Choosing health insurance plan while pregnant

[mushroom]

Edited from the original for simplification and a change in plans:

Would love some help deciding on a health insurance plan during open enrollment for 2015.

I am 13 weeks pregnant, due end of April. So far this is a low risk pregnancy and I'm healthy.

Currently I'm on a plan with a restrictive network that would cover everything 100% (including my hospital stay) as long as I stay in network. I would have an out of pocket max of $5000 should I choose to go out of network. We have plenty of savings to cover this.

I have the option of moving to a different plan with a broader network that would include name-brand hospital (NBH), which is very nice, has the best NICU, where I did my pediatrics residency and has my former OB/GYN that I love. Going with this plan would guarantee that I pay $1550 more - the cost of a hospital stay at NBH would be very high even for a normal vaginal birth, but I would also hit my out of pocket max with it and everything else should be covered 100%.

Premiums are similar between the two plans, so basically $0 for my pregnancy/birth in a hospital that I would feel comfortable in as long as everything was fine vs. $1550 for the name-brand hospital.

I'm leaning towards staying with the low-cost plan since I think I have a 99% chance of everything being ok. But then I start thinking, gosh, my husband and I have great salaries and am I just being stingy, trying to save a few dollars when we're talking about the health of my brand new baby? What if there's an emergency with no time to transfer and would I regret not being in the place with the most resources? What do you guys think?

[zhelud]

Have you looked at how the insurance plans cover non-pregnancy related issues as well?  If you get a baby who has any medical issues, even minor (my first kid's first 2 years were a blur of ear infections and other weird ailments, some of which required specialists), all those doctor visits and prescriptions can add up. (And then I got kid number 2, who hardly ever had a sniffle. Go figure.)

It might still make sense to go with the lower cost option, but it all depends on the plan.

[mushroom]

As long as I'm in-network, the sick visits should be cheaper with the low-cost plan, too. Copay of $20/$40 to see PCP/specialist vs. $25/$50 under the premium plan, plus the low-cost plan would cover any outpatient services at 100% vs. a $250 deductible + only 90% coverage of labs, x-rays, etc. However, if the kid got really sick, the max OOP for the higher cost plan would ultimately be $2500 as opposed to $9000 for the low-cost plan.

[nobody123]

The birth of a child is a "qualifying event" that should let you change your elections / options.  Why not go with the more expensive / better coverage plan for the short term then reevaluate after the baby is born.  Usually you have 30 days after the life event to change, so if everything is fine, switch to the lower cost plan if you're comfortable with it.

[TeresaB]

I am also pregnant (due beginning of April). We had to pick between an HMO with no out-of-network coverage and a PPO with out-of-network coverage. We picked the PPO for peace of mind. It also has a slightly lower in-network oop max, so if everything is in network it will still be a little cheaper. I think. We are noobs at this whole pick your own health insurance thing.

How much cash do you have? If, God forbid, something terrible happened and you got stuck with the 9k oon oop max, would you be able to pay for it or would it bankrupt you? For me, this would be the deciding factor.

Nobody, does having a baby really allow you to change the whole plan? I got the impression that all we could do was add the kid. Darn, I guess we wasted some money. Oh well, live and learn.

[mushroom]

Teresa, it depends on your employer policy whether you can switch the plan too in addition to adding the baby. At least this is what I was told by the insurance company and my husband will be meeting with HR soon to sort it out.

We'd be able to handle a 9K OOP max without a problem.

I think I'd go with the broader network plan if it were just a question of slightly higher premiums, but the 90% coverage vs. 100% coverage for inpatient and outpatient services makes a huge difference and seems like such a wild card to me in terms of figuring out how much I'll spend and need for my FSA.

In a nutshell, my pregnancy/birth/well child visits will cost a total of $270 with the more restrictive network as long as I stay in network. If I go with the broader network, I'm guaranteed to spend more, probably a minimum of $1000, up to the individual max of $2500 or up to the family max of $5000 if the baby is sick. I guess I have to ask myself whether $750+ is worth the broader network.

[mushroom]

I'm going to edit my original post since I called the name brand hospital to ask for an estimate on the cost of a normal vaginal delivery and it was $21,000(!).

[La Bibliotecaria Feroz]

My instinct is to stick with the plan that covers everything 100%. When things didn't go as planned and I asked for an epidural, for instance, it was nice to feel that sweet relief without wondering what the bill would be. (Epi plus CS resulted in anesthesia charges of $16K--just for the needle in the back. No idea what the three days in the hospital cost.)

[mxt0133]

I'm going to edit my original post since I called the name brand hospital to ask for an estimate on the cost of a normal vaginal delivery and it was $21,000(!).

Don't focus on that number, that number is based on no insurance.  You have to find out what the negotiated rate is for your particular insurance that you will have at the time you incur the medical expense. 

I went through this exercise with my first child trying to get a more accurate cost of delivery and my possible out of pocket costs so I could select the appropriate amount for my flex spending account at the time.  The hospital would not give me a specific number.  At first I thought it was some kind of conspiracy to prevent people from shopping around between hospitals/providers, but then they explained that it was all depended on the insurance you carry at the time when the service is provided.

So basically you and your baby will more than likely reach your out-of-pocket maximums. If you have a $2500 per person, you will be on the hook for up to $5000 of out of pocket expenses or up to your family out-of-pocket maximum. As for future medical expenses, since you will reach your out-of-pocket maximums you will not be on the hook for any other expenses for the year

[nobody123]

Nobody, does having a baby really allow you to change the whole plan? I got the impression that all we could do was add the kid. Darn, I guess we wasted some money. Oh well, live and learn.

Obviously I would check with your employer's plan to make sure, but according to heathcare.gov you have 60 days after an event to change your coverage https://www.healthcare.gov/how-do-i-report-life-changes-to-the-marketplace/

[La Bibliotecaria Feroz]

I was able to change plans after my kids were born. I went with the gold-plated during pregnancy, then changed once they were born healthy.

[TeresaB]

Oh darn, I shouldn't have switched onto my husband's plan. Oh well. Live and learn. Thanks for the clarifications!

[VirginiaBob]

While pregnant, I'd go for the FFS/PPO plan.  We had twins that both spent months in the NICU.  The total costs were over a 1/2 million dollars.   We would have been hit pretty hard (the yearly maximum + deductible, copays) on the HDHP/HSA plan.

[mushroom]

Thanks for the input, everyone.

Teresa, it just depends on your employer policy whether you can make a change to a different plan vs. just add a new person on.

VirginiaBob, both plans are PPO - do you mean go for the one with the lower out of pocket max? If we stay in network, the out of pocket cost for the more restrictive network should theoretically be 0 even with a prolonged NICU stay. If we wanted to go out of network, the OOP max would be $5000. If we went with the broader network plan, whether there's no complications or a long stay, it would be $1550 regardless. Either plan, it wouldn't break the bank even if the baby were sick.

[mushroom]

Update: my husband met with HR, and we found out that while of course we could add the new baby to the plan, we wouldn't be able to change the type of plan until the next open enrollment. So I think we're probably going to stick with the cheaper plan. Thanks for all the feedback!

[mm1970]

FWIW, when I was pregnant during open enrollment, I went with an HMO, standard in network, and it was fine.

[mushroom]

Thanks mm1970, that does make me feel better. There's so much stuff that could be scary about pregnancy and having a kid that I have to remind myself that most of the time everything works out fine, and I'm healthy and low risk. Plus the cheaper plan is still at least a PPO so I don't have to deal with the crazy HMO paperwork/bureaucracy.