonder what I would do if I were stage IV. I think I would pay out of pocket for a 2nd opinion at UCLA and then take the suggestions back to my Kaiser onco. If it was in any way possible I think she would try to get me the treatment I wanted.)

One thing we've learned about dealing with Kaiser -- they like to keep you in your geographical area BUT you can get referred to other areas. Like, San Diego has a great pain center so we got my daughter with chronic headaches referred there and they gave her the treatment that finally got her functional again. I have mild lymphedema and my Kaiser doesn't have a fully trained therapist for it. They tried to pawn off an OT who didn't know how to do complete decongestive therapy on me, but when I said that I needed someone fully trained, I got someone in another area. I know that my area only does implant reconstruction, but there are SoCal Kaiser plastic surgeons who do other types and some women have been referred to them. Again, you have to be proactive, but isn't that the way all medicine is getting?

Also, many docs want to be in a system like Kaiser's so that they can have a life, treat patients, and not have to deal with insurance issues. They have a lot of quality physicians as a result, especially women. I'm ok with male docs (my PCP is one) but I also thought it was cool that my whole bc team -- surgeon, medical oncologist, radiation oncologist -- were female. 

Dx 1/28/2008, IDC, 2cm, Stage II, Grade 2, 1/20 nodes, ER+, HER2-
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May 22, 2011 08:44PM socallisa wrote:

please see my pm...

Biography: DX 11/2000 LCIS,DCIS,IDC 2B, Grade 1, ER+,PR+ Her2Neg 1 pos node Lumptectomy, CMF chemo X 6 mos, DX 8/2001, IDC same breast--Mastectomy , Left Breast Lumpectomy... Tamoxifen, one year...Armidex, Four years
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May 26, 2011 10:46AM Thriver wrote:

Hi Soccermom,

I posted a reply yesterday.  Not sure what happened to it.  But here is a basic overview of the situation re: your insurance decision

*From what I understand in your post, you don't qualify for Cobra re: ex's PPO because you already had your own insurance - Kaiser.

*You wouldn't be able to get the new PCIP California insurance plan - - because you must have been without insurance for 6 months before applying and have a current medical condition.  You can't do that. You would not want to risk being without insurance for 6 months. The new California plan is partially subsidized so it is a little cheaper than some of the other plans though.

*Re: buying your own PPO - an individual plan.  Well, this has been a problem for years.  It is very hard to be accepted for an individual PPO plan.  They do underwriting first - that means that they look into both past and present conditions.  If you are presently taking any medication - that could be called a current condition. You could be denied coverage.  For this reason, it has been very difficult for folks to buy a private policy in the US unless they are very healthy.

*Even if you could pass the underwriting, you might not be able to afford an individual PPO plan.  I have seen them cost anywhere from $600 to $1,200 per month - for someone between 50 or 60 years old.  Increasingly, they are more in the $800+ range per month.

*Yes, it is true.  You are lucky to have an employer sponsored plan where the employer pays most of the premiums.  Have you asked the employer if they offer more than one plan during the yearly open enrollment?  Most larger companies offer a number of plans - HMO and PPO.  However, the new copays and out of pocket maximums can really be expensive.

*Some patients don't like HMOs because they can't get a referral outside of the plan to see a specialist who might have more expertise.  For that reason, they want to stay with a PPO.  Increasingly, I see that most patients can't stay in the PPO - even if they have the choice at work - because of the cost of these plans - not the premiums but the out of pocket maximums. 

* One important thing to remember is that you can always appeal to the HMO.  This means that you ask them to send you to the outside specialist.  Your HMO then pays the bill.  I have done a number of these appeals and have won a number of cases.  However, we usually had to prove that the HMO did not have a specialist - for a particular type of rare cancer- within the HMO.  In cases of rare cancers, that is not too difficult to prove.  There may be only one or two specialists in a region who are experts.  And, those two specialists don't work for the HMO.  Those cases usually have positive results.  The HMO agrees to send you out of plan.  And, the HMO pays. 

*The problem comes in when the HMO has many qualified specialists in your type of cancer.  Then, it is very difficult to win the appeal. 

*At any rate, it is always worth a try.  Most patients don't understand how to appeal and how to win their case. 

Good luck. 

Thriver

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May 28, 2011 09:22PM soccermom wrote:

Fantastic advice! I really appreciate the thorough research and info. I'm getting a real education in health care insurance and financial issues..only way to survive these days I guess..

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+
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May 28, 2011 09:23PM - edited May 28, 2011 09:26PM by soccermom

http://finder.healthcare.gov/

good link on health care reform-- 

"to dance beneath the diamond sky with one hand waving free" -Bob Dylan Dx 10/20/2003, IDC, <1cm, Stage IIA, Grade 2, 2/12 nodes, ER-/PR-, HER2+

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