Guest Opinion | Comparing Premera and Kaiser health plans

Grab a cup of tea and read on…

— from Pegi Groundwater —

How do Premera‘s new Medicare Advantage plans compare to the Kaiser plans that many islanders have now? SHIBA volunteers in San Juan County are hearing that question every day. The answer is complicated; they are similar in some ways but different in others.

Premera’s plans, like Kaiser’s, are HMOs, which means that you must get your care from providers who are in their network or they will not pay for the services. There is an exception for emergency or urgent medical care when you are traveling anywhere in the world. Patients need a referral from their primary care doctor to see a specialist and most medical services require pre-authorization.

Both companies provide a number of free preventive health services and annual hearing and vision screening benefits with additional visits covered if medically necessary. The copay for these screenings depends on the type of provider doing the screening.

Like Kaiser, Premera is offering two plans, the Core plan for $12 a month and the Core Plus for $75 a month. Both are lower than the Kaiser premiums.

Both Premera plans include drug coverage, which is great for most people but a problem for people who had the Kaiser plan that did not include drugs. Unless they had comparable drug coverage elsewhere, such as through the VA, they will pay a penalty, which increases their monthly premium.

The Core plan operates much like Medicare, paying 80% of most costs, but it has some important differences. It includes prescription drug coverage and, unlike Medicare, it has a maximum out of pocket (MOOP) of $6,300. This means that if you get sick and need lots of medical and hospital services you will only have to pay until you hit the maximum and then the plan pays all additional charges.

The Core Plus plan drops the MOOP to $5,000 replaces the 20% coinsurance for many items with set copays, and includes basic preventive dental, a $150 eyeglass allowance and a $1,000 per ear hearing aid allowance. Copays for the Plus plan are generally in line with the Kaiser plans.

Premera and Kaiser both have copays for doctor visits.

Premera and Kaiser both cover physical therapy visits with a referral from your primary care doctor. Premera’s Core plan has a $40 copay, while the Core Plus is $20. Kaiser’s copays are $40 for the Harbor plan and $30 for the Haven.

Hospital visits are $360 a day for the first four days with Kaiser’s Harbor plan and $200 a day for the first three days with the Haven plan. They are $450 a day with both Premera plans. These are not an annual amount. If you are in the hospital more than once and your visits are at least 60 days apart, you will pay the copays for each visit, just like you do with Medicare.

Ambulance services, including fixed wing and rotary, are covered by both companies, but we have been told that they use different methodologies to determine if the service was medically necessary. According to Premera’s representative, Kaiser uses the diagnosis made at the receiving facility, while Premera uses the medical determination made by the EMS staff and their medical director. This means that if EMS felt a patient was having a medical emergency, such as a stroke, and had the patient flown off island but the receiving facility later determined that the problem was less severe, Premera would pay for the flight. The Premera copay is $300 one way while the Kaiser copay is $150 one way.

Kaiser and Premera both have a 20% copay for Part B drugs. Those are generally medicines that are given to you in a hospital and medications that are injected or infused into you in a medical setting. This includes chemotherapy treatments and anti-nausea medications given along with chemotherapy. They also both have a 20% copay for radiation therapy. For patients unfortunate enough to be diagnosed with cancer this is one area where the medical bills can add up quickly.

Outpatient surgery, such as cataract surgery, has a $300 copay with the Kaiser Harbor plan and a $200 copay with the Haven plan. Premera Core members pay 20% of the cost while Core Plus members only pay $350.

Diagnostic testing costs for lab work and outpatient x-rays are similar for Kaiser and Core Plus members, but Premera members pay 20% of the cost for tests like EKGs, MRIs and CT scans .