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Employer's health insurance too high - considering self-coverage

June 2007

I have been debating for a long time whether to put my family on independent health insurance (e.g., not covered through my employer) because of the high costs through my employer. I pay $670 per month to cover my spouse and 2 kids (employer pays my portion) for Kaiser with $15 copays (except for emergency room, which is $50). I am wondering whether there is another plan that would be good for them and not break the bank. We are generally a healthy family, making a few visits a year for ear infections, etc. but not much else. Thus, my main concern is being covered if something major should happen. Because there are SO many plans out there (with differing deductibles, co-pays, co-insurance, etc), I was hoping some of you folks could tell me about your specific experience with self-coverage and the specific plans you are using. Overall, I am happy with Kaiser after my first 4 years of using it (especially the lack of paperwork, referral requirements, etc.) but am open to other suggestions. Also, if any of you know of a specific ''hotline'' I could call to talk to someone who is knowledgeable about different plans (I really didn't find calling the providers very helpful) and could give me a recommendation, I would appreciate it. Puzzled About Healthcare


I opted for a Blue Cross plan with a $2500 deductible for two reasons: 1. The lower premium more than makes up for the amounts I typically spend out-of-pocket during the year. 2. If I were to become seriously ill, I would be able to see any doctor I needed to and would not be locked into a network of second-rate doctors and hospitals. 3. If I were to be hospitalized with a medical emergency, I would pay only the amount negotiated by Blue Cross, not the exorbitant amount that hospitals charge people without insurance.

Hope for the best, but prepare for the worst. If you were to find out tomorrow that you had spinal cancer, what health plan would you want to be on? My friend was sent home to die by his HMO, but luckily his wife's insurance allowed him to go to Boston for treatment that saved his life. Life is priceless


Hi - Health care is confusing! I am a Certified Financial Planner but also a licensed health/life insurance agent (independent). I've worked with many health care plans and Kaiser is one of the most affordable. It sounds like you may be a candidate for a high deductible health care plan (you pay the first $0 - $5000 in costs, the insurance picks up the major costs).

If you like Kaiser, they recently introduced a few high deductible options with varying benefits and deductibles (copay $0/deductible $1500; $0/$2700 and $30/$2700). That might be a good place to start. You can learn more about their plans in summary form from their website http://ckp.kp.org/locations/california/individuals/personaladv/paBenefits.htm If you have any questions, you can certainly call Kaiser for assistance or I'd be happy to help. JUlie A.


Kaiser has a deductable plan that you can switch to. I forget exactly what it's called. I think it's 2,500/5,000 plan. I switched to that plan about a year ago and we're saving over $300/month. We do have to pay more for visits, however, the monthly saving outweigh that expense. Good luck. Anna
Every time there's a question posted here about health insurance coverage I feel like folks are missing the boat by not calling a health insurance broker. Health Insurance brokers do not charge a fee, but rather make a commission off of their referrals. That said, Denise spent a lot of time working with our complex situation and did not hesitate to recommend plans that would save us money but even if she wouldn't make a commission off of it. Also, she not only knew all about the many plans available, but was good at matching the plan with the individual - what's right for my 1-year old is not necessarily right for my doctor-phobic husband. Health insurance is complex, but very important. Why not let someone else help you figure it out! I want to second the recommendation for calling Denise Lombard (510-530-8086) and point out that she's a lot like the ''hotline'' you were asking about. - still insured

Private-pay plans and pregnancy: managing the co-pay & deductable

June 2006

Hi.. I am seeking advice on health insurance plans/companies for pregnancy. I had really good insurance through my job for our first baby, but am now a stay at home mom.( I didnt keep my health benefits through Cobra because it is very expensive and it wouldnt have worth it to pay that every month until I got pregnant again)

My husband is a general contractor who just started his own business recently so I'm not insured through his job either. Actually we are all insured under a Healthnet Family Plan together right now. We decided that this is good for us while I'm not pregnant as it is a good plan for if one of us gets sick etc. and then just I will switch to a plan and we will pay more for just me during my pregnancy care..

I live in the Bay Area and when I get pregnant again plan on delivering at CPMC again. Our current healthplan has a 4500 deductible that we will be responsible for at time of admission and delivery and there might also be additional charges incurred during prenatal visits. I think we can do better than this, so I'm looking to switch.

My question is has anyone had any great experience with a health insurance plan that wasn't a group plan(through someones job) What was it? Deductible, co pay etc. It's harder now that the insurance is not through my job because when it was I knew up front I had a $10 co pay, no deductible and then paid like $150 for hospital charges..EVERYTHING else was covered. That's what they told me upfront and that's what it was. I'm just trying to weigh the benefits of paying more every month(9 month pregnancy) for a better plan to make sure that there isnt an even bigger bill at the end. I know that I can also consult with an insurance broker but would like to appeal to families first as I am not pregnant yet and still have some time Thanks so much for reading!! mimosagirl


My husband and I are self-employed and self-insured through a Blue Shield PPO. Our monthly coverage (me, my husband and our son) is around $400 with a $750 deductible (we are still in the under 30 bracket so this makes the monthlies cheaper). Before getting pregnant I switched to a lower ($500) deductible. What we didn't plan on was the fact that my pregnancy (June-March) went over a calendar year so the deductible had to be met twice! I had a healthy pregnancy and delivered a healthy baby with midwife assistance at The Birth Home. In other words, we had no complications that would have increased costs, yet the whole thing still cost $3000-$4000 (copays, standard tests, birth facility fees). Hate to say it but having a baby while self-insured seems to be way more expensive! And I don't think there is any possibility of a ''set fee'', it all depends on what happens along the way. That said, I felt Blue Shield covered their percentage on just about everything (even the less conventional Birth Home delivery) without any gliches anon
I would recommend insurance broker Denise Lombard - Health & Long Term Care Insurance Specialist P. O. Box 27147 Oakland, CA 94602 dtlombard@sbcglobal.net Phone: (510) 530 8086 Fax: (510) 531 - 1269 Stu S

Switching from private-pay to employer-pay with health issues

April 2006

I need advice regarding health insurance. We are currently self insured through Blue Cross and the premiums are exorbitant. My husband has just started a new job that offers the same health insurance much cheaper.

Problem is, my husband and I are in our 50's with some preexisting health issues. We have 2 young kids, one that has some health issues.

I am scared to death about what will happen when/if my husband changes his job. If we ever had to self insure again, I have heard that either our already high fees would sky rocket, or we may not even be insurable. Is this possible? Is there some kind of resource that could help me decide whether it is worth the risk of using my husbands insurance. My agent has actually been great, but I'd like to talk to an unbiased source also.

Thanks for any advice. Stressed!


Isn't it crazy that health insurance is tied to employment? It creates all sorts of problems.

I had a similar situation. My daughter and I had independent insurance, my husband convinced me to switch us to his cheaper insurance through work, then lo and behold he lost his health benefits at work. My husband and I found insurance for ourselves, but it took me 6 months to find insurance for my daughter because of a very minor health problem. It all worked out in the end, but it was a big hassle and it caused me 6 months of anxiety. In retrospect, I do regret switching to his work-based insurance.

In your family, 3 out of 4 of you already have medical issues, so chances are good that *someone* will have problems finding affordable insurance in the future. If you are worried about your husband changing jobs again, you must also feel that his job (and its health insurance) are not terribly secure. I don't think I would want to take the risk if I were in your situation.

You might ask your agent if it is possible to switch to a higher-deductible plan now in order to make your premiums more affordable. But, as you already know, it is risky to give up your independent coverage altogether. Good luck, and I hope it all works out! happy to be independent


If you leave your private insurance, you will probably never be able to be insured again privately. Insurance plans provided by companies cannot, by law, exclude you for having a pre-existing condition. But that law does not apply to personal insurance companies. They can, and will, deny you coverage. If you change private insurance companies, the same applies. Amanda
I am not an expert in this area, but I think some of the information that has been posted is not entirely accurate.

The Health Insurance Portability and Accountability Act (HIPAA) limits the ability of insurance companies to deny coverage to someone with a pre-existing condition.

There are lots of rules about when HIPAA does and does not apply, and they vary depending on whether you are moving from one group plan to another, from a group plan to an individual plan, etc. There are also state-level variations. HIPAA does not prevent insurance companies from totally gouging you in the premiums they charge, but it may prevent them from dropping you altogether. One of the key factors is having continuous coverage, so you want to avoid any gaps in coverage.

But you probably want to look carefully at this and the rules that apply before you decide what to do. You might find out you have more freedom than you anticipated.

Another law you should know about is COBRA, which requires certain employers to continue your health insurance for 18 months after you leave a job, although you usually have to pay the full cost, which can be a lot. But it is often a way to avoid gaps in coverage - you continue COBRA until you can find something else. You may want to find out if that is an option that will give you some protection if you are feeling iffy about the job.

Here's some resources from the web about HIPAA:

Official federal government info about HIPAA from the Dept. of Labor: http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

from the AARP website (http://www.aarp.org/health/insurance/private/a2003-05-02-hippa.html)

You could also contact an advocacy organization directly like AARP, Families USA (which focuses on insurance needs - FamiliesUSA.org) or Workplace Fairness (workplacefairness.org) and see if you can find someone to help answer your questions directly or to put you in touch with legal or other resources. Currently juggling health plans myself


Insurance issues are scary & frustrating. And private insurance sure is expensive. But don't forget to look into what possibilities COBRA and HIPAA might offer.

In my family's situation we were all on my employer's insurance, and then I decided not to return to that job after I had my baby. We then all went onto COBRA and started looking into private pay insurance. Although my baby and I were considered ''uninsurable'' for a number of reasons, Kaiser did have a (very unattractive) plan that they would let us join.

I actually worked with Denise Lombard (510-530-8086), who I found on this site, to figure out what to do. She recommended keeping me and the baby on COBRA and found good plans for my husband and baby. She mentioned something about being eligible for HIPAA plans post-COBRA, but honestly, I don't remember the details. As with everything, things change quickly, and I recently started a new job and will be eligible for their coverage in a few months.

Also, one thing to know about COBRA - you pay 102% of whatever premium the employer was paying. And you don't get to chose your plan - it's whatever you were on with the group plan. You probably can call the potential employer and ask what their plans & premiums are and figure out what you would potentially be paying if your husband left that job.

Good luck! COBRA mama


Privately paid Health Insurance-which one to get?

Sept 2005

After a job change, it just dawned on me that as of Sept. 1, I am no longer covered by ANY health insurance. My new job does not offer this benefit (but does offer the option of paying into a pre-tax account of my own to pay my own premiums). My husband's employer will let me add to his plan, but the full premium must be paid by us (the employer will not contribute to my premiums). So.........since I'm obviously buying my own plan anyway, I can get whatever I want! We already pay for an individual Kaiser plan for our son. I'm a pretty healthy person, but would like to have another baby sometime in the near future (probably will start trying within the year). I had my son through Kaiser and thought it was great. LOVE our pediatrician through Kaiser as well. The NP who I saw throughout my pregnancy is no longer with Kaiser so I'm really not attached to anyone there, I have to begin again with a new doctor anyway. I was surprised to price Kaiser out at $195/month for me alone...then again, I haven't ever priced individual health insurance for myself before, so maybe the sticker shock is from ignorance. I don't need to be ''sold'' on Kaiser, I know how it works and I know that I have to work the system. What I'd like recommendations on are which insurance plan gives me the most ''bang'' for my bucks?


$195 per month is pretty good. I pay $169 per month for Blue Shield PPO, but have a $35 per visit co-pay and a $750 deductible, and I think I would be responsible for 30% of maternity costs. The bottom line is that health care is expensive, but you can't afford to be without it. well-insured
Hi--we were just in the same boat as you about a month ago. I now know more than any one person should about all the different health plans, and what pitfalls to avoid, etc. I am a do-it- yourself kind of person, so I checked out ehealthinsurance.com and was going to go with them to enroll in a private health plan. They seemed fine. However, my husband's work recommended a health insurance agent who worked miracles to get me and our kids on a really good plan several weeks less than it would have taken if I had done it any other way. He helped me figure out the best way to word stuff on the forms (this makes a HUGE difference in how you get approved or not), knows how to cut through the bureaucracy of underwriting while in midst of the application process, etc.. He can also help you decide on what's best for you from all of the various options-- POS, PPO, HMO, high-deductible, HSA, etc. His name is Bill Killips and his number is 925-906-0630.

FYI, the $195/mo at Kaiser is actually a decent rate, if it includes maternity. Just check and see what they charge for hospitalization-- is it a daily rate, a one-time co-pay? What if you're released and need to be re-admitted for some reason, do you have to pay all over again? It's a good idea to look at the ''evidence of coverage''. Also, DO NOT let them know you plan to get pregnant (don't confirm or deny grin). And... don't be pregnant when you're applying. It is considered a ''pre-existing condition'' like cancer, and they won't insure you.

Just 4 years ago, we had to pay $220/mo for our kids and myself, since my husband's firm only pays for his coverage. The same plan (with much higher copays and less overall coverage for things like hospitalization and labwork) is now $870/month. I got a HealthNet high deductible plan for my two kids and myself for $270/month, but it doesn't include maternity... Even if we maxed the deductible, it's still cheaper than the plan we've been on through my hasband's employer. We're really happy with it. Blue Shield is also quite good. Good luck!!!


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