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As some of you know, my son suffered an elbow injury in January, likely a torn ulnar collateral ligament that will require Tommy John surgery. Since that time, I've received quite an education about the differences of insurance plans and the importance of having the right one if you want your son seen by the best docs for his injury, not just the best guy his primary medical group has on staff.

Like so many who visit these boards, we have HMO coverage. It's less expensive for monthly premiums and the deductibles are lower too. The down side is that you have to use the doctors in your primary care provider's group, unless they don't have a doc qualified to do the procedure you need. If that happens, they'll send you to another medical group that they are contracted with, and you'd better hope that someone in that group is qualified.

What we have learned is that not a single orthopedic surgeon in our primary physician's medical group has ever performed a Tommy John procedure. The group they want to refer us to has some excellent orthopedic surgeons, but only one of them has TJ experience, and he's only done two of these surgeries. We have also been referred, through some wonderful people associated with an MLB club, to an outstanding surgeon in San Francisco who has done a large number of TJ surgeries, and operates on professional and college baseball players as a regular part of his practice. Certainly, he's a good enough doc for my son, who still hopes to play juco baseball next spring.

At this time, we are wading through the mess that is managed health care. What I've learned over the last two months, and wish to share with everyone here is that: IF we had a PPO - Preferred Provider Organization for our health insurance, my son would most likely have already had the surgery, and with the Dr. we want to perform the operation. Monthly premiums for PPO coverage are higher than HMO premiums, and the deductibles are higher too. When you don't have many medical needs, or any attention that is required is for fairly minor needs, an HMO is a great way to go. However, if you or more importantly your kids need something major, a PPO can be a much better way to go, especially if you want to have a say in who operates on your kid.

We expect to eventually get the surgery performed by the surgeon we want, but have been told to expect the "process" to take about 2 more months, and require a couple visits to doctors who'll have to decline to do the surgery because he still aspires to play college baseball. To say this has been time consuming and frustrating would be an understatement. About the only good thing I can say about our HMO coverage is that it isn't with Kaiser Permanente. There is another local kid who's also torn his UCL and Kaiser has been an absolute nightmare for him. They have a surgeon who's never done a single TJ surgery that is insisting he's qualified to operate on this kid, and won't agree to refer him out of group for the surgery. If that kid has the operation by this surgeon, he's quite likely done playing baseball.

When your health insurance plan options are given at work, I suggest you give strong consideration to which type of coverage will best suit your kid's needs if they require a major procedure. I will be switching to PPO coverage at the earliest opportunity, but unfortunately it won't be until December when we have our next benefits change period.
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Catcher Dad, sorry to hear about your sons injury and the insurance problem. My son got hit by a fastball while batting a year ago and took him to the ER due to breathing problems. Luckily there was a Doctor in the stands and said he saw what happened and was sure he had a ruptured splean. We take him in, they call in a surgeon ready to do surgery. Dr. decides to wait overnight to see if bleeding gets worse before he jumps into surgery. Thank goodness we were able to avoid surgery but required numerous days in the ICU unit. HOM wouldn't cover part of it because the surgeon wasn't on their list. The guy actually saved them from paying for a surgery. Luckily our legion had insurance that picked up part of the difference. You never think something like this will happen to you. Hang in there and good luck to your son.
06CatcherDad - I'm a nurse for an insurance company. You are exactly correct on what you say about the differences in plans. What many people don't understand is that the employee is purchasing a plan that is chosen by your employers. Some employers are going to offer a PPO/HMO option. Sometimes, certain employers won't. Typically an insurance company will have a variety of plans to choose from that have different levels of benefits. You pay for what you get so to speak. Often, companies/employers, will be self insured. If they are, then they completely choose what benefits they want their employees to have - not the insurance company. Insurance can be a very complicated process if you don't understand all of the pieces.

I'm sending you a PM dad on your particular situation.
Sympathize with you had the same experience. One further thing you will want to begin is getting rehab in place for after the surgery. Insurance Co's bulk at that also. If you run into a surgeon who has not done the operation but insists on doing it, ask for his CV and the name and contact number for his malpractice insurance company so you can turn them over to your attorney for some research. This makes them take a deep breath and reconsider learning how to do a new procedure on your son.
We at least don't expect to have the problem of running into a doc who doesn't have the experience yet insists he can do TJ. In fact, the surgeon we expect to be referred to has done the procedure twice. His one of his fellow surgeons in their group called to talk about my son and once I told him my son would be playing college ball next year, he immediately said his partner would refuse to do the procedure and would recommend the doctor that we have already found and want to do the surgery. He indicated that his partner can do the surgery and make my son able to function normally, but that he won't suggest that he has anywhere near the experience to get things "just right" to enable him to continue playing baseball at a higher level. They too, think we should be seeing the doctor we want. Problem is, we need to jump through some significant hoops and withstand some long delays to get the right guy and have insurance pay for it.
This is what's great about the HSBBW family. It's not just 'baseball' - it never ceases to amaze me how much people are willing to share so that the rest of us may benefit.

Thank you for starting this thread! It caught my eye because I hope to be self-employed someday (career change) and am worried about health/life insurance for my family. I found this site which was helpful in explaining some of the different options, and thought someone else out there might benefit:

HEALTH CARE OPTIONS
06CatcherDad ~ So sorry to hear about all the troubles you are having with the insurance company. Hopefully, everything will work out in your favor. I know the waiting can be just as frustrating. Your information is good food for thought for most of us when considering medical insurance.

Younger son injured his elbow two weeks ago during a game, but we have not had the nightmare you are experiencing. Orthopaedist in ER set the dislocation and referred us to a children's orthopaedic sports specialist (who actually left for a conference and the elbow specialist in the group performed the surgery)for the surgery. Coach was also in ER and told orthopaedist my son was a ballplayer and planning a future in baseball.
A few years back we opted for a PPO Policy with a high deductible, $4800. BUT our premiums are about $400/month less. Like you said, our boys are older and we aren't seeing doctors all the time. With this type of policy you can now opt for a Health Savings Account (HSA) where you can save that $400 per month for the times you might need it. You can also use that money for dental deductibles, etc. It is also deductible on your taxes "above the line". It's not subject to the 15% of income that other medical costs are. We're able to go to any doctor on their list and not be charged anymore than the agreed upon amount. When our son was facing possible shoulder surgery we were happy to find out that the top shoulder guy in the area wasn't going to cost any more than any other. It's certainly something to consider.
The other side of the coin....we are paying $1085/month,(self-employed premium) for a PPO plan.....with son across country we had to keep a plan that would enable him to go to Doctors of choice....

Catcherdad....so sorry for your difficulties....hope by posting the story you get some new info or help....good luck.
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Interesting discussion.

Noted that there was no mention of the school's coverage.

Trying to remember if there is some coverage from the high school. I'm sure it's not the same across the country.

I thought the high school had some coverage.

And, I am recalling some paperwork at the collegiate level where there was coordination with the school and personal coverage but can't recall exactly the arrangement.

Anyone remember?
FO - Schools typically do have insurance that pays as a secondary payor. The injury has to be reported and received while playing the school sport. So, depending on how a situation has occured, etc., the secondary may pay.

I've used our HS insurance with my daughter for a concussion she received catching a softball with her forehead! Also, used it with son when he sprained his ankle while we were in Florida. It can certainly be a valuable piece of the puzzle with sports related injuries!
I can't speak for the other parents on here, but my son's injury was outside of high school. We were playing in a tournament in Southern CA, and his elbow "popped" on one throw down to second. High school insurance, and yes it is secondary, wouldn't apply in our case.

Glad to see that others are sharing/getting usefil information about this topic. That's why I started it in the hope that it would save others from going through what we're dealing with.

Thanks lafmom, for your advice and guidance. I sincerely appreciate it!
06catchersdad,

Not my field of expertise (insurance that is) Unfortunately, have had some experience with TJs.

Don’t know if it pertains here and suppose you’ve checked it out, but did the team he was playing on have insurance that could possibly be used for secondary coverage. Any team that enters our tournaments must turn in insurance coverage. Depending on the actual event and where it happened, it’s possible there could have been some coverage.

Because of the individual events we run, we carry much more than the mandatory amount of insurance. It was recommended because of the high number of potential early draft prospects who sometimes attend. One good thing is that our coverage also extends to and covers individuals who play on teams in our tournaments. I know of players who have been hurt in our tournaments who did receive coverage from our insurance company. I’m not sure how it works exactly, but just in case you hadn’t checked, thought it might be worth a try.

Once again, I might be wrong on the above. Don’t personally handle that stuff. I just hope your son gets the best possible surgeon. Good luck
quote:
FO posted: I am recalling some paperwork at the collegiate level where there was coordination with the school and personal coverage but can't recall exactly the arrangement.


As lafmom points out also, my understanding from paper work I read is the college picks up costs not covered and payed by the players insurance.
Last edited by Dad04
PG, thanks for the thoughts about insurance. I never thought about my team insurance possibly covering some of the cost. We are covered for my team, and I've never had a claim. I'll have to check in to that.

Now, as to injuries at PG showcases, are you telling me that when my son was injured at the National Underclass in 2004, that I didn't have to pay the emergency room bill deductible myself? noidea He had to get stitched up after a collision, I didn't ever think about checking into seeing if your insurance would pay it, I just reached into my pocket for the deductible. Eek
Where son goes to school, scholarhip players cannot be covered by an HMO. They do not want the hassle of not being able to send the player to where they want. School picks up whatever insurance does not pay.

Just an FYI, for any interested parent, if son is over 18, has a legit address, you can get medical insurance with great hospitalization benefits from state where he goes to school. It may be cheaper.

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