Health Insurance Deductible "Reset" Date

February 6, 2014 8:25 AM

So, my wife is going to give birth in Mid-to-End of June. She has a deductible "reset" date of June 1. How does this work?

She has a $3,000 deductible on her insurance policy, which we just reached due to a ton of visits to the OB-GYN and prenatal specialists. It really sucks, but at least now we're on the 90/10 plan.

As noted, the issue is that her plan has a deductible reset date of June 1 with the baby due Mid-to-Late June, which if I understand it correctly would mean that we would be responsible for an additional $3,000 for the delivery of our baby... Is this right?

I'm afraid I know the answer, but if so, I'm hoping if anyone has any particular advice on how to navigate this. We already broke the bank reaching the deductible so far...

Also, this got me thinking... While not exactly analogous, but if one was hit by a bus on May 28th and subsequently had to meet the entire deductible, what would happen come June 1st if they were still in ICU? Pay the deductible again?

posted by Debaser626 to Work & Money (11 answers total)

As to how your hypothetical works, in ever case I've ever had to deal with, it's "date of service", not "date of bill", so anything you incurred between 5/28 and 6/1 would fall under last year, and anything after that would be post-reset.
posted by Oktober at 8:28 AM on February 6, 2014

Call your insurance company for a definitive answer, but insurance is based on dates of service when billing.

So, if baby were to be born on 5/31, then all the delivery stuff will be before the reset, but the maternity and baby care in the days after would be on the new deductible year, so you'd have to pay the deductible for that part, yes, but not for the delivery.

Just to give you an idea, my son receives some therapies that take a long time for insurance to pay out. So I once received a bill with a date of service from the end of 2012 more than halfway through 2013. Our copay went up from $15 to $20 on Jan 1, 2013. So, for the 2012 visits, we paid the $15 copay when we were billed for them in 2013 and for the 2013 visits, we paid the $20 copay. On the same bill.
posted by zizzle at 8:37 AM on February 6, 2014

Agreed, you need to call your insurer. With the being hit by a bus thing, if you're in the hospital from 5/28 to 6/15 inclusive, you might only count as having been in the hospital *once*, starting in the old year. But you would then still quickly meet the deductible for the new year with followup visits and PT and stuff.
posted by mskyle at 8:43 AM on February 6, 2014

Best answer: It really sucks,

Yes it do, yes it do. Start saving your pennies; in my personal experience, you're going out of pocket again.

The good news (maybe) is that birth of a child is generally treated as an opportunity to change the funding elections on a flexible spending account, if you have one.

Congratulations on your expensive bundle of joy!
posted by Admiral Haddock at 8:45 AM on February 6, 2014 [1 favorite]

With one of our children it was really important that the billing was for services after a certain date, and we were pregnant well before it. The arrangement with the obgyn was that the entire service (pregnancy plus birth) would be dated to the date of birth (and after if need be) as one package. Thus, everything fell into one deductible. It sounds it's too late for you to work this out, but I'm mentioning it for anyone else who might be reading this and facing the same issue.
posted by michaelh at 8:46 AM on February 6, 2014

The pregnancy rider sometimes works differently than the standard coverage in that the 9 month course of the pregnancy is sort of viewed as one long appointment. So it's possible you won't be on the hook for the deductible again. You need to clarify with the insurance company or your agent.
posted by COD at 9:01 AM on February 6, 2014 [2 favorites]

While not exactly analogous, but if one was hit by a bus on May 28th and subsequently had to meet the entire deductible, what would happen come June 1st if they were still in ICU? Pay the deductible again?

Pretty much. This is something people with expensive chronic health issues know too well, the dreaded yearly deductible reset.
posted by ThePinkSuperhero at 9:10 AM on February 6, 2014

Seconding what COD said -- sometimes pregnancy works differently for your insurance. In my pregnancies, I only paid the copay once for all prenatal visits and the delivery itself, because it counted as one long service in the eyes of my insurer. You'll have to call your insurance company to find out for sure, but it's possible that there's still hope for you.
posted by Andrhia at 9:40 AM on February 6, 2014

Best answer: Call your insurer - my child was due at the very end of our plan year, and I was afraid of this exact scenario. They had a policy where some percentage of what we paid in the last three months of the year was carried over into the new plan year if the costs were for the same condition, and pregnancy qualified for that. So instead of owing $3,200 I would have owed something like $1,400 if she had been born after the new plan year started. Pregnancy is a weird condition in the way it is billed and paid - you aren't the first couple to experience this, so they have probably worked something out.

And if your insurer doesn't have a policy, your provider probably does. But definitely have these conversations now!

(And congratulations!)
posted by peanut_mcgillicuty at 10:38 AM on February 6, 2014 [1 favorite]

Response by poster: Thank y'all so much for the advice and the congratulations!

I let my wife know to contact her insurance ASAP, hopefully her CIGNA policy has a decent pregnancy rider, but I guess it's somewhat comforting to know that we're not screwed straight off the bat.

Also, I guess saving pennies now certainly couldn't hurt with a baby on the way.

Quite scary about the thought of getting seriously sick/hurt right around "reset" time. I'll have to stock up on bubble wrap and hide in a basement or something.
posted by Debaser626 at 11:47 AM on February 6, 2014

Also, max out that FSA! You can spend the full amount on day 1 of the plan year even though it takes you a full year to make all the contributions. Those dollars are pre-tax and it also serves as a payment plan if you spend it all right away.

And FYI - your employer can NOT ask for this money back if you quit or are terminated before the end of the year. That's the flipside to the "use it or lose it" rule of FSAs.
posted by JoeZydeco at 1:13 PM on February 6, 2014