Surgical Procedures & Disease Management

f someone is going to have major surgery, say a hysterectomy, is there a better plan for this and managing any care/complications?

In the case of planned surgery, we recommend four things. First, if you know who your surgeon will be, talk to him or her (or office staff) about which plans will be in network next year, and about any plans recommended for providing better coverage for your procedure. Second, when you have the operation, make sure that the surgeon, the anesthesiologist, and the hospital are all in your plan network. Third, when using the Guide you should probably use the "high" cost or "most you can pay" column rather than the "average" cost column as your primary basis for selecting the lowest cost plan. (Which column is better will depend on just how expensive your surgery is likely to be). Finally, do not enroll in a plan until you have looked at what its brochure says about its surgical benefits.

What would be the best plan if I were to need knee replacement surgery?

You need to be sure you use a surgeon, anesthesiologist and hospital who are preferred providers in the plan you choose. Assuming you use preferred providers, we recommend that after you get to the main results page in the Guide, you select the Cost Comparison view, then go to the "High" health expenses column, select the column head to rearrange the order of the results, and choose one of the plans near the top of the ratings. Our "High" estimate are for expenses near $30,000. A knee (or hip) replacement surgery generally costs about $25,000. So our "High" column gives you ratings very close to your situation.

I have multiple sclerosis. Although I am stable right now, I face a range of costly services if I my condition worsens. I am trying to manage it with diet, exercise, acupuncture and chiropractic services. What is the best insurance for someone like me?

What we recommend you do is join one of our higher ranked plans with a low catastrophic coverage limit, relative to other plans. That way you will be well protected against bad luck. Several plans have good "average cost" results as well as low limits, and we suggest looking for that combination. Please don't ignore High Deductible plans, as their combination of low limits and a savings account that you can keep in reserve, or even augment during the year, may be ideal for you.

What if I am about to have a major operation?

Pay particular attention to catastrophic limits. If you know for sure that you are going to face high bills, then pick a plan with a tight limit on your costs. In comparing catastrophic expense limits, use Guide figures. Our estimates include the "for sure" premium expense and adjust for inconsistencies among stated catastrophic limits, such as failing to include deductibles in the stated limit. If you are not sure what plans will work best in your case, check brochures and consult your surgeon to discuss which plans work best. Be sure your surgeon is in your plan network or will give you a network rate. And set up a Flexible Spending Account. FSA tax savings will reduce your share of costs by about a third.

My wife will be undergoing bariatric surgery and would like to be able to use the bariatric surgery team that she is already comfortable with. How do I best make sure she can use them?

In situations like your wife's, we have a simple recommendation. Talk to the surgery team that you plan to use and ask them (or their office managers) exactly which PSHB plans include them in their network of preferred providers, and of those, which pay best for your procedures. The answers to these two questions will likely focus you on just a few plans that you know will meet your needs. To be completely safe before an expensive procedure, we would suggest that you also check directly with the plans to be sure the information is correct.

Do you compare plans for gender affirming care services?

That is a topic we don't cover in our plan comparisons. Some plans have recently added surgical benefits related to transgender status. We don't review those in detail, but there is a fairly easy way for you to review things. First, download plan brochures one by one. Search each on the word "gender." That will take you to the page or pages where these benefits are described. The second strategy is to talk to the surgeon(s) you are likely to use, or their staff, and ask them which plans cover your surgery best among the networks they are in. These benefits are quite new, however, so information may be partial or incomplete. There is a third strategy, if you find a few plans that look promising, you could call them and see what their representatives say. Be cautious, however, as these staff may not know of or understand the benefit. Fourth, you could use your own networks, online or personal, to ask others what they have found about coverage.

I have an expensive condition that I am not sure is covered by several plans that you rank high. What should I do?

The first step is to get those plan brochures and compare them side-by-side. OPM's policy for standard brochure formats is one of the best things about the PSHB program. If you read and compare the specific language you may find the answer. If you do not, call at least one plan, and preferably several plans, and call again to protect yourself against mistakes that plan representatives sometimes make. If you are still not sure, consult providers who deal with your condition, or other patients with your condition, or both. Sometimes there is no way around doing your homework.