Do any individual or family insurance plans offer decent maternity coverage?

September 8, 2007 8:41 AM

Do any individual or family insurance plans offer decent maternity coverage?

My wife and I run a small business (technically an S-Corp) and are our only employees. Right now we're just looking at going the Individual/Family plan route for insurance.

We're looking to possibly get pregnant in the next couple of years and so far we've found practically no insurance company that offers individuals any sort of halfway decent maternity coverage.

Where could we possibly look in to getting some sort of maternity coverage? United Healthcare says it has maternity coverage but what they cover is pretty much just what you put in so it just doesn't seem worth it.

posted by JPigford to health & fitness (9 comments total)

I'm not a benefits administrator, just a member, so I'm not in a position to evaluate whether this plan is available for you, but following is my benefits summary for maternity care through Oxford Health:

Type of Service - General: BASIC SERIVCES: MATERNITY CARE

Oxford covers this service when medically necessary and appropriate.
This benefit has no maximum payment or visit limit.

Type of Service - Inplan: Care rendered by an Oxford Participating Provider is covered at 100% after initial visit. Initial visit only is subject to the members PCP copayment.
Services received may be accessed directly from the oxford participating specialist without a referral from the primary care physician.

Type of Service - Outplan: Care rendered from a non participating provider is covered subject to the deductible, coinsurance and usual and customary allowance.

Precertification is required. If precertification is not obtained, services are subject to a penalty of 50% of the cost.
posted by bunnycup at 8:52 AM on September 8, 2007

This report has information about consumer-driven health plans and maternity care - and might give you an idea of things to look for (and avoid) in a plan (e.g. - if the pregnancy covers 2 plan years, you might have to pay 2 years of deductibles; some plans don't won't count maternity care check-ups towards the deductible, etc.). There's also some discussion of HMOs and PPOs, but all in a general sort of way.
posted by rtha at 9:24 AM on September 8, 2007

One thing you might keep in mind with buying your own insurance...the concept of pre-existing condition. Do not be pregnant at the time of underwriting. Honest. Many insurers will see that as pre-existing and throw a rider in your contract for pregnancy...basically either disallowing maternity coverage altogether, or tacking-on an addition grand to your deductible, or shifting pregnancy to a separate deductible schedule, etc.
posted by Thorzdad at 11:00 AM on September 8, 2007

It is extremely difficult to find individual policies that do not exclude maternity for at least 12 months after the policy is written--and typically these policies are not equivalent to the group policies that larger businesses buy for their employees.
You need a good agent who can walk you through this. There are a lot of agents who specialize in helping small businesses find the best deal. Seek one out.
posted by FergieBelle at 11:24 AM on September 8, 2007

Quick note: I am indeed aware that most policies have a 12-24 month period that is excluded at first. So that's something we realize we'll have to keep in mind.

I'm not so much looking for a specific "plan" that we could be pointed to but rather some leads to some different insurance companies that might have something for maternity coverage.
posted by JPigford at 11:44 AM on September 8, 2007

My wife and I looked into buying it on our own and it would have been at least $900 a month and wouldn't cover anything for a year.
posted by Mick at 12:21 PM on September 8, 2007

Medical insurance doesn't work -- it can't work, really, if you think about it -- if you can plan to incur covered care which exceed your premiums. That's why individual policies will always have hefty maternity waiting periods and exclusions which assure that you will effectively pre-pay.

And it's not like group coverage is any different -- it's just that with more employees to spread it around it doesn't feel like the employer is prepaying maternity, but believe me, it is. Coverage of maternity is a big reason why even large employers can pay over $12,000 a year per employee for coverage.

Does this mean that you shouldn't take on one of those expensive and wait period plans? NO! This is because those plans will still be real insurance for the unexpected component of maternity costs, if complications could arise. In other words, you'll prepay the $6,000 or so that an average uncomplicated pregnancy costs, but you will also pay another $6,000 in actual insurance premiums against the $100,000 or more you might incur in a high risk pregnancy or complicated delivery.

Needless to say, it is very important that the policy you opt for will have good provisions for adding the children you want to have. A premature or sick infant can easily add another $500,000 to your costs, and you want to insure against that, too.
posted by MattD at 12:31 PM on September 8, 2007 [1 favorite has favorites]

In all reality, the reason why you won't find many policies that have 'decent' maternity coverage is to prevent people from starting the insurance, having their baby and then ditching it. The insurance doesn't work if you only get it when you need it.

Most group policies are subject to governmental regulations regarding preexisting conditions. This includes requiring you to have a prior carrier for at least a year with no longer than a 63 day gap as well. But on group policies, maternity is not a preexisting condition. These regulations do not apply for individual or administrative service policies.

You may be able to get a group policy as your corporation and be able to enjoy the benefit of maternity not being preexisting but the trade off is that group insurance is astronomically expensive. Expensive unless you have a pretty high deductible, like an HDHP with an HSA plan. Historically group policies are cheaper for employees because of the company subsidizing the insurance. You may pay $100 in premiums per check, and sure, this seems like alot until you realize that this is probably only about 20% of the actual cost.

The reason to have insurance is not so much to pay for the costs of the delivery and care prior to the delivery but rather to get the discounts that contracted providers give to insurance companies. I work for an insurance company and on average, the typical bill for delivery is about $10,000 for the physician and facility charge. After discounting this total could be closer to $2,000. That is a pretty significant reduction in price and providers do it all the time.

If you have complications with the pregnancy and require specialists and intensive care, the sky is the limit as far as costs go, and specialist are able to leverage MUCH smaller discounts. Because normal doctors are pretty common, while it's much harder to find pediatric nephrologists or a critical care internist.

So the problem is that insurance really won't save you money if you have a normal birth with no problems, because with a group plan $2,000 might be only 3 months of premiums depending on the underwriting. The problem comes in that if there is a problem and you don't have insurance, to be harsh, you're pretty fucked. I've seen $100,000 neonatal intensive care unit claims. You know how you hear about people having medical bills that cause them complete bankruptcy? That's a pretty good example of what they're talking about.

Your best bet is to go to an Insurance Broker, tell them your situation and have them run you some group insurance quotes for you. They should be very willing to help, because brokers get pretty hefty commissions for group policies. They should be able to lean you towards one type of plan or another. If you want to keep your premiums down, I would look into an HDHP plan with a HSA account, that way you can save money for the delivery and not have to pay it all at once.

Otherwise depending on your situation and income, you might want to look for state funded insurance, I know that a lot of state governments are working on trying to help out people who are in a situation like yours, especially over the past couple of years. A quick google search pulls up a site that might be able to help.

Insurance might not seem like it really helps, but it's just that: insurance. Its the insurance of knowing that if something goes wrong and you need some insane specialty provider flown in from Bombay, you're not going to be looking at huge medical bills that you can't pay. For a long time people assumed that insurance meant that everything was covered and you only had to pay your $10 copay. This is changing due to all the costs associated with advanced medical care.

MRI or CAT scans? These are million dollar pieces of equipment.
Procrit infusion for anemia in AZT patients? That stuff costs over $1,000 a dose, per month.

Medicine is getting more advanced more designer, especially as the boomers age, so I really don't see these costs going down much without serious and major reform. On the positive side, if your life is saved by one of these treaments, you'll be pretty happy about all the money that went into the R&D for it.
posted by gregschoen at 12:53 PM on September 8, 2007 [2 favorites has favorites]

I should clarify that, you may have a preexisting condition, clause if you didn't have insurance but on group policies, maternity is not considered a preexisting.

Also, I've seen women get a job through an employer who offers health insurance, get pregnant, have the baby and then quit. It happens more than you might expect. Not saying that this is a bad thing, but it happens.
posted by gregschoen at 12:59 PM on September 8, 2007