Health insurance -- cost of pregnancy & delivery

[Sylly]

I currently have open enrollment and need a bit of help deciding on health insurance plan.

We're currently on an HDHP, and have no issue with it.

Except..

There is a possibility we will be trying to have a baby this year (we're not sure, but we haven't ruled it out), and I don't know what kind of costs pregnancy and delivery would entail, that may make something other than an HDHP make more sense (i.e., maybe an HMO?). So some questions for those who may have some experience and/or knowledge in this:

To complicate matters, my health insurance period goes June - May, whereas DH has the usual Jan - Dec.
He's currently on my plan as it's cheaper that way. Assuming dropping him from my plan is a qualifying event, he can get on his own plan. We're also not sure if I can opt out of my workplace plan and get on his. This would mean changing doctors,  however, as his has a separate network (Kaiser).

1. What health services do I need to take into account relating to pregnancy and delivery?

2. To those who have experience, what was your out of pocket cost & insurance type?

3. Has anyone had experience switching health plans mid-year due to voluntarily opting out of previous health insurance on different time period?
I've asked mine over the phone before, and was told DH leaving my plan would be qualifying event, but I'm still not 100% sure. He will ask his HR, if he/we would be able to enroll in his if he/we opt out of my plan.

For reference, the info for the available plans are as follows:
Pre and post-natal care is no charge for all plans
Price listed is for employee alone / employee + spouse.
We currently max HSA, and in 25% bracket.

HDHP (23/34 mo): 2000/4000 deductible, 4000/6850 out of pocket max, 20% co insurance after deductible for pretty much everything else.
PPO (43/90 mo): 1000/2000 deductible, 4000/8000 out of pocket max, 25 copay dr visits, 30% co insurance other things
HMO (54/113 mo): 0 deductible, 4500/9000 out of pocket max, copays: 30 dr visit, 50 specialist visit, 100 tests, 500/day (max 5) delivery

DH's plan (60/ ? mo): I recall it being a plan with good coverrage, though I don't currently have the details, but will see if we can  pull one up even though it's not his open enrollment season. I do know it's 10 copays for dr visits.

If I know what kind of costs are associated with pregnancy and delivery, we can probably do the math. However, I have no idea -- hence the questions.
We can afford the deductible / out of pocket, regardless of what plan we end up with; however, we still want to optimize our expenses.

I appreciate any input anyone can give. I can provide more info on my plans if necessary -- I'm not sure what all would be necessary in considering pregnancy/delivery costs.

[La Bibliotecaria Feroz]

My sister had a home birth, for which she simply paid $4000 out of pocket. (Insurance did not cover home birth.)

I had an unplanned hospital c-section. I paid nothing, but the EOB for the anesthesiologist alone was $16K.

Which is to say, you can't possibly know!

Yes, I have switched plans during someone else's open enrollment. It was considered a qualifying event.

A question to ask HR is whether you can change plans after a baby arrives.  I've done it, but not all employers will let you. You could IN THEORY:

Wait until you get pregnant
Change to more comprehensive plan during next open enrollment period (preferably soon after getting pregnant)
Have healthy baby
Switch back to HDHP immediately after birth or during next open enrollment.

It took me a year and a half to get pregnant--would have sucked to be paying higher premiums all that time just in case.

[seattlecyclone]

We had a baby in December, on an HDHP. I posted about it here. The total billed amount was $15k for the hospital and physician services, plus about $1,500 more in various lab tests and imaging fees before the birth. This was a very uncomplicated, unmedicated birth.

Rough out-of-pocket numbers for your plan based on $16,500 total cost would be as follows:
HDHP: $408 premiums, $4,000 toward the deductible, ($12,500 * 20% = $2,500) of coinsurance for post-deductible expenses. Total cost: $6,908
PPO: $1,080 premiums, $2,000 toward the deductible, ($14,500 * 30% = $4,350) of coinsurance for post-deductible expenses. Total cost: $7,430
HMO: $1,356 premiums, $1,000 for two days in the hospital, $1,000 for various tests and doctor visits. Total cost: $3,356

None of this takes into account the free prenatal and postnatal care (I'm a bit surprised this is even allowed for an HDHP, but I'll take your word for it). Also keep in mind that your premiums will generally be paid before income taxes and payroll taxes, and so will HSA and FSA contributions, so adjust these numbers downward by a factor of your tax bracket as appropriate. If you have any complications with the pregnancy, the bills will be more, and you should probably not be surprised to pay the out-of-pocket max for whatever plan you're on if that happens. Also, since a pregnancy lasts nine months there's a high probability that at least some of your prenatal expenses will be in a separate plan year (and thus count toward a separate deductible) from the hospital expenses. Also you might not be able to become pregnant as quickly as you would like, so opting for a more expensive health plan "just in case" may prove to be a bit more premium expense than you would like. Lots of variables here!

[forummm]

The average commercial claims total (the total of what was paid by insurers plus the amount paid by beneficiaries for people with private health insurance) for maternity, delivery, and 3 months of newborn care was $30k for vaginal and $50k for caesarian delivery. I think that's about what our bills totaled to (but not quite). Probably $5k pre-baby, $15k delivery, and $1.5k the first few months. We paid a few hundred of that out of pocket because we have a zero deductible plan and a lot of the preventive care is free for kids and our pregnancy coverage is fantastic. Our plan is more expensive, but I valued knowing exactly what the entire situation would cost. The range of costs is quite large, and figuring out how your insurance would deal with each aspect of it is irritatingly complicated if you don't have such a nice plan as ours.

[SKL-HOU]

I would get the one with the best coverage and least OOP. You cannever know what can go wrong and healthcare is expensive. My pregnancy was going great until out of the blue it wasn't. I gave birth very, very early. I was in the hospital a fewdays before birth.  The NICU bill was 500k, i paid $1250x2 (twice because my son was born jan 1). Of course, this is an extreme case but pregnancy and birth have too many things that can go wrong.
You can always downgrade if all is okay (birth is a qualifying event).

[forummm]

I would get the one with the best coverage and least OOP. You cannever know what can go wrong and healthcare is expensive. My pregnancy was going great until out of the blue it wasn't. I gave birth very, very early. I was in the hospital a fewdays before birth.  The NICU bill was 500k, i paid $1250x2 (twice because my son was born jan 1). Of course, this is an extreme case but pregnancy and birth have too many things that can go wrong.
You can always downgrade if all is okay (birth is a qualifying event).

Almost every plan will have an OOP max for the year that will be $13k for the family or below. So, as bad as a $500k NICU bill is, almost anyone with insurance will only be on the hook for whatever their OOP max is (as in your case). The OP should know what the OOP max is for her plan and be prepared to pay that amount for a pregnancy (unless pregnancy related care has a special provision that makes it cost less--like our plan does).

[COlady]

I would get the one with the best coverage and least OOP. You cannever know what can go wrong and healthcare is expensive. My pregnancy was going great until out of the blue it wasn't. I gave birth very, very early. I was in the hospital a fewdays before birth.  The NICU bill was 500k, i paid $1250x2 (twice because my son was born jan 1). Of course, this is an extreme case but pregnancy and birth have too many things that can go wrong.
You can always downgrade if all is okay (birth is a qualifying event).

Ditto. All went great with my twin birth. We then switched to my husbands HDHP (because I quit working) and one twin was hospitalized in the ICU with RSV at 12 weeks. The bills totaled $99K and we had to pay $11K (OOP max). I'd keep a higher premium lower deductible and OOP max for at least the baby's first year.

[VaCPA]

Definitely get the best insurance if a pregnancy is looming. Best case scenario there are no issues and you just have routine OB appointments and sonograms and the delivery. But even in that scenario you're racking up some $$ bills for insurance to pay. Then there is the scenario where there are complications and costs can be extraordinary. On our 3rd child the sonogram showed a possible abnormality and they recommended amnio and full blown genetic testing due to my wife's age. That alone costed like 8k before insurances portion.

[Sylly]

Thanks all for the input.

It seems that regarding cost, a fair summation is -- Get ready to pay your OOP, or at least your deductible.
All the plans available to us have good coverage, essentially different just in their costs (between premiums and OOP). Given that, the plan with the least OOP cost seems to be the best option. Currently, that's DH's HMO plan (~60/130 mo).

I wouldn't say that pregnancy is looming. It's a possibility, but not a certainty. We haven't even decided to start trying (or if we even will), so we have some time yet. We've figured that staying with the HDHP is the best option for now. If pregnancy becomes looming or a reality, we still have the option of getting on DH plan for Jan 2017. While we can potentially switch over starting this June, considering our time frame, I think staying with current plan isn't a problem.

ps. seattlecyclone -- it says routine prenatal and one post-natal is no charge. I just assumed good prenatal makes financial sense for insurance companies.

edit: typo in number

[I'm a red panda]

I have a PPO.

A few highlights from my pregnancy  (what was billed, what I paid as coinsurance or copay):

Misc OB charges: $950; I paid $67
20-week ultrasound: $709- I paid nothing.
25- week growth follow up ultrasound- $386- I paid nothing
MFM Ultrasound: $6,257   - I paid, $36
Fetal Echo/Fetal Cardiologist consult: $1,222- I paid $16.50
Amnio and Fetal Micro-array: $3,042  - I paid nothing 
Maternal Genetic testing- $3,042 - I paid nothing  (Paternal testing cost $2,000 we paid, as he had a HDHP)


That's just like a greatest hits; I had a shit-ton of ultrasounds, weekly appointments with specialists.  Because of the nature of my pregnancy I had a plethora of other expensive tests.  The number of fetal/pediatric specialists I would have had to visit would have been massive if the baby had not passed away in utero, as they wanted to meet with every specialist who would have to care for him in the NICU to start testing before he was born.

Delivery for a stillborn costs the same as for a live birth.



If I had a HDHP, I would have easily hit the deductible. The one thing I learned this pregnancy is that it is very possible to go over the out-of-pocket max; I though max meant you were done. But if you need emergency procedures out of network, and have to pay upfront, the "allowable charges" adjustments really screw you over.

To me, insurance is more for the situations you don't plan for than for the ones you do. The costs quoted from our OB for a healthy pregnancy were a small fraction of what we ended up paying.

[VaCPA]

To me, insurance is more for the situations you don't plan for than for the ones you do. The costs quoted from our OB for a healthy pregnancy were a small fraction of what we ended up paying.

Exactly. As with most insurance you pretty much have to look at the worst case scenario and decide if you will be ok if that happens and you don't have coverage. Anything medical related has the potential to be extraordinarily expensive.

[seattlecyclone]

If I had a HDHP, I would have easily hit the deductible. The one thing I learned this pregnancy is that it is very possible to go over the out-of-pocket max; I though max meant you were done. But if you need emergency procedures out of network, and have to pay upfront, the "allowable charges" adjustments really screw you over.

This is an important point. If you stay in network, the maximum really is the maximum. If you get care from an out-of-network provider, you're basically at the mercy of the billing department. Not only is there typically a higher deductible and maximum for out-of-network care, but even after that if they happen to bill more than what your insurance considers "reasonable" you're on the hook for the entire difference. Therefore it's very important to make sure the network for your chosen plan has enough doctors in your area that you're unlikely to need care from anyone else.

[Jesstache]

Ditto what everyone else said and I'd add that they will make sure you hit your out of pocket max by spreading the "individual" charges out between you and the baby and over multiple plan years if they can get away with it.

Our family out of pocket max was $6000 and individual was $3000 with our second kiddo.  He was born in September and our plan year ended in July, I believe.  They were able to spread the charges out between the two plan years years by billing all of the OB stuff ahead of time (per policy, of course) in the plan year before he was born to me and all of the hospital and delivery charges on the next year.  We ended up paying $8000 in deductibles for his prenatal care, birth and delivery (c-section) in 2013 with a $6000 out of pocket max 2k deductible for 2012-2013 plan year, 3k for me and 3k for baby on 2013-2014 plan year.  The only reason it wasn't $9k total was because I had already paid the rest of my 2012-2013 individual deductible of about $1k the previous fall for a D&C from a miscarriage. 

My daughter was born in 2011 under a different insurance plan with no deductible and we paid a grand total of $40 out of pocket for Dr co-pays (she was also a c-section, what can I say, I grow my babies breech!).  Actual cash we ended up shelling out was probably about the same though as we were paying about $1100/month in insurance premiums (no employer contribution) and now we pay about $600/month (with employer contributions).  At least the higher insurance premiums were pre-tax.

[SKL-HOU]

If I had a HDHP, I would have easily hit the deductible. The one thing I learned this pregnancy is that it is very possible to go over the out-of-pocket max; I though max meant you were done. But if you need emergency procedures out of network, and have to pay upfront, the "allowable charges" adjustments really screw you over.

This is an important point. If you stay in network, the maximum really is the maximum. If you get care from an out-of-network provider, you're basically at the mercy of the billing department. Not only is there typically a higher deductible and maximum for out-of-network care, but even after that if they happen to bill more than what your insurance considers "reasonable" you're on the hook for the entire difference. Therefore it's very important to make sure the network for your chosen plan has enough doctors in your area that you're unlikely to need care from anyone else.

Well you still need to read the fine print. Sometimescopays are not included in deductible or oop. It happened to me but it wasn't too bad. Maybe 5-6 times $30 copay after oop was met (in network).

[I'm a red panda]

Deleted

[Sylly]

This is an important point. If you stay in network, the maximum really is the maximum. If you get care from an out-of-network provider, you're basically at the mercy of the billing department. Not only is there typically a higher deductible and maximum for out-of-network care, but even after that if they happen to bill more than what your insurance considers "reasonable" you're on the hook for the entire difference. Therefore it's very important to make sure the network for your chosen plan has enough doctors in your area that you're unlikely to need care from anyone else.

Thank you for stressing this point. This is not something I had considered. I *think* either networks available to us is big enough to have sufficient variety of doctors, should their specialty be needed. There's benefit to being in a decent size metro area, and a couple hours away from an even bigger one, I suppose. I have experience with out of network services, and do know for a fact that my insurance plan does keep separate tally for in and out of network deductibles, and only count allowable charges. That would be very undesirable in the kind of cost ranges I'm seeing here.

Ditto what everyone else said and I'd add that they will make sure you hit your out of pocket max by spreading the "individual" charges out between you and the baby and over multiple plan years if they can get away with it.

That's another thing that I hadn't really considered. So in effect, I should expect the total cost to be the deductibles and OOP for (at least) two years! This just means that if we do decide to move forward with this, DH's HMO is by far the better choice (1500 per person, 3000 family OOP -- much lower than any of mine).

[muckety_muck]

I would go for the PPO. I had PPO for my first, ZERO out of pocket for any ultrasounds (there were many!) bloodwork, dr visits, hospital admission, labor/delivery, anesthesiologist (would have been a total of about $13k OOP just for a routine hospital delivery, 2 days stay).

A relative of mine had HDHP and prenatal visits/labor-delivery spanning 2 yrs. High risk, lots of appts & bloodwork, ultrasounds etc. First year, about $8k (didn't meet OOP max) and next year (baby born in april) was $11k just for her, another $3k for baby.

For 2nd baby, we had PPO that covers EVERYTHING except a $175 admission for labor/delivery. It's just a tad bit cheaper than the PPO we had for the first delivery, no big deal.

Good luck w/ your decision, but I would have PPO absolutely for the year that you plan to GET pregnant and the year that you DELIVER (which could span 2 yrs like my relative). Then switch to HDHP as long as you & baby are healthy.

[SKL-HOU]

A couple more things.

In a high deductible plan, the deductible for a family plan applies to the individual. Maybe most people know this but i found out the hard way. So when they say deductible 2500 individual/5000 family, they mean if you are on a family plan the deductible is 5000, whether met by 1 person or combination.

The other thing is make sure you only get billed for what you are supposed to. I had an ambulance ride with my pregnancy. The ambulance company was just contracted by the hospital i guess. They decided they didnt like how much the insurance paid them (the allowable) and tried to bill me the difference. One call to the insurance took care of it.

[FLBiker]

We have an HMO.  Wife and I both work at the same place, which is a state university, so our insurance is good.

I don't have the bills in front of me, but I remember that we paid $250 for labor and delivery.  And I believe that all of the prenatal stuff was free.  Oh, we went to the ER once with some bleeding so that would have been $50 or $100.  This was for an uncomplicated, unmedicated birth w/ a midwife at a major hospital.  DD's heart rate got low during active labor so there were NICU docs in the room, but we still just paid that flat $250.  And this included a free infant carseat. :)

[mm1970]

I have had both my children on HMO, and I found that it was a better deal, overall.

First birth in 2006 was about $8500 (epidural, 2 days in hospital).
Second birth in 2012 was $14,000 (no epidural, 1 day in hospital).

First birth OOP cost was $700 + the $20 copays for each visit. (A few hundred bucks maybe?)

Second birth OOP cost was zero, but we had double insurance coverage then.  My HMO paid most, husband's HDP/HSA paid the rest.

It's important to note that my co-pays were about $20 both times, and my premiums were not high.  The amount of the premium will have a large effect on the particular choice.

It got to be funny that a couple of my coworkers (at both companies) would ask me every year "which one should I use??" because I always ran the numbers.

As an aside, my second child had a birth defect that necessitated surgery at nine months.  I think the surgery was on the order of $20,000.  It was a complete pain in the ass to get that paid for, and took 18 months to get all the bills settled.  First you have to get the approval for the surgery - our home pediatrician referred us to the specialist surgeon, who referred us to UCLA because he doesn't do the surgery.  You get a referral number.

Even with that, my HMO denied payment because "it's not an emergency surgery".  Well, duh, that's why we got the referral number and pre-approval.  Eventually it got paid, but the doctor had to bill our home doctor's office, who then submitted it to the insurance.  (I think my husband's insurance got screwed, because they were the secondary and they just went ahead and paid their portion without quibbling.  Which is weird, because they were both Anthem BC). 

In the midst of all this, we went through open enrollment when I realized that outpatient surgery costs to me were $125.  So, we called the insurance company up and they said "you are right!" and then it was paid.

Sadly the hospital billed separately, so we had to do it all over again when they started billing.

Out of Pocket: zero
Number of hours on phone: dozens.

[brycedoula]

I'm in Canada so can't comment on insurance costs, but i wonder if you have other options in terms of keeping your costs lower?

Specifically I'm wondering about things like finding a GP who does obstetrics (instead of automatically going to an OB/GYN), or even seeing a midwife. Depending on your state & insurance, midwives may do hospital/birth centre/home births, which I'd imagine would be significantly cheaper than a OB/GYN-attended hospital birth.

Also, most (if not all) of the tests offered to pregnant women are in fact NOT mandatory. For example: if you are tracking your cycle & sure of your dates you could reasonably decline a dating ultrasound. Or, if you would continue a pregnancy regardless of any less-than-normal test results (indicating Down Syndrome, other trisomies, spina bifida, etc) you could opt not to have the testing done in the first place.

The book Expecting Better by Emily Oster is a good book to read regarding some of the testing I've mentioned above.

[lsalinas]

You mentioned that your husband's insurance is Kaiser.  I would just like to add that I have had a great experience with Kaiser.  I live in the Los Angeles area, I am not sure if the service is uniform throughout the Kaiser system or not.  I think Kaiser might have different levels of HMO plans, but the one that I am on covered everything.  Since everything is either covered 100% or has a $15.00 copay, and I only go to a non-Kaiser doctor if Kaiser refers me there, I haven't received a medical bill in 5 years, so I don't know how much my pregnancy actually cost.  However I ended up having an emergency c-section, the twins were in the NICU for 6 weeks and I was in the hospital for almost a week and I paid nothing.  It was a huge relief to not have to think about money during that time. 

[I'm a red panda]

Or, if you would continue a pregnancy regardless of any less-than-normal test results (indicating Down Syndrome, other trisomies, spina bifida, etc) you could opt not to have the testing done in the first place.

Many of these tests will have to be done once the baby is born anyway though, so putting them off doesn't really save you anything.  They don't do these tests unless you have an indicator that they are needed, insurance isn't just going to pay for extensive genetic testing.

One of the reason much of extensive the prenatal testing is done so that you can establish a care team for the child and prioritize his/her needs.  The prenatal testing I had done let the doctors see which issues my son had would be the greatest, and a conference was planned to help prioritize the 15 or so surgeries he would need in his first 2 years, because there is no way his body could handle all the 'fixing' at once. It also allowed my care team to plan for who would need to be there for the delivery. 


As for the early screenings, well, you could decline them, but then if something is wrong, you've put off a huge opportunity to prepare for that.

[brycedoula]

Or, if you would continue a pregnancy regardless of any less-than-normal test results (indicating Down Syndrome, other trisomies, spina bifida, etc) you could opt not to have the testing done in the first place.

Many of these tests will have to be done once the baby is born anyway though, so putting them off doesn't really save you anything.  They don't do these tests unless you have an indicator that they are needed, insurance isn't just going to pay for extensive genetic testing.

One of the reason much of extensive the prenatal testing is done so that you can establish a care team for the child and prioritize his/her needs.  The prenatal testing I had done let the doctors see which issues my son had would be the greatest, and a conference was planned to help prioritize the 15 or so surgeries he would need in his first 2 years, because there is no way his body could handle all the 'fixing' at once. It also allowed my care team to plan for who would need to be there for the delivery. 


As for the early screenings, well, you could decline them, but then if something is wrong, you've put off a huge opportunity to prepare for that.

Yes I'm aware of that, and agree with you. I recently gave birth & DID chose to have the screening bloodwork done. I mention it because it's presented to pregnant women as a "must"; but depending on a woman's beliefs/culture/religion/philosophy she doesn't have to have it done.