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sam1  
#1 Posted : Wednesday, November 30, 2011 9:38:12 AM(UTC)
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Considering doing the switch from BCBS basic to GEHA this year but have some questions on it.  Here's my background:

Was in a terrible accident this year (20+ broken bones, couple of transfusions, still in therapy, have more surgeries to go to get back to normal - on slight meds, but nothing expensive)  with the BCBS basic, I'm only out $4400~ from a total of over $370,000 in medical bills. So I am not complaining about BCBS in any way Big smile As far as service goes, the only dr. that I care about keeping is the ortho surgeon and he takes both of the insurances.

Now I really like the way that the basic plan has stuff laid out, simple copays in dollar amounts are listed, it's nice knowing the outpatient places charge $75, and the surgeons are always $150 a pop. etc..

With GEHA, they have a % of plan allowance listed for everything, and I'm not sure on how to track any actual costs down.  These copays are the largest concern with me, since without question I have more surgeries to go next year, I don't want to get stuck paying 15% of a plan allowance if that is going to be 15% of $4000 when with BCBS I know from the get-go it's only going to be $150.

If anyone has experience with any kind of major services with GEHA, I would really like to hear about some of your costs to get some kind of idea of what they're working with.
upandup  
#2 Posted : Wednesday, November 30, 2011 10:28:59 AM(UTC)
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First off, what motivates you to consider this switch?

Secondly, in this case it's good to clear up the difference between a co-pay and co-insurance: In insurance lingo, a copay is a flat-rate and co-insurance is a percentage rate.

If you want very predictable out of pocket costs and are happy to stay within the BCBS PPO Network, then you are probably best served by BCBS Basic. BCBS Standard and all of the other nationwide Fee For Service Plans have percentage co-insurance for many services such as surgery. You will be protected by the catastrophic cap of out-of-pocket expenses ($5,000 for PPO services under GEHA Standard; separate cap for prescription drug expenses). BCBS Basic's annual catastrophic cap is also $5,000, but that includes prescription drug copayments for generic and preferred brand-name drugs.

As for estimating the percentage costs, that's difficult. There are some cost guides online, but perhaps the best estimate method would be to look at the BCBS PPO allowed amounts for some of the procedures you had done in the last year. While they won't match GEHA's PPO rates completely, they'll give you a ballpark. GEHA uses different PPO networks in different states--in your state (TN) they actually use the network they own and operate (PPO USA), but in most states they buy access to other networks.

Flat-rate copays give you the advantage of predicting costs, but they sometimes result in higher out-of-pocket than percentages for cheaper services. For more expensive services, the converse is true. At any rate, you will likely hit the yearly catastrophic max more quickly under GEHA Standard than under BCBS Basic--with $370,000 in bills, you still haven't reached $5,000 out-of-pocket. If all of that were 15% coinsurance--even assuming a 50% network discount--you would have reached the 15% co-insurance after $66K in billed charges ($5K coinsurance on $33K allowed charges).

Lastly, this is an excellent example why everyone should have some sort of health insurance.
sam1  
#3 Posted : Wednesday, November 30, 2011 8:16:28 PM(UTC)
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no specific reason for switching, just weighing the cost options because GEHA is a cheaper plan out the door.  Not going to switch without having a complete understanding of the differences

and agree with you on having insurance... the first year I worked many many moons ago, I didn't have insurance and one of my coworkers died of cancer, i heard of how expensive her last few months were and when open enrollment came around i signed up asap.  won't go a day without being covered now and thank god for it!
Angel1955  
#4 Posted : Thursday, April 12, 2012 9:20:17 PM(UTC)
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If you like what you have = and with your past experience - I sure wouldn't change row boats in the middle of the ocean - - knowing what to expect is half the battle - I had GEHA for one year long ago - went back o B/BS standard
taxman  
#5 Posted : Thursday, November 07, 2013 4:16:22 AM(UTC)
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Thought I would bump this thread. I have a similar question.

Looking at switching from BC/BS Basic to GEHA Standard [their lower option.]

My wife and I are pretty healthy and don't go to the doctor that much, but do have prescriptions that all have generics available. GEHA seems cheaper as far as premiums and copays, and it seems like there are plenty of doctors in our area that accept GEHA.

I do have my labs done once or twice a year and that seems pretty easy to do with BCBS, not sure if GEHA would be different.

Is there a catch? What would be some of the drawbacks of GEHA vs. BCBS? Is GEHA one of those plans where it's fine until you have something serious happen?

It's not a major difference in cost for someone like me who only has a couple of medications and 1-2 doctor visits a year, but it does add up to a fair amount when I consider the lower premiums. Just wondering if there were any drawbacks to GEHA that would make it would paying an extra $65-70 per month for BCBS.

taxman2013-11-07 12:22:48
edalder  
#6 Posted : Thursday, November 07, 2013 6:04:56 AM(UTC)
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From what I remember with GEHA standard (and its been awhile), you got a lab card or logo on your insurance card for labs. As long as you used the preferred lab (or labs), there was no copay. Read the current plan brochure to be sure it still works this way. Tt's been a few years.

With GEHA standard, your catrosphic out of pocket is going to be higher. From what you said, you have seldom reached out pocket medical expenses that were high enough to meet the somewhat lower out of pocket threshold with BC-BS basis in an average year. Ergo, you probably will not get there with GEHA most years. But, insurance is something that you get to protect against the worse case scenario. So, just be sure you can live it GEHA's out of pocket limits, if you should happen to have "a bad year".

My experience with GEHA is that it was a lot harder to estimate your potential out of pocket with GEHA than with NALC and some of the other plans, particularly on prescription drugs, but even with certain procedures. There are tradeoffs in life and this is one of them. In my experience, however, your co-insurance (not co-payments) may be somewhat higher with GEHA than with other plans, but I cannot give you a direct comparison with BC-BS since I have never had any of their plans.

Finally, like most plans. GEHA standard really will punish you for going out of network (I am assuming you are not old enough for Medicare). Verify the availablity of network doctors in your area if you are not in the Washington, DC area or some other area with many Federal/Postal employees. You may not be very happy if the nearest network doctor is located 50 miles away and you have to book an appt with him or her two months in advance.



Kivi
TotallyRetired  
#7 Posted : Thursday, November 07, 2013 6:56:03 AM(UTC)
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taxman wrote:
...I do have my labs done once or twice a year and that seems pretty easy to do with BCBS, not sure if GEHA would be different...


For routine labs, I go to Quest & there is no charge to me.

Here in Kansas, Quest labs are very well run & have enough staff so that the wait time is minimal. I just sign in, hand them my doctor's order, & am on my way in less than 15 minutes.

The only negative is that the doctors here all expect their patients to use his/her own in-house lab. I always have to explain that the lab test is not fully covered unless I go to Quest.

I have GEHA High option.
spleuchan  
#8 Posted : Thursday, November 07, 2013 7:00:27 AM(UTC)
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Some of what Edalder said is true, but some is not. I had BC/BS basic for about 7 years and then switched and have had GEHA standard for the last three years.

Catastrophic out of pocket is actually lower with GEHA. With BC/BS basic it is $5,500 per person and $7,000 per family. With GEHA its $5,000 for both per person and per family.

Estimating out of pocket for prescriptions is a breeze with GEHA. On their website, they have a link for pharmacy medication costs and it will tell you exactly what you will pay for a particular medication.

Regarding out of network, you are punished, but it at least pays you a little vs. BC/BS basic which pays you nothing.

You sound like an ideal candidate for GEHA standard. Their main drawbacks are:
- In some areas you don't have as much dr choice (but at least in the DC area most seem to take it)
- If you take a lot of brand name prescriptions there are cheaper plans out there (although in most cases BC/BS basic is not one of those)
- If you go to the hospital you will likely pay more (15% vs a flat fee for BC/BS basic)
- You have a deductible (however, deductible plus premiums is still cheaper than the premiums for BC/BS basic)
- Dental is better than most plans, but not BC/BS basic, which has awesome preventative dental
- I have to specifically request my dr. goes through quest to get free lab work done. Sometimes my wife forgets to tell the Dr and they go through labcorp, which then I have to pay 15% of GEHA's rate, which (always so far) equated to only a few dollars.

There are a lot of things I like better about GEHA. Copays are cheaper than BC/BS basic. GEHA has a very good website and they have always answered the phone within a minute or two when I've called them. I'd definitely recommend GEHA standard to those not heavily medicated or know they will be in the hospital a lot.spleuchan2013-11-07 15:11:53
TotallyRetired  
#9 Posted : Thursday, November 07, 2013 7:06:49 AM(UTC)
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edalder wrote:
...With GEHA standard, your catrosphic out of pocket is going to be higher...


We had a bad year back in the 80s & used the catastropic coverage for the last few months of the year. It went very smoothly.

At that time (don't know about current practices), GEHA computers maintained a running total of our out-of-pocket expenses as a line item on the claims payment form. Their computer automatically transitioned to 100% coverage after we reached the limit.

To manage the massive pile of bills, I maintained my own log & regularly checked to be sure that GEHA computers had an accurate tally of our out-of-pocket expenses. (It did.)

We had a GEHA high-option family plan & lived in a Virginia suburb of Washington, D.C. TotallyRetired2013-11-07 15:13:22
TotallyRetired  
#10 Posted : Thursday, November 07, 2013 7:29:24 AM(UTC)
TotallyRetired

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sam1 wrote:
...With GEHA, they have a % of plan allowance listed for everything, and I'm not sure on how to track any actual costs down.  These copays are the largest concern with me...


If you decide to go with GEHA, my suggestion would be to go online & systematically study each of your claims until you are something of an expert on the way GEHA computers processes your bills. I always call GEHA customer service íf something doesn't make sense to me & always found them very willing to explain everything.


I have GEHA High option.TotallyRetired2013-11-07 15:47:56
TotallyRetired  
#11 Posted : Thursday, November 07, 2013 7:33:26 AM(UTC)
TotallyRetired

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sam1 wrote:
no specific reason for switching, just weighing the cost options because GEHA is a cheaper plan out the door.  Not going to switch without having a complete understanding of the differences...


If you decide to go with GEHA & expect to need a lot of physical therapy, I'll do another post on how I managed that with GEHA.TotallyRetired2013-11-07 15:49:53
getting close  
#12 Posted : Thursday, November 07, 2013 9:27:32 AM(UTC)
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I've used GEHA forever (at least 20) years and have been very satisfied. Our usage has been moderate, we do the free lab work at Quest, and I have never had a problem with claims processing. We still use some brand name prescriptions and I think they are high on some of them but I never felt motivated to look for an alternative.
OUtside  
#13 Posted : Thursday, November 07, 2013 12:08:15 PM(UTC)
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I don’t understand spleuchan’s comparison of the catastrophic limits between BC Basic and GEHA Standard; he said ‘Catastrophic out of pocket is actually lower with GEHA. With BC/BS basic it is $5,500 per person and $7,000 per family. With GEHA its $5,000 for both per person and per family.’

Where does this account for the Std 2 x $350 = $700 deductible (vs. none for Basic) and the possibly high out of pocket cost for Std’s brand name drugs at 50% per co-pay? Isn’t there a separate limit for prescription drugs of $6000? Brand name drug expenses can get very expensive for powerful new and costly drugs these days and, as I understand it, are included in the Basic limitation.

Per the limitation and re: the brand name drugs portion, I think maybe Basic is the better plan and possibly the far better plan based on the factor of brand name drugs.   The reasoning would be, if health expenses are high enough to approach the limit, brand name drugs are probably an important treatment component.OUtside2013-11-07 21:23:37
spleuchan  
#14 Posted : Thursday, November 07, 2013 7:45:29 PM(UTC)
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Per GEHA's plan brochure, the deductible does count towards your catastrophic maximum.

Even if that wasn't the case (which it is), I previously stated GEHA's deductible plus premium is cheaper than the premium for BCBS basic. Even if it didn't, $5,000 + $350 is still cheaper than $5,500 and $5,000 + $700 is still cheaper than $7,000.

Regarding heavily medicated people, I mentioned in my post that GEHA standard isn't the best option. However, if you are heavily medicated you shouldn't pick BCBS basic either.spleuchan2013-11-08 04:57:50
OUtside  
#15 Posted : Thursday, November 07, 2013 8:47:23 PM(UTC)
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It’s seems still cheaper than $7000 but Standard excludes from the limitation the co-pay for dr office visits according to their brochure (which Basic does not); depending on the number of visits, these can be more than $700. If there is a high health expense year, there can be any number of visits.

Similarly, prescription drugs, if a high expense year, prescription drugs expenses will probably be high, probably quite high. Maybe it’s an oversimplification, but on day one of the year, a subscriber may not be a high prescription drug person, but on day 2 health situation could change for the worse and so could the requirement for prescription drugs.

I am not saying a decision between the plans should be made on this factor alone. I am saying that Std is probably not the better plan with respect to the catastrophic limitation because I don’t think you can look just at the $5000 number as the entire story. You would have to look at what is included as well as what is excluded by the number. Dr office visits and prescription drugs (having their own limitation) are big exclusions.

‘Specialty Pharmacy medication not dispensed by Express Scripts/Medco Specialty Pharmacy‘ ($500 co-payment 30-day supply) is also excluded from the limitation.   This exclusion, defined as ‘Medications dispensed by other sources including physician offices, home health agencies, outpatient hospitals,’ has the potential to be very costly.OUtside2013-11-08 04:53:57
taxman  
#16 Posted : Thursday, November 07, 2013 9:47:27 PM(UTC)
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Thanks for the advice and discussion. A lot to think about.

I did check and it looks like there are at least 1-2 labs nearby where we could use the LabCard.
spleuchan  
#17 Posted : Friday, November 08, 2013 5:47:57 AM(UTC)
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I actually didn't realize there were differences between plans on what contributes to the catastrophic maximum. I guess they are trying to make it as difficult as possible to compare plans. So in some situations GEHA will have a higher catastrophic maximum and other sceanrios BC/BS will have a higher maximum.

I'm not too worried about the dr. copays, $10 and $25 won't add up to much. Prescription is one area you could get burned. GEHA has a separate $6,000 max for prescriptions.

I'll still be sticking with GEHA though. For me, the money I save with GEHA vs BCBS basic is worth the very small risk of my family requiring thousands in medication. It depends on your risk tolerance I guess.
sparksals  
#18 Posted : Saturday, December 07, 2013 4:46:17 AM(UTC)
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We switched to Geha last open season from NALC b/c I had some expensive emergency dental work last year and wanted the coordination of dental as well as a supplemental dental.

Turns out, I had a major surgery and the OOP costs were ALOT compared to NALC. There were also very difficult to get procedures approved. They denied many things and had to be resubmitted.

I had a double neck fusion and my doc prescribed physical therapy. They would only approve FIVE sessions. My PT said they were the MOST difficult to deal with for that.

In MN, they are through United, so it may be different elsewhere. I was really unsatisfied with pretty much everything, despite the lower cost than NALC.

We are switching back to NALC. We were with BC/BS Basic before NALC and switched to NALC b/c of the increasing costs at BC/BS. Xrays, prescriptions were FAR more expensive on BC/bS basic than NALC.

I have never had any problems with NALC, never any denials and if it is, it is an error... like when I hit my head with the tailgate and cracked my head open. The ER miscoded and it took awhile to get it fixed to get the 100% coverage for an accidental injury.

If you only have day to day medical issues and no hospital stays or surgeries, GEHA is an inexpensive option. Once you cross over into hospital stays, surgeries etc., you pay big bucks. We met our catastrophic coverage, so have 100% until Jan 13/2014. Making sure to get as much stuff done as possible.

OUtside  
#19 Posted : Saturday, December 07, 2013 9:43:29 PM(UTC)
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Could you provide some examples for your comment NALC Hi is much less expensive than Basic for out of pocket expenses?

When I looked at the plans sides by side, I saw NALC has a $600 deductible vs. no deductible for Basic, a factor in Basic‘s favor.   I couldn’t make a judgment on the Rx for NALC 30% brand name drug vs. Basic $45/month, unless to go mail order each time with NALC but then I think you have to fill 3 months at a time.

I didn’t have enough real life examples to make a comfortable conclusion on Rx. I even asked a pharmacist about the 30% vs. $45 and they said it depends on the drug (which I sorta knew but didn’t have guesstimates on what drug prices might be as plan allowances except for one drug which came out close between the two plans non mail order).
sparksals  
#20 Posted : Sunday, December 08, 2013 8:08:55 AM(UTC)
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Scripts are far cheaper on nalc...If you go to cvs 900 day supply is between 8 and 12 bucks on generics. I paid 03 month for bcbs basic. You get the mail order Price at cvs.

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