aetna vs bluecross/blue shield for service (Falmouth: health insurance, buying a house)

[istillfly]

i am being offered a choice of either aetna or blue cross/blue shield for our work health plan - both are pos. anyone out there have a preference for one over the other?? thanks!

[ScituateAl]

Provider-wise, it is likely pretty hard to beat BSBS of MA. I believe I had Aetna from a prior employer and have found we now have many more choices with BCBS. I'm going to assume there may be a difference that is important to you in your particular situation: perhaps one is more expensive but has lower co-pays or better perscription costs?

Most recently we went from my wife's plan at Tuft's to BCBS. The most noticable thing is that co-pays went up another $5 to like $20/visit, but we happen to now have a dental plan that has man more providers than before.

The good news is that you have both a job and health insurance!

[goyguy]

For the record - to paraphrase the late Sy Spurling - I'm not only an Aetna employee, I'm also a client. But when people are "shopping around" I give them the full rundown on whatever specific criteria they're looking to meet. There's no point in omitting or sugar-coating anything in order to gain a policyholder who might end up unpleasantly surprised.

What's often not fully appreciated is that health insurance is a major purchase that should be treated as such. I'm pleased that the TO is making this inquiry for that reason. Folks who spend months deliberating over all the small details before buying a house, car, or computer will dash head-on into selecting coverage which could end up not serving them as well as that from another policy. Due to this, the first question I'd put to each company would regard what sort of "escape clause" they offer - is there flexibility in terms of cancelling, or are you "locked in" for a period of time?

Scrutinize deductibles, the sums of money which have to be accounted for before benefit payments begin. While it's tempting to pay a lower premium up front in exchange for higher deductibles, someone who's generally in good health may end up with a poor return on their investment if they go with a high-deductible plan. But if the deductible is waived for certain medical services (emergency-room visit, routine physical) it'd prove to be a smarter investment. Find out whether there are separate deductibles (i.e. for prescriptions) and also whether there are different ones to meet when providers both "in" and "out" of network are utilized.

Any health care provider should be able to tell you whether or not they're considered participants with any given insurer and policy type. Aetna offers to the public, through the aetna.com Website, the nationwide "Doc Find" directory; any person or facility listed there should be "in network" and therefore payable accordingly. BC/BS and other insurers probably offer a similar resource. Realize also that for the protection of policyholders on any plan with any company, there are provisions which allow for benefits to be paid at the higher in-network rate (subject to "out of network" limitations) under certain circumstances: an ER visit at a participating hospital where the physician on duty isn't a plan participant, anesthesia during childbirth given by an out-of-network provider, etc. These provisions fall under what's called RAPS (Radiology/Anesthesia/Pathology/Surgery.) So it could be the case that a certain hospital, for instance, is on board with both potential plans but has a surgical staff which doesn't participate with one or either. RAPS could conceivably make this beside the point.

"Pre-existing condition" has become part of the national vocabulary. Look into whether each policy has limitations along those lines. They could be stringent (no benefits for a year, even none whatsoever) or non-existent. And if a "Pre X clause" does exist, it could still not be an issue if there was previous coverage. The suggested federal guideline for an allowable lapse between the end of one plan and the start of another is 63 days, but inquire of each insurer (or consult their sites) because this can and does vary.

Co-pays (set fees per service) shouldn't be used in and of themselves as a means of comparing benefits. There could be a higher co-pay on one policy, but better coverage once the co-pay is accounted for. "In-network" payments are made based on an agreed-upon contract rate. So one plan may offer an 80% benefit after a $20 co-pay, while another allows for 90% coverage after a co-pay of $50. But the contract rates may differ enough between plans to make it so that the actual out-of-pocket expense could be lower for either example.

"Large local network" is an easy trap to fall into. If the same family practitioner has been used for 37 years, and s/he participates with both potential plans, what does that matter? Look into how far the network net is cast. It's part of Murphy's Law that people become sick or injured while out of town for business or pleasure. Are both policies linked in with nationwide networks, and if so how extensive are they? This only seems like a minor consideration until someone wakes up in Vegas not with a new wedding ring but with appendicitis, or trips over Minnie Mouse during the Main Street parade at Disney World and earns a compound ankle fracture as a souvenir. Find out also whether the respective plans extend their benefits around the world. It's a hassle to file medical statements and pay for services up front, but even an "out of network" benefit check from the insurer is better than nothing. One may never leave the US according to plans, but life doesn't work that way - deep discounts on air fare could make a trip to New Zealand or Romania suddenly possible, whereupon Murphy's Law might go into effect.

If there are dependent children in the family, inquire specifically as to whether and when there's a cut-off age. I regularly assist folks who never let that thought cross their minds until a letter from their insurance company arrived to let them know Tyrone Jr's policy will expire at the end of next month because he reached his 23rd birthday. Status as a full-time college student also has an effect on how long offspring can stay on a parent's plan. Why face the aggravation of getting Ty Two onto another policy if you don't have to?

One last thing to consider is that BC/BS' status as "non-profit" tends to be misleading. They have revenue targets and contract limitations exactly as private insurers do. That's why I have the opinions about single-payor systems and public options that I do, despite potential implications to how I make a living.

Treat this as a free customer-service call or time off from Web surfing But remember that Aetna, BC/BS, and every insurance carrier have trained and dedicated staff to help with any questions. Thanks again for looking before you leap.

[Menauhant]

Thank you goyguy. My wife recently went in for surgery at Falmouth Ma hospital. The surgeon and hospital were in network. The anesthesia and pathology lab were treated as out of network providers. Consequently we received a bill for $2500. I have appealed this to United Health Care and hope that RAPS will be what saves me from having to pay this bill.

[jaywalkin]

I've used both providers. I like my BCBS plan MUCH better. Of course, both companies offer a variety of plans so you have to read up on what's being offered...
For me BCBS is less complicated, less red tape, simpler, overall easier to work with.
Aetna always made me wonder why everything had to be so complicated. Once I switched to Blue Cross, I realized that it didn't have to be.

[Elpis]

Thank you goyguy for a very structured post.
My family is on a shopping spree for family insurance. Our COBRA will expire in 3 month. We were relatively healthy so we did not big problems with medical bills, so did not pay much attention to it. But now we are self-employed and have to go on the market for individuals. There is so much to read and learn about insurance plans. It is overwhelming.
Any advise will be greatly appreciated. Thanks.