Posted by Racer on June 4, 2004, at 11:33:35
My husband and I need to choose from two insurance options offered by his new job: HMO or PPO. The PPO has a six month pre-existing condition exclusion, the HMO has none. Since I'm uninsured, it would seem like a no brainer, wouldn't it? It's not. I really distrust what I read on the company's website about their "Managed Behavioral Health" program:
1. Decisions about what care is appropriate are made by a Customer Service Representative after a "Clinical Evaluation" done by that CSR via telephone. The CSR then authorizes a certain treatment plan and then refers you to a provider from their list of providers who comply with the company's "Problem-focused, results-oriented" treatment guidelines.
2. The website describes their network as being closely monitored and supervised by the insurance administrators to ensure compliance with their guidelines.
3. There's a little glitch that allows prospective members to read something directed at employers regarding 'cost consciousness' in the care guidelines. In other words, they do have something in writing that specifies that they keep their costs as low as possible by offering short term treatment models through their network.
Basically, aside from being more than a little freaked out by the thought of a CSR deciding my treatment plan rather than a doctor, it looks to me as if I'd be better off waiting the six months for the PPO mental health exclusion to pass than going the HMO route and having to wait up to 12 months for an open enrollment period so that we can change over. My husband strongly disagrees. (He's never experienced an HMO, and his pre-existing condition -- diabetes -- is not subject to exclusion.)
I'm willing to admit that I'm not in a state to see this issue very clearly. To me, right now, it just looks as if I'd be going from bad to worse, with less chance of it improving within anything like a reasonable period. During the six month period, I would be eligible for other services through the PPO, which could include things like getting my meds even if they don't help, so the PPO would provide an immediate benefit.
Anyway, I wanted to hear some other perspectives on this issue. (But remember that I really am pretty fragile right now -- that is an issue regarding the care I receive: if the care went from the "Not Good" that I'm getting now to "Even Worse" under the HMO, I'm not sure I could survive that. At least now, if we take the PPO, I know that in six months we can look forward to things changing and probably for the better. Maybe that's not enough to make it worth the wait, but it really feels that way to me.) So, anyone have any scathingly brilliant insights into this dilemma?
Thank you very much.
poster:Racer
thread:353743
URL: http://www.dr-bob.org/babble/social/20040602/msgs/353743.html