Author Topic: Insurance Time: HDHP vs PPO for new preganancy  (Read 1342 times)

mojingly

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Insurance Time: HDHP vs PPO for new preganancy
« on: November 18, 2020, 02:01:58 PM »
Hi, all!

I'm newly pregnant (yay!) and need to decide whether to keep myself and my husband on my employer's HDHP or transition us to the PPO option. Our benefit advocate was unhelpful, so I'm hoping for some mustachian advice and another set of eyes. Both my husband and I are healthy and on no medication, so we typically accrue no health care out of pocket costs and this is all new to me. Our new addition is expected in July 2021.

PPO
Yearly cost: $4,897
Family Deductible: $2,000
Out of Pocket Max: $6,400
Office Visits: 30 primary care, $60 specialist copay
Preventative Care: 100%, no deductible
Hospital Care: 80% after deductible

HDHP (no employer contribution to HSA)
Yearly Cost: $2,882
Family Deductible: $5,000
Out of Pocket Max: $7,350
Office Visits: 100% after deductible
Preventative Care: 100%, no deductible
Hospital Care: 100% after deductible

I keep circling back to the HDHP with the lower premium and HSA tax savings, especially with the full preventative care, but may be missing something. I have a few days to decide, and I'm afraid my brain has given out. I would greatly appreciate any advice or collective wisdom!

-M

seattlecyclone

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #1 on: November 18, 2020, 02:31:05 PM »
With a childbirth you can kiss your deductible goodbye. Expect to spend the out-of-pocket max, and be pleasantly surprised if that doesn't happen.

A first stab at a comparison would look something like this (assume 22% income tax bracket + 7.65% payroll tax):
PPO: $4,897 premiums ($3,445 in after-tax dollars) + $6,400 out-of-pocket max = $9,845 in after-tax dollars. Subtract a bit if you can run the out-of-pocket costs through an FSA to save tax money on these too.
HDHP: $2,882 premiums ($2,027 in after-tax dollars) + $7,350 out-of-pocket max - $2,135 HSA tax break (29.65% of $7,200 max contribution) = $7,242 in after-tax dollars

That's the worst case for each, and the HDHP is looking pretty good in the 22% bracket. Adjust the math as needed for your own tax situation.

I do have a question about the post-deductible costs in the HDHP. It says that office visits and hospital care are fully covered after the deductible. What costs do still apply after the deductible? If you don't know of any that might apply in your case, you might be able to get away with just paying the deductible if you're on the HDHP. That would make the gap a bit wider.

v8rx7guy

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #2 on: November 18, 2020, 02:38:38 PM »
Hi, all!

I'm newly pregnant (yay!) and need to decide whether to keep myself and my husband on my employer's HDHP or transition us to the PPO option. Our benefit advocate was unhelpful, so I'm hoping for some mustachian advice and another set of eyes. Both my husband and I are healthy and on no medication, so we typically accrue no health care out of pocket costs and this is all new to me. Our new addition is expected in July 2021.

PPO
Yearly cost: $4,897
Family Deductible: $2,000
Out of Pocket Max: $6,400
Office Visits: 30 primary care, $60 specialist copay
Preventative Care: 100%, no deductible
Hospital Care: 80% after deductible

HDHP (no employer contribution to HSA)
Yearly Cost: $2,882
Family Deductible: $5,000
Out of Pocket Max: $7,350
Office Visits: 100% after deductible
Preventative Care: 100%, no deductible
Hospital Care: 100% after deductible

I keep circling back to the HDHP with the lower premium and HSA tax savings, especially with the full preventative care, but may be missing something. I have a few days to decide, and I'm afraid my brain has given out. I would greatly appreciate any advice or collective wisdom!

-M

I too believe you are likely to hit the OOP Max... in which case I am 100% on board with seattlecyclone's analysis and would steer you toward the HDHP.  We had all 3 of our children while on the HDHP, we felt confident it was the better choice.  I also wondered the same thing about how one would actually get to the OOP Max in the HDHP plan if everything is covered in full after the deductible?

mojingly

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #3 on: November 18, 2020, 02:50:31 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

v8rx7guy

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #4 on: November 18, 2020, 02:55:56 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

How far along are you in the pregnancy?  Try to get as much of the expenses to land in 2021 as possible.  For instance if you have a window of December 28 and Jan 11 to have an ultrasound appointment or something... choice after the new year.  Just a little trick to save money.  It's sad but with the cost of healthcare in the USA you actually have to think about this stuff... ideal time to get pregnant is like December to February these days to keep all expenses in one calendar year - can mean the difference in thousands out of pocket.

seattlecyclone

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #5 on: November 18, 2020, 03:04:59 PM »
Another thing to consider is that childbirth is a qualifying event for insurance changes. You will likely have the opportunity to switch your coverage retroactive to the child's birth date. My gut says that this won't pay off in your case because you'll be racking up some expenses on the HDHP before the birth (ultrasounds, lab tests, etc.) and would be starting all over on the deductibles with the change, but it's worth considering.

mojingly

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #6 on: November 18, 2020, 03:11:25 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

How far along are you in the pregnancy?  Try to get as much of the expenses to land in 2021 as possible.  For instance if you have a window of December 28 and Jan 11 to have an ultrasound appointment or something... choice after the new year.  Just a little trick to save money.  It's sad but with the cost of healthcare in the USA you actually have to think about this stuff... ideal time to get pregnant is like December to February these days to keep all expenses in one calendar year - can mean the difference in thousands out of pocket.

Yeah I thought of this about a month late! My first appointment is early-mid December, and for peace of mind I'm definitely keeping that on the books. Thankfully the majority of our expenses will hit in 2021.

reeshau

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #7 on: November 18, 2020, 03:25:02 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

How far along are you in the pregnancy?  Try to get as much of the expenses to land in 2021 as possible.  For instance if you have a window of December 28 and Jan 11 to have an ultrasound appointment or something... choice after the new year.  Just a little trick to save money.  It's sad but with the cost of healthcare in the USA you actually have to think about this stuff... ideal time to get pregnant is like December to February these days to keep all expenses in one calendar year - can mean the difference in thousands out of pocket.

Yeah I thought of this about a month late! My first appointment is early-mid December, and for peace of mind I'm definitely keeping that on the books. Thankfully the majority of our expenses will hit in 2021.

Waiting 3 weeks for your first ultrasound -- $250 saved
Knowing your baby is doing well ahead of the holidays and all the family questions -- Priceless

v8rx7guy

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #8 on: November 18, 2020, 03:26:00 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

How far along are you in the pregnancy?  Try to get as much of the expenses to land in 2021 as possible.  For instance if you have a window of December 28 and Jan 11 to have an ultrasound appointment or something... choice after the new year.  Just a little trick to save money.  It's sad but with the cost of healthcare in the USA you actually have to think about this stuff... ideal time to get pregnant is like December to February these days to keep all expenses in one calendar year - can mean the difference in thousands out of pocket.

Yeah I thought of this about a month late! My first appointment is early-mid December, and for peace of mind I'm definitely keeping that on the books. Thankfully the majority of our expenses will hit in 2021.

Waiting 3 weeks for your first ultrasound -- $250 saved
Knowing your baby is doing well ahead of the holidays and all the family questions -- Priceless

There's a reason I chose December 28 ;)

mojingly

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #9 on: November 18, 2020, 03:35:55 PM »
Thanks! Glad to know I wasn't wildly off base here.

The costs after reaching the deductible on the HDHP had me confused too. It seems to mostly apply to out of network providers and services (then it's usually 30% after deductible met), and some copays on medications.

How far along are you in the pregnancy?  Try to get as much of the expenses to land in 2021 as possible.  For instance if you have a window of December 28 and Jan 11 to have an ultrasound appointment or something... choice after the new year.  Just a little trick to save money.  It's sad but with the cost of healthcare in the USA you actually have to think about this stuff... ideal time to get pregnant is like December to February these days to keep all expenses in one calendar year - can mean the difference in thousands out of pocket.

Yeah I thought of this about a month late! My first appointment is early-mid December, and for peace of mind I'm definitely keeping that on the books. Thankfully the majority of our expenses will hit in 2021.

Waiting 3 weeks for your first ultrasound -- $250 saved
Knowing your baby is doing well ahead of the holidays and all the family questions -- Priceless

There's a reason I chose December 28 ;)

I caught it!

As an aside, we're lucky that this is a happy expense, and one that we're able to plan ahead for. But I'm an intelligent person, and I've been researching this for days now, and I'm exhausted.  I can't even imagine having to navigate this with a horrible, unplanned, negative, medical expense bill. What a system. (end vent).

Can't tell you how much I appreciate all the advice!

yachi

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #10 on: November 18, 2020, 03:43:27 PM »
Hi, all!

I'm newly pregnant (yay!) and need to decide whether to keep myself and my husband on my employer's HDHP or transition us to the PPO option. Our benefit advocate was unhelpful, so I'm hoping for some mustachian advice and another set of eyes. Both my husband and I are healthy and on no medication, so we typically accrue no health care out of pocket costs and this is all new to me. Our new addition is expected in July 2021.

PPO
Yearly cost: $4,897
Family Deductible: $2,000
Out of Pocket Max: $6,400
Office Visits: 30 primary care, $60 specialist copay
Preventative Care: 100%, no deductible
Hospital Care: 80% after deductible

HDHP (no employer contribution to HSA)
Yearly Cost: $2,882
Family Deductible: $5,000
Out of Pocket Max: $7,350
Office Visits: 100% after deductible
Preventative Care: 100%, no deductible
Hospital Care: 100% after deductible

I keep circling back to the HDHP with the lower premium and HSA tax savings, especially with the full preventative care, but may be missing something. I have a few days to decide, and I'm afraid my brain has given out. I would greatly appreciate any advice or collective wisdom!

-M

I too believe you are likely to hit the OOP Max... in which case I am 100% on board with seattlecyclone's analysis and would steer you toward the HDHP.  We had all 3 of our children while on the HDHP, we felt confident it was the better choice.  I also wondered the same thing about how one would actually get to the OOP Max in the HDHP plan if everything is covered in full after the deductible?

I disagree that you should expect to pay the out of pocket max on both plans.  From what you shared of the HDHP plan, you don't get hit with any costs after your deductible is met.  You might have something like a per office visit copay of less than $100, but it would take forever to add up to the out of pocket max. 

When we had our kids, we paid some of the childbirth costs upfront during the pregnancy, have you done anything like that?  If so, that would be something to consider keeping the plan you're using now.

v8rx7guy

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #11 on: November 18, 2020, 04:29:37 PM »
Hi, all!

I'm newly pregnant (yay!) and need to decide whether to keep myself and my husband on my employer's HDHP or transition us to the PPO option. Our benefit advocate was unhelpful, so I'm hoping for some mustachian advice and another set of eyes. Both my husband and I are healthy and on no medication, so we typically accrue no health care out of pocket costs and this is all new to me. Our new addition is expected in July 2021.

PPO
Yearly cost: $4,897
Family Deductible: $2,000
Out of Pocket Max: $6,400
Office Visits: 30 primary care, $60 specialist copay
Preventative Care: 100%, no deductible
Hospital Care: 80% after deductible

HDHP (no employer contribution to HSA)
Yearly Cost: $2,882
Family Deductible: $5,000
Out of Pocket Max: $7,350
Office Visits: 100% after deductible
Preventative Care: 100%, no deductible
Hospital Care: 100% after deductible

I keep circling back to the HDHP with the lower premium and HSA tax savings, especially with the full preventative care, but may be missing something. I have a few days to decide, and I'm afraid my brain has given out. I would greatly appreciate any advice or collective wisdom!

-M

I too believe you are likely to hit the OOP Max... in which case I am 100% on board with seattlecyclone's analysis and would steer you toward the HDHP.  We had all 3 of our children while on the HDHP, we felt confident it was the better choice.  I also wondered the same thing about how one would actually get to the OOP Max in the HDHP plan if everything is covered in full after the deductible?

I disagree that you should expect to pay the out of pocket max on both plans.  From what you shared of the HDHP plan, you don't get hit with any costs after your deductible is met.  You might have something like a per office visit copay of less than $100, but it would take forever to add up to the out of pocket max. 

When we had our kids, we paid some of the childbirth costs upfront during the pregnancy, have you done anything like that?  If so, that would be something to consider keeping the plan you're using now.

That was noted in my response... I was confused as to how the OP could get to the OOP Max if everything is covered after the deductible, there is missing information in my opinion.  If anything, however, that just makes the argument for the HDHP stronger if correct.

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #12 on: November 18, 2020, 06:54:41 PM »
For my pregnancies, there is a copay for the first visit, then that is it for office visits for the whole pregnancy. Birth was a separate cost, and also some costs for prescriptions. I may also have paid for lab work at one point? But yeah, check out pregnancy-specific info on the PPO, it could be really good. I think I paid like $600 all told for high-risk twins. Also consider what is covered re NICU stays, just in case.

tawyer

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #13 on: November 18, 2020, 09:45:25 PM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

seattlecyclone

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #14 on: November 18, 2020, 10:14:55 PM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

... Except for once you go to the hospital and they start billing for the baby too.

ericrugiero

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #15 on: November 19, 2020, 09:15:43 AM »
It looks like you are clearly better off with the HDHP.  Max out the HSA and use it for medical expenses.  Even without the tax savings the HDHP looks slightly cheaper at max out of pocket.  There is a range in the middle where the PPO is even once you figure tax savings.  But, for both minimal expenses and max out of pocket the HDHP is cheaper.  Paying with tax free dollars makes it a no brainer. 

Worst case scenario, you end up in the middle range and you break even with the HDHP after you figure in tax savings.  Best case scenario, you save a couple thousand dollars with the HDHP or you end up with extra money in your HSA.

socaso

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #16 on: November 19, 2020, 11:44:33 AM »
I don't want to make your head explode but there is another thing to consider here and that is what insurance your child is going to be on once they arrive. You want to find out the rules in your state. Where I gave birth, the child was covered under the mother's policy for the first few weeks but then had to have their own policy, usually a family policy with the mother. Children have tons of visits in the first year and if you are planning to add your child to your own policy you may want to be sure you have something that has more office visits allowed.

Most of my child's first year visits were office visits and immunizations and those were covered under the copay of our policy.

There's a lot of information to learn and much like you I studied all the angles to find the best fit for us. You are lucky to be having a child with the ACA in place. I gave birth right before it went into effect and it was much harder to maneuver when pre existing conditions kept one from changing policies.

tawyer

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #17 on: November 19, 2020, 01:52:03 PM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

... Except for once you go to the hospital and they start billing for the baby too.
A healthy newborn, IME, barely makes a dent on the *family* deductible/OOP max once the birthing parent is taken care of. If anything the distinction pushes the OP even further toward an HDHP.

seattlecyclone

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #18 on: November 20, 2020, 11:27:43 AM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

... Except for once you go to the hospital and they start billing for the baby too.
A healthy newborn, IME, barely makes a dent on the *family* deductible/OOP max once the birthing parent is taken care of. If anything the distinction pushes the OP even further toward an HDHP.

This is contrary to my experience. We had two healthy babies. The first one (in 2015) had a ~$3,000 hospital bill in his own name, plus another ~$500 split between the pediatricians who gave him a quick check while he was there and the hearing test they give to all the newborns. The second one (in 2018, same hospital) was billed ~$4,000 by the hospital and another ~$700 for those additional services. Our insurance plan at the time didn't have separate individual deductibles; everyone in the family contributed to the same pot of expenses. The additional amount we had to pay for my sons' bills was therefore just a fraction of the billed amount since we had already blown past the deductible with my wife's care. However if your plan is structured so that each person works toward their own separate deductible, you would do well to expect mother and baby to both hit their deductibles.

tawyer

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #19 on: November 20, 2020, 04:07:55 PM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

... Except for once you go to the hospital and they start billing for the baby too.
A healthy newborn, IME, barely makes a dent on the *family* deductible/OOP max once the birthing parent is taken care of. If anything the distinction pushes the OP even further toward an HDHP.

This is contrary to my experience. We had two healthy babies. The first one (in 2015) had a ~$3,000 hospital bill in his own name, plus another ~$500 split between the pediatricians who gave him a quick check while he was there and the hearing test they give to all the newborns. The second one (in 2018, same hospital) was billed ~$4,000 by the hospital and another ~$700 for those additional services. Our insurance plan at the time didn't have separate individual deductibles; everyone in the family contributed to the same pot of expenses. The additional amount we had to pay for my sons' bills was therefore just a fraction of the billed amount since we had already blown past the deductible with my wife's care. However if your plan is structured so that each person works toward their own separate deductible, you would do well to expect mother and baby to both hit their deductibles.
TIL, thank you. Were the $3K and $4K before or after what your plan paid, before considering max deductible and OOP max?

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #20 on: November 20, 2020, 09:15:18 PM »
The piece you are likely missing is Prescription Drugs.  This is probably what applies after the deductible on the HDHP.  Regular routine Rx doesn't usually amount to much, but if you had something chronic and expensive (diabetes, autoimmune, etc) this adds up.  I did an analysis on plans similar to this for a family friend last year who has a son with Type 1 diabetes.  They paid 20% of Rx after deductible in whatever tier his drugs were in.  The HDHP was still the best option.

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #21 on: November 20, 2020, 09:37:10 PM »
For my pregnancies, there is a copay for the first visit, then that is it for office visits for the whole pregnancy. Birth was a separate cost, and also some costs for prescriptions. I may also have paid for lab work at one point? But yeah, check out pregnancy-specific info on the PPO, it could be really good. I think I paid like $600 all told for high-risk twins. Also consider what is covered re NICU stays, just in case.
Right; all "normal" prenatal care is counted as preventative under ACA. So you're really just looking at the actual birth plus anything unusual. And some (maybe all?) insurance plans will count the initial hospital stay of the infant under the mother's deductible, assuming they're discharged together (and if they aren't, as mentioned upthread, birth is a qualifying event to switch plans as of that day).


Another ACA thing that's helpful for pregnancy specifically: it's one of the examples every plan spells out on the last page of its Summary of Benefits and Coverage. The estimates shown there won't exactly match your circumstances, but they're comparable from plan to plan, so you can pretty easily take them as a reference and compare the total shown plus the premiums as a pretty good starting point.

seattlecyclone

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Re: Insurance Time: HDHP vs PPO for new preganancy
« Reply #22 on: November 20, 2020, 11:50:20 PM »
I think there is usually a distinction between **family** and **individual** deductibles and out-of-pocket maxes that is relevant to this calculation, as in this case it is the individual who pregnant and receiving the related healthcare.

... Except for once you go to the hospital and they start billing for the baby too.
A healthy newborn, IME, barely makes a dent on the *family* deductible/OOP max once the birthing parent is taken care of. If anything the distinction pushes the OP even further toward an HDHP.

This is contrary to my experience. We had two healthy babies. The first one (in 2015) had a ~$3,000 hospital bill in his own name, plus another ~$500 split between the pediatricians who gave him a quick check while he was there and the hearing test they give to all the newborns. The second one (in 2018, same hospital) was billed ~$4,000 by the hospital and another ~$700 for those additional services. Our insurance plan at the time didn't have separate individual deductibles; everyone in the family contributed to the same pot of expenses. The additional amount we had to pay for my sons' bills was therefore just a fraction of the billed amount since we had already blown past the deductible with my wife's care. However if your plan is structured so that each person works toward their own separate deductible, you would do well to expect mother and baby to both hit their deductibles.
TIL, thank you. Were the $3K and $4K before or after what your plan paid, before considering max deductible and OOP max?

The numbers I quoted were the insurance-negotiated rates for these services, in network. Our plan at the time had a 90% coinsurance rate. We paid the other 10%. If the insurance had separate deductibles for each person, we would have been on the hook for the whole amount up to the deductible. Due to the uncomplicated delivery both times (no C-section or anesthesia), I don't think we quite hit our out-of-pocket max in either case. Got close though.