Health insurance for a newborn in NICU

[ncornilsen]

Hi,



I am trying to determine how to handle a sudden change in my familie's situation.  My wife was due Sept 19, but delivered at 30 1/2 weeks. The baby is in for a 5 to 6 week NICU stay. this will probably cost $200,000 by the end of it. I am blessed to be able to fuss over small details like a few thousand dollars because my daugther and my wife are doing so well.

Leading up to this, my wife was hospitalized for 5 days before due to the pre-term labor... they kept her to administer magnesium, steroids, etc to give our daughter the best shot at everything. This costs over $34,000, plus whatever she incurred during her pregnancy checkups.

Now, My wife has her own plan through her employer, and I have one through mine.

Her plan is $1000 deducible/$3500 OOP Max for individuals, and $2000 ded/7,000 OOPMax. Adding me and or the baby to her plan is several hundred a month.

My plan is $5,000ded/6450max oop per family member... and adding just my daughter is another $100 per month.


The issue is coordination of benefits.


I can assume my wife's out of pocket maximum has been reached... and the child's NICU costs will meet the OOP max of whatever plan she's added to. I think I want to add her to my wife's plan to take advantage of the fact we will pay at LEAST $3500 out of pocket for her... the child adds a marginal $3500 of Out of Pocket costs for her plan.

If my plan is primary (it would be - my birthday comes first.) will the secondary plan pay for the Out of pocket Maximum cost not covered by the primary? IE, would this double coverage ultimately eliminate the out of pocket cost for the kids NICU stay? (both plans have the care provider in network... no out of network nonsense.)   both plans have the same coordination of benefits language, I think it's state law.

Ultimately, does double covering her eliminate the entire OOP amount due for my daugther's NICU stay, or do I just have two out of pocket maximums that I have to meet?

This is so confusing, and nobody can give me an answer.
Thanks

[Dr Kidstache]

I'm so sorry you're going through this. It's incredibly stressful to be in the NICU even with both mom and baby doing well. Congratulations on your new daughter!
Most/all NICUs have a social worker available. Ask to speak to the social worker and s/he may be able to help you resolve this question or direct you to someone who can. Good luck!

[Sibley]

You'll have to meet the OOP max of whatever plan she's on I believe. Call your insurance company(ies) and explain the situation, they probably have a care coordinator or some such that can help you navigate.

Hope baby is doing well.

[SimpleCycle]

I'm glad your wife and daughter are doing well.  Congratulations on the new family member!

Double coverage rarely makes sense in situations like this, because as you noted, there is coordination of benefits that often washes out the differences between plans.  You are subject to both deductibles, and are subject to the OOP maxes of both plans.  So without both plans in front of me, I would say you just have to determine which plan has the lower OOP costs when you add premiums plus OOP max for the rest of this year.

Are the networks similar for both plans?  Because while you have the hospital bills to contend with right now, you'll also probably have several specialist visits in your daughter's first year of life, and so you may want to take that into account too when picking a plan.

Good luck, and if you have questions, I agree the NICU social worker should be able to help.

[Jrr85]

Hi,



I am trying to determine how to handle a sudden change in my familie's situation.  My wife was due Sept 19, but delivered at 30 1/2 weeks. The baby is in for a 5 to 6 week NICU stay. this will probably cost $200,000 by the end of it. I am blessed to be able to fuss over small details like a few thousand dollars because my daugther and my wife are doing so well.

Leading up to this, my wife was hospitalized for 5 days before due to the pre-term labor... they kept her to administer magnesium, steroids, etc to give our daughter the best shot at everything. This costs over $34,000, plus whatever she incurred during her pregnancy checkups.

Now, My wife has her own plan through her employer, and I have one through mine.

Her plan is $1000 deducible/$3500 OOP Max for individuals, and $2000 ded/7,000 OOPMax. Adding me and or the baby to her plan is several hundred a month.

My plan is $5,000ded/6450max oop per family member... and adding just my daughter is another $100 per month.


The issue is coordination of benefits.


I can assume my wife's out of pocket maximum has been reached... and the child's NICU costs will meet the OOP max of whatever plan she's added to. I think I want to add her to my wife's plan to take advantage of the fact we will pay at LEAST $3500 out of pocket for her... the child adds a marginal $3500 of Out of Pocket costs for her plan.

If my plan is primary (it would be - my birthday comes first.) will the secondary plan pay for the Out of pocket Maximum cost not covered by the primary? IE, would this double coverage ultimately eliminate the out of pocket cost for the kids NICU stay? (both plans have the care provider in network... no out of network nonsense.)   both plans have the same coordination of benefits language, I think it's state law.

Ultimately, does double covering her eliminate the entire OOP amount due for my daugther's NICU stay, or do I just have two out of pocket maximums that I have to meet?

This is so confusing, and nobody can give me an answer.
Thanks

I am guessing that your insurance contract provides that additional insurance reduces their exposure, not yours.  When you enrolled in insurance, you probably had to represent whether you had any other health insurance.  That has been the case for every employer provided insurance policy I have had in the states. 

I did ahve a coworker who had coverage under his and his wife's employer provided insurance, and he said that he was able to actually come out a little ahead (as in make money from child birth, not just avoid out of pockets) by giving the hospital information for one plan and then filing for reimbursement himself under the other.  Pretty sure that was insurance fraud though.  It was also several years ago; with all the electronic records, I'm not sure that would still work. 

[Marley09]

Congratulations on your new daughter!  I am glad to hear that mom and baby are doing well.

My husband and I ran in to something similar when our son was born in 2014.  First, on a separate note, this is going to be a hard time for you and your wife as everything feels so out of your control.  If you have someone who can come and help out on the home front- cooking meals to eat when you get home at 10pm, freezer meals, cleaning, setting up crib/items at home, etc it makes this time a little easier.  Also, no matter how well you think your wife is doing, please be there for her emotionally and urge her to talk to someone if needed.  I still tear up to this day thinking about leaving my son in the NICU, while I was discharged from the hospital.   It was one of the worst days of my life- I blamed myself for his NICU stay and was physically and emotionally drained with the expectations of new motherhood.  Please take care of your wife and yourself, I am sending lots of hugs and prayers your way!

**Disclaimer: Please make sure to call your company to figure your own policies out.**  On the insurance side, my husband and I also had separate health insurance policies; I decided to add my son to my insurance and everything bumped up to the family deductibles (for the 2 of us): $4500 ded/ $11,000 max OOP.  In the end, we had to pay *only* the $11k max OOP for my family deductible.  Everything that I had paid toward my individual deductible, was moved to the family deductible once my son was added.  Also, I am sure you know, but make sure you add your daughter within the allotted time frame for life events. 

Finally, as a small heads up.  Even though I delivered at an in-network hospital, the NICU was run by another company who was considered out of network; meaning I received a NICU bill in the  mid 6 figures.  I called my insurance company and explained that I had no choice of NICU, as it was in the hospital where I delivered.  They told me that I had to dispute the bill twice and then they will generally accept the charges as in-network- which worked!!  PM me if you have any other questions :)
 

[Taran Wanderer]

Our daughter spent a week in the NICU after complications during birth. It was the most stressful, awful week of my life. I’m sorry you have to go through it, but I am happy to hear that things are stable and lookin good. One thing that helped me was visiting with a social worker who asked many questions about our marriage, family, employment, financial, and insurance situation. I realized how good we had it - in all areas.  And then, as our daughter’s health situation stabilized, we began to feel like the most fortunate people in the NICU. (Everything has turned out great despite CPR in the delivery room and several scary days.)

Our week in the NICU cost $70,000. Fortunately we were double insured at the time, and our insurance (both of them) automatically added our daughter when she was born. As the bills came in, I built a spreadsheet to track them and the payments from the two insurance policies (same insurance company, but different employers). In the end, we paid about $125 out of pocket on the $70,000 in total charges across two hospitals and an ambulance transfer. In our case, at least, the deductibles and our of pocket maximums were nearly fully covered by the overlapping coverage of the two policies.

[mm1970]

Her plan is $1000 deducible/$3500 OOP Max for individuals, and $2000 ded/7,000 OOPMax. Adding me and or the baby to her plan is several hundred a month.

My plan is $5,000ded/6450max oop per family member... and adding just my daughter is another $100 per month.

This is tricky, and I'm not sure how it would really work, esp with your plan being the primary.  Essentially, you have to go through your full $5k deductible first. 

I would guess that after that, you have to pay a portion, say 20%.  You could submit that to the coinsurance but you would need to hit that $1000 deductible.  That would mean that you would have to have $5000 costs over the deductible before you hit your wife's deductible.

But I don't really know for sure.


In reality, I have double coverage, but it's a little different.  Husband's insurance is HDHP with HSA, mine is HMO.

Whenever I go to the doctor, I do not have a copay because of the co-insurance.

My childbirth cost $0 because of the co-insurance.

When my little one had a $25k surgery, the HMO covered most of it, and the HDHP covered the rest - but it was really the HSA that covered it.


Who have you asked?  The insurance companies?  Your HR department?  Our HR department contracts with a company that does all the insurance, and they have people on staff to figure these things out.  Sometimes the insurance companies might know, but I don't really trust them.

Have you asked the hospital?  I am sure there are people in the billing department in the hospital who have had this situation also.

https://www.insure.com/health-insurance/primary-health-plans.html

http://www.4j.lane.edu/files/benefits/4J_BENE_Coordination_Example.pdf

[ncornilsen]

Thanks everyone.

We spoke to the hospital billing people, my hr department, her hr department, the social worker, and incalled both insurance companys customer service 3 times to see if i could get a different person. Universally thier answers boiled down to "the only way to know is to add her and find out!" Or "ita complicated and we dont know how that will work." Its frustrating, and pointless for all of this to be so opaque! At the end of the day, due to the premium for adding her to my wifes plan being $600 a month, i could at best save $1000 or at worst be out $4500 compared to just having her on my plan, so the upside is small and im going to just add her to mine and be done with it.

Thanks!