Author Topic: California ACA health questions. Medi-Cal and/or Kaiser?  (Read 714 times)

msilenus

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California ACA health questions. Medi-Cal and/or Kaiser?
« on: December 02, 2018, 08:43:14 PM »
Hi all,

We're planning out our transition from COBRA to the ACA.  Two adults, two kids.  We're in Silicon Valley.  We're not expecting a lot of health care expenses next year.  We have tons of income flexibility with a mix of earned* and dividends and optional capital gains.  We're expecting about $60k gross, but could make that as much higher as we want (by selling stock) or as much as ~35k less (IRA/401k/HSA.)  So we can apply based on an expected income of 15k -> whatever, without lying.  I'm trying to decide what I want our plan to be and hence where I want to put our income next year.

Concern/Question #1:
According to The Chart**, kiddos are on Medi-Cal (medicaid) up through $66,766.  So keeping the kids off of Medicaid would require giving up a lot of premium subsidies for us and all options for CSRs.  I've heard the quality of Medicaid varies a lot by state.  Does anyone here have any experiences with Medi-Cal specifically for their kids who can recommend or warn me off of it? If we went this way we'd probably continue to pay the same pediatrician out of pocket for primary/routine care because that's an important relationship, but I want to understand how good the care availability is if they need something more serious.

Concern/Question #2:
I don't love any of the networks on the lower-cost plans and am loathe to pay a $500/mo bump to get a couple of our preferred primary care providers into our network.  So I'm thinking of just getting a cheaper plan and relying on it only for expensive/emergency care that might hit the $12k deductible.  The biggest risk with that would be accidentally receiving care out of the network (or being forced to by circumstances) in the event that we do need serious care.  So I'm thinking of *gulp* just getting Kaiser for this for my wife and I (at least), on the theory that if we wind up needing complex care we'll be in a system that won't accidentally screw us by leaning on out-of-network providers.  My wife would want to rely on her existing non-Kaiser primaries and probably use Kaiser as catastrophic coverage.  Does any of that that seem crazy?

Concern/Question #3:
I'm not sure I won't go back to work eventually.  If I did that, we'd lose subsidies and quickly wind up ineligible for Medi-Cal.   I'm not worried about losing subsidies because my understanding is we'd just have to pay the government back for what they paid the insurer and I understand those amounts.  No problem.  How do any clawbacks work if my kids wind up ineligible for Medi-Cal after all?

Thanks everyone!

* Don't call the retirement police, but my wife is still working a little bit.
** https://www.coveredca.com/PDFs/FPL-chart.pdf
« Last Edit: December 02, 2018, 08:47:00 PM by msilenus »

ysette9

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #1 on: December 02, 2018, 09:01:45 PM »
Is there any reason for you to not just got with Kaiser, presuming it doesn’t cost you significantly more? Kaiser is wonderful in our experience, and in the Bay Area the network of facilities and services is substantial.

msilenus

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #2 on: December 02, 2018, 09:27:56 PM »
Is there any reason for you to not just got with Kaiser, presuming it doesnít cost you significantly more? Kaiser is wonderful in our experience, and in the Bay Area the network of facilities and services is substantial.

Thanks.  I'll take that as a vote in favor, and I appreciate it.  I don't think I've ever met someone who was 'meh' on Kaiser.  Some people really like them and some people really hate them. 

I have an old friend who thinks they mishandled his care and left him in chronic pain for life.  And members are sort of trapped within their system, right?  I've always been afraid of that aspect of it.  But I'm coming around to see some upside to that boundary.

Abe

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #3 on: December 02, 2018, 11:17:23 PM »
Medi-Cal is decent for children. For adults it's a whole different matter. There are so many restrictions it drives me nuts trying to get my MediCal patients taken care of (even for cancer, which most insurances are fairly hands-off about). Kaiser is much better. They will not pay for expensive treatments with weak evidence, so there's that. For most guideline-based care it is great. From the physician's side, a lot of well qualified people are joining Kaiser since they're more interested in a stable, balanced life rather than making the big bucks in private practice.

ysette9

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #4 on: December 03, 2018, 10:24:39 AM »
Kaiser has been pretty excellent for us. My experience is as a boring healthy kid and then adult, as well as multiple pregnancy losses, high-risk pregnancy, and premature babies in the NICU. I feel enormously grateful for kaiser every day I look into the eyes of my two alive, healthy, strong girls who would not be here today without the care we all got.

The nice thing about being all in one system is you never have to worry about in-network vs. out-of-network changes. There are no surprise bills showing up randomly in the mail 6 or 12 months after a procedure as my friends experience with PPOs. You don’t have to become experts in medical billing codes to fight to have things covered by insurance. You don’t need to wonder whether the referral to a specialist will be covered. When they write a prescription (“write” - it is all computerized) you just head downstairs or over to the next building after your appointment to pick it up. No need to go to Long’s or Walgreens in a separate trip.

Their philosophy is prevention so things like immunizations and prenatal visits are usually free (at least in my experience). I have heard complaints from some people that they do less well figuring out unique challenges or difficult-to-pin-down problems. That really hasn’t been my personal experience, but I am sure that no one system will make everyone happy.

lhamo

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #5 on: December 03, 2018, 04:49:37 PM »
Paging @TNT for possible input on MediCal coverage -- I know she had it herself for  major health issues involving surgery and extended hospitalization, not sure if her kids were on it, though.

cchrissyy

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #6 on: December 03, 2018, 05:38:43 PM »
Quote
Does anyone here have any experiences with Medi-Cal specifically for their kids who can recommend or warn me off of it?

Medi-cal for kids is excellent!  They cover everybody and everything at UCSF and Oakland Childrens hospitals, Stanford Childrens, all the Sutter and Bayside doctors and the outpatient clinics related to Stanford Childrens and Oakland Childrens... all the common imaging places and blood labs... every pharmacy.   

I have one kid who has it while the rest of us do not, and this has been the case for about 12 years now. (He's in a waiver program based on his medical needs not my income). It has been great and has not limited his care options in any way.

TNT

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #7 on: December 03, 2018, 07:04:02 PM »
Paging @TNT for possible input on MediCal coverage -- I know she had it herself for  major health issues involving surgery and extended hospitalization, not sure if her kids were on it, though.

My kids havenít been on it because they still have XHís insurance, but itís been so great for me, I would think Medi-Cal for kids would be just fine!

msilenus

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #8 on: December 04, 2018, 02:17:12 AM »
Thanks, everyone!  This was very helpful.  Pretty sure we'll go with Medi-Cal for the kids and Kaiser for us.

Dicey

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #9 on: December 04, 2018, 07:32:06 AM »
Kaiser has been pretty excellent for us. My experience is as a boring healthy kid and then adult, as well as multiple pregnancy losses, high-risk pregnancy, and premature babies in the NICU. I feel enormously grateful for kaiser every day I look into the eyes of my two alive, healthy, strong girls who would not be here today without the care we all got.

The nice thing about being all in one system is you never have to worry about in-network vs. out-of-network changes. There are no surprise bills showing up randomly in the mail 6 or 12 months after a procedure as my friends experience with PPOs. You donít have to become experts in medical billing codes to fight to have things covered by insurance. You donít need to wonder whether the referral to a specialist will be covered. When they write a prescription (ďwriteĒ - it is all computerized) you just head downstairs or over to the next building after your appointment to pick it up. No need to go to Longís or Walgreens in a separate trip.

Their philosophy is prevention so things like immunizations and prenatal visits are usually free (at least in my experience). I have heard complaints from some people that they do less well figuring out unique challenges or difficult-to-pin-down problems. That really hasnít been my personal experience, but I am sure that no one system will make everyone happy.
Except for the baby part I could have written ^this^. Kaiser isn't perfect, but nothing is. On the main, it's a good experience once you learn the system. As with any medical provider, the ability to self-advocate enhances the experience. Dicey waves to fellow KP member @ysette9 from across the Bay.

ysette9

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #10 on: December 04, 2018, 10:01:42 AM »
Kaiser has been pretty excellent for us. My experience is as a boring healthy kid and then adult, as well as multiple pregnancy losses, high-risk pregnancy, and premature babies in the NICU. I feel enormously grateful for kaiser every day I look into the eyes of my two alive, healthy, strong girls who would not be here today without the care we all got.

The nice thing about being all in one system is you never have to worry about in-network vs. out-of-network changes. There are no surprise bills showing up randomly in the mail 6 or 12 months after a procedure as my friends experience with PPOs. You don’t have to become experts in medical billing codes to fight to have things covered by insurance. You don’t need to wonder whether the referral to a specialist will be covered. When they write a prescription (“write” - it is all computerized) you just head downstairs or over to the next building after your appointment to pick it up. No need to go to Long’s or Walgreens in a separate trip.

Their philosophy is prevention so things like immunizations and prenatal visits are usually free (at least in my experience). I have heard complaints from some people that they do less well figuring out unique challenges or difficult-to-pin-down problems. That really hasn’t been my personal experience, but I am sure that no one system will make everyone happy.
Except for the baby part I could have written ^this^. Kaiser isn't perfect, but nothing is. On the main, it's a good experience once you learn the system. As with any medical provider, the ability to self-advocate enhances the experience. Dicey waves to fellow KP member @ysette9 from across the Bay.
:)

Lake161

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Re: California ACA health questions. Medi-Cal and/or Kaiser?
« Reply #11 on: December 06, 2018, 07:58:04 PM »
We are post-FIRE in California and arrange for our income to be at a level that qualifies for the maximum subsidy and CSR.  Would do Kaiser in a heartbeat, but they do not cover our area. It is such a pain to sort out what is in and out of network with Blue Shield.