Many times, this results in the same approach as a non-HMO situation.
But not always.
The key word there is “cost effective”.
Let’s look a real world example (actually happened with a client).
Let’s say someone has severe knee pain. Very common these days (30 years of basketball is not helping my situation).
If the knee pain is significant and the result of loss of “padding” menisicus, etc, there are different paths to take.
They may involve anti-inflamation pain medications, physical therapy, orthoscopic surgery, all the way up to full-knee replacement.

Sometimes, that’s actually better!
There’s an argument that doctors are too quick to jump to surgery. We see it all the time (think prostate surgeries).
BUT (always a but)
There are situations where an HMO might be too slow to move to a course of treatment that is needed or will not go there at all.
Keep in mind that procedures have to be approved by an HMO. They can say no.
99 times out of 100, they’re on the same page.

Cancer comes to mind.
With Kaiser, you’ll generally have to stay within their network.
There may a great doctor who specializes in your ailment outside of the network.
This illustrates the two biggest drawbacks to HMO’s and Kaiser.
Less control over what is done and who does it.
What about Blue Shield of California?
Let’s look at their pro’s and con’s and then we’ll jump into the individual market segments.

Blue Shield Of California Pros And Cons

Let’s look at the contender…Blue Shield.
Blue Shield offers a range of networks including PPO and HMO.
We’ll actually break up the Pro’s and Con’s into PPO and HMO sections since they’re so different.

HMO with Blue Shield

Pro’s

1. Blue Shield contracts with independent hospitals, medical groups, and doctors
2. Pricing is lower than PPO but probably higher than Kaiser except for narrow network HMO’s

Con’s (same issues with Kaiser for HMO’s)

1. Less flexibility and control
2. Must stay within HMO network
3. Cost constraint in health care decisions

So Blue Shield’s big difference for HMO versus Kaiser is that they contract with independent hospitals, doctors, and medical groups.

Maybe THE deal!
Let’s look at the PPO with Blue Shield (Kaiser doesn’t really have a PPO)

PPO with Blue Shield

Pro’s

1. Much larger network of independent doctors, hospitals, and providers
2. You refer yourself to specialists
3. You and doctor have more say as to what medical care is provided
4. You’re not locked into an area and can access providers in other States as part of the Blue Card network

CON’s

1. Pricing. That’s about it. PPO’s are generally more expensive.

So what’s more important to you when comparing the two networks?
It partially comes down to your area.

Do you have great Kaiser facilities?
Are the Blue Shield contracted providers dominant in your area?
Is more control over health care decisions with your doctor important to you?
Important enough to pay more?
All great questions and sometimes complicated.
We can help you walk through your situation. Our services are 100% free to you.
You can always run your Quote free here:
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Let’s jump into the 3 separate markets as there are differences in each between the two carriers.
Here are the market segments:
Individual and Family (including Covered California)
Small Business (1-100 employee)
Senior (Medicare eligible)

Individual And Family – Kaiser Versus Blue Shield Of California

This is the market that is in flux since 2014.
Kaiser and Blue Shield have fully embraced all the changes and Covered California.

This includes Covered California business.
Keep in mind that the options are the same in Covered California as off-exchange.
Same plans. Same rates. Same networks.
By law.

With this, we can compare the two carriers equally.
So…how do they compare?
Let’s look at the core components we use to compare the two plans.

Individual Family Pricing

Kaiser’s hard to beat.
In any given area, they’re going to beat Blue Shield’s plans most of the time.
There are places where Shield is priced better but it’s rare.
Blue Shield doesn’t have narrow network options available on the individual/family market like they do on the group market.
There’s one PPO network and one HMO network.
The pricing reflects that.
Kaiser on the other hand will have HMO as their primary if only available plan.
HMO is usually cheaper than PPO plans since the benefits are standardized.
That brings up an interesting point.
The plan benefits have to match.

This is also true if we’re comparing a Kaiser Silver plan versus a Blue Shield Silver plan.

The first step is to run your individual/family quote here:

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This quote can include tax credits based on income and head of household.
We’re happy to walk through your situation to see what you’re eligible for.

Individual and Family Network

As we mentioned in the top level comparison between Kaiser and Blue Shield, this is really the big difference (aside from price).

With Blue Shield, you can use independent hospitals and doctors that contract with Shield under
HMO or PPO models.
So it comes down to this…
Do you want to see doctors outside of Kaiser or do you want to use Kaiser facilities?
That’s the question aside from pricing.
Of course, there’s the question of how HMO’s work themselves.
If you want more control over healthcare decisions and more flexibility for where and what is the course of treatment, that favors PPO.
HMO is more “managed”. There is a cost-constraint for course of care.
You can get a great explanation between HMO and PPO.
PPO will allow more choice and flexibility. You’re not locked into an area. Decisions are generally made between you and your doctor although there are more pre-authorizations needed these days.

Under any plan, you’ll see a link for Provider.
Net net…think of your local area and which hospitals and/or medical groups are highly regarded.
If you have both, that’s great news!

Individual and Family Customer Service

Let’s look at Blue Shield and Kaiser in terms of the user’s experience.
Just a forewarning…
Your take on the HMO and PPO way of doing things may affect this.
Kaiser Strengths

1. Integrated medical records and one stop shop
2. Strong online account services
3. Access to records easily
4. Pretty streamlined billing and claims process

Kaiser Weaknesses

1. Slower process through medical care options
2. Services can be delayed or denied (it is an HMO)
3. Medications can be changed according to sitewide purchasing

So basically, Kaiser has the mechanics down pretty good (claims, records, appointments, billing, etc).
The issues are with the HMO model itself.
You may have to push to get certain labs done or enter into a course of treatment.
That process can be frustrating if you’re in the middle of a health issue.
Read above about HMO versus PPO!

What about Blue Shield?

Blue Shield Strengths

1. Claims process is pretty streamlined considering multiple providers
2. Online accounts are good and went through a recent upgrade.
3. Claims process works well although mental health needs better integration

Blue Shield Weaknesses

1. Blue Shield is updating billing system which is desperately needed. Billing and membership were two separate systems and headaches abounded when they grew very quickly
2. More expensive than Kaiser in many areas

We’re happy to walk through these two carriers with you.
The best approach is to first run your quote between the two to see how rates compare here:
Our services are free to you at 800-320-6269 or by email.

Employer Health Plans – Kaiser And Blue Shield Comparison

We run dozens of group health quotes daily.

We first quote across all the major carriers at the most popular plan level (Silver).
Since the plans are standardized, this gives us a good indication of pricing.

That makes this comparison very important.
Add to that the strength in certain areas (Bay Area and Sacramento for example) of these carriers and you have further reason to compare.
We discussed in the first section how the HMO model of Kaiser compares with Blue Shield but let’s get more specific to the group health market.
We’ll also discuss the benefits of offering BOTH of them to your employees.

Blue Shield and Kaiser Group health Networks

First, we have to talk about networks (doctors and facilities) since the employer market has different options than individual/family now.
Better options!

Blue Shield Employer Networks

Kaiser is Kaiser so that’s easy but Blue Shield has a range of network options available.

It’s the “old” PPO network and includes most doctors/hospitals in most areas.
This is a big deal since many good doctors are not in the individual/family networks now.
There are also narrow networks available to bring down the cost within Shield.
For the Blue Shield employer HMO networks, we also have a full HMO network and some narrow network options to
bring down costs.
Some of the narrow network HMO Shield plans actually compete with Kaiser in terms of pricing.
When you request your employer group quote below, we can provide detail on the networks.

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Here’s the deal.

It’s tough to please everyone with just one option.
Luckily, we don’t have to!
I’ll take a Wrap please!

Blue Shield And Kaiser “Wrap”

Blue Shield and Kaiser “Wrap”

Employee Choice

We can discuss this option further, but here are the broad strokes.

Kaiser Wrap Bullet Points

1. We offer choice of Kaiser and Blue Shield plans to each employee
2. We cap the employer’s contribution based on a given plan (usually Kaiser)
3. Employee picks plan that meets their budgetary and health care needs
4. Employer still pays as if they were on the delegated plan regardless

Employee has choice and power! Employer has control over cost.

Since Kaiser is priced much better usually, there’s a cost incentive for people to go that way
BUT
They can go with Shield to keep their doctors and pay the difference.
This tends to put downward pressure on health plan costs to the employer.

You can request your Kaiser Blue Shield wrap below or ask us any questions on how it works.

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Medicare Supplement – Kaiser And Blue Shield

For Seniors, Kaiser and Blue Shield are very popular now.

If they’ve been with Kaiser for 10 years, they’ll probably get Kaiser for an Advantage plan.
If they use out of Kaiser networks, they’ll probably look at Blue Shield.

There’s also the question of Supplement versus Advantage plans.

Supplement Versus Advantage Plans – The Kaiser – Blue Shield Difference

They even beat AARP many times.
The Advantage plan versus Supplements is really the first question since Kaiser is an HMO carrier.
Below are the highlights but you can get more info on how they’re different here.

Supplement Deciding Factor

Since benefits are standardized with supplements, that’s really a question of pricing and Blue Shield is dominating there.

Advantage plan Deciding Factor

For Advantage plans, it’s a question of who want to see – Kaiser providers or independent doctors/medical groups.
You can quote both options and both carriers below but we’re happy to help with any questions.

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Kaiser Versus Blue Shield Comparison Final Notes!

We’ve discussed the two very different models for these carriers.

In any given segment (except group health where we can offer both side by side), if you want to use Kaiser
facilities, it’s Kaiser.

If you want to use independent doctors/hospitals, it’s Blue Shield.

The second consideration is HMO versus PPO.

Very different ways of operating to the end user.
We’re happy to walk through any questions you have comparing these two leaders.
Both are non-profit (which is interesting) and both have strengths and weaknesses.
Hopefully, we’ve spelled out what’s important to consider when comparing the two!