Personal Consumer Issues • Health insurance choices and choosing a potential "secondary" doctor

I am not asking for medical advice, only the consumer side of medical insurance and finding a doctor.

Question 1:
I get my health insurance via my employer. As I am now in my late 50's, I am wondering whether my current health insurance is still best for me. My employer offers the following 3 options.
1) Blue Cross PPO: $550 (single)
2) Blue Cross HMO: $250 (single)
3) ABC HMO: $100 (single) ABC is a regional/state company so I am not listing the name.

Main features of the first option: One can see any doctor in the system without a referral. However it has a $300 deductible for the year and 20% coinsurance. The max for coinsurance is $1200 and the max out-of-pocket is $6500 for the year. Coinsurance applies to blood test etc if it is diagnostic but no coinsurance if it is preventative.

Main features of the second option: Everything is via PCP including referral and have to wait for explicit approval. No deductible and no coinsurance. So blood test etc is covered 100%. In order to stay in this good option, one needs to meet health criteria every year; otherwise, there are deductibles and coinsurance similar to the first option.

Main features of the third option: One can see any doctor in the system without a referral. No deductible and no coinsurance. So blood test etc is covered 100%. In order to stay in this good option, one needs to meet health criteria every year, otherwise; there are deductibles and coinsurance similar to the first option.

As I age, I may need more health service. My main objective is to minimize hassles. Currently I use the second option. My experience for the second option, the referral and meeting health criteria are stress inducing but so far I have very good customer service. Needing to keep track of deductible and coinsurance in the first option also seem like a hassle. The third option is clearly the best on paper: cheaper and no referral needed. I talked to 6 colleagues who have/had it. Four have no complaints but two of them complained about customer service and billing errors. Another advantage of the first and third options is I can go see a specialist that I want rather than the one referred by the PCP. So any insight on which option I should use given that my objective is to minimize hassles.

Question 2:
I like my PCP, who is part of a large hospital system. Obviously I am not qualified to evaluate his medical knowledge. However, he has very good bedside manner and I feel comfortable talking to him. The problem is he is too popular and it is difficult to get an appointment. Before the pandemic, I was able to get next day/same week appointment. Now I may have to wait several weeks. I remember one time last year (or the year before), I used an urgent care facility instead because I couldn't get an appointment. In another thread, I learned about direct primary care. (These are not concierge care.) They don't take insurance and it is subscription based. I find several near me, the upside is better chance of getting same day/next day service as they limit the number of patients, and they spend more time with you in a visit. The cost is about $1000 a year. If I do use such a service, it will be secondary when I could not get to see my PCP. Also good to have a second opinion. Another advantage is that if I choose option 1 or option 3 for insurance, I can ask for more suggestions for specialist referral. One hesitation is I don't know how to choose a direct primary care. When I first came to this city over 25 years ago, my colleague suggested my doctor. When he retired, his replacement became my PCP. Any suggestions on how to make my selection and whether the plan of having a secondary PCP is good?

Thanks for any suggestion you can give me.

Statistics: Posted by nonnie — Sat Jul 06, 2024 12:47 am — Replies 1 — Views 264