What type of health plan should a pregnant person pick?

October 29, 2011 1:48 PM

My partner and I just found out we are newly pregnant, and are unsure which health insurance offered through my employer we should pick for next year.

The baby is due in the summer, so it's still very early. My company offers several different insurance options- a new high deductible health plan, an HMO, and several POS plans with different levels of coverage- 80%, 90%, 100%. Should we shell out the big bucks monthly to join a 100% plan (or 80 or 90)? Or would it make more sense to join the HDHP for a very low monthly fee and use the linked healthcare savings account to put aside money to pay the bills? It's enough to make your head spin. Is there a simple formula one should use to figure it out? And what about plans who require you elect a PCP- will that affect maternity services? Does that make it a bigger PITA then if you don't have to elect a PCP? We're generally healthy and don't deal much with our present insurance provider; bureaucracy is annoying to us and it would be nice to keep things simple. Any insight those who have been there before can offer would be appreciated. Country is US, state is NY.

posted by anonymous to Health & Fitness (19 answers total)

I speak from some ignorance about insurance, but with some confidence as someone who has a 3 year old and a 9 month old. I would get the most coverage possible, knowing that this awesome event was going to happen. We have really good insurance, but even so were out of pocket about $4,500 for birth and newborn related medical expenses. If a more expensive insurance plan would have covered those costs, we would have come out ahead overall, even paying higher monthly premiums. And that was with everything going pretty well.
posted by procrastination at 1:54 PM on October 29, 2011 [3 favorites]

Not only do you need to consider the cost of prenatal care and the birth, but how much you will be going to the doctor the first couple years of the baby's life. Even if he is never sick (unlikely!), you'll be going for well checks and shots every 3 months. My kid is relatively healthy and we've been in for sick checks 4 times in the first year, plus an ER visit. Get all the coverage you can.
posted by chiababe at 2:05 PM on October 29, 2011

What I did when I was in the same boat was do the math and figure out what your maximum cost would be with each.

Each plan has a premium. Most also have a deductible. Some have a copay. And they should all have a maximum out of pocket. (For copay plans, the max out of pocket does not ordinarily get you out of the copay when you hit it.)

Add them up, to see which truly has the maximum out of pocket. Babies can be a big expense, even with insurance, and this will give you some idea of how big the expense would be if you end up with complications, expensive procedures, etc.

Also, if your employer offers a Flexible Spending Account, put some of your paycheck into it! Figure out the minimum you're likely to spend and put at least that aside in the FSA.
posted by rabbitrabbit at 2:07 PM on October 29, 2011

I would NOT do a HDHP/HSA with a baby on the way. Those mostly work for people who don't have to go to the doctor a lot. Babies and kids go to the doctor a lot, healthy babies and kids go to the doctor a lot, just imagine if there is even something a little tiny bit wrong.

I'd go at least 90% if I had a kid on the way.
posted by magnetsphere at 2:32 PM on October 29, 2011 [1 favorite]

And yeah, on top of that max out your FSA dollars too.
posted by magnetsphere at 2:33 PM on October 29, 2011

I thought I'd do the 90% plan too, but when I looked at the premium for that one ($125/mo in my case) vs. the cost for the copay plan which paid 60%/80% and had a monthly premium of $35, in the end, because of the money I was saving on the premium, the copay plan made more sense in most cases (as long as I stayed in network) which is why I say you should look at the big picture of how much each plan costs in total.
posted by rabbitrabbit at 2:39 PM on October 29, 2011

Make a decision for this year based on maternity coverage. I'd seriously consider where you want to deliver, and if that's in-network for your HMO, pick theHMO. This calculus might change once kids are outside, but this approach can make your prenatal care, labor and delivery very inexpensive out of pocket. An additional facet is detrmining which insurers cover which prenatal care; the second-tri anatomical scan can run in the low thousands if not covered.
posted by chesty_a_arthur at 2:41 PM on October 29, 2011

Your benefits people can probably help you run the numbers, if running the numbers yourself is too stressful. Call your ob/gyn and get a number for prenatal care, for standard vaginal delivery, and for C-section delivery. Also see if you can get a ballpark (maybe from friends) on first-year well-baby care or see what sort of well-baby care is covered by the plans. You also need to ask the benefits people (or the health care plans themselves) if the ob/gyn is considered a primary care provider or whether you'll have to designate a PCP to refer you to the ob/gyn you choose.

(For reference, my (comprehensive, single-price) prenatal care was about $3800 (half paid at 20 weeks, the other half at delivery), and uncomplicated C-section delivery around $11,000. But tests and screenings were not included in either number, and those do add up. I live in a low-cost-of-living area but a high-medical-malpractice-insurance state. Both of those numbers were then discounted to the insurance company's contracted rate, which was something like HALF for the C-section delivery. I forget exactly how much I paid out of pocket because there was an FSA and an HCSA and differing rates of coverage and co-pays and all that shit. I have an inch-high stack of EOBs from the first baby, I decided to save it in his baby box so he can marvel at it when we have universal health care in 20 years.)
posted by Eyebrows McGee at 3:34 PM on October 29, 2011 [1 favorite]

Just something to consider: 30% of a c/section delivery with complications can cost you far more than you budget. (If you go with a 70/30 type of plan). My son had to pay out of pocket $125 for 3 ultrasounds done by a perinatologist while my daughter in law was pregnant, in addition to the 3 done by her OB. He paid the OB $600 before delivery, the hospital $1800 before delivery.

They still owe roughly $15k to the hospital and various doctors since there were complications. And this is with city employee insurance. I'd go with the 90%, even if it's just for a year.
posted by hollygoheavy at 3:49 PM on October 29, 2011

Are you sure that any of the options will let you sign up when you are already pregnant? IE, are these plans with different companies, or are they all options offered by the same health insurer?

I had one employer who offered three different plans, two with one company and one with the other. A coworker discovered (unfortunately AFTER switching) that her pregnancy was considered a pre-existing condition and was not covered by that insurer - had she stayed with the original, it would have been.

I would personally triple-check this detail and then check it again.

Also, congratulations!
posted by peanut_mcgillicuty at 4:30 PM on October 29, 2011 [1 favorite]

My choice between a PPO and an HSA plan was not influenced by pregnancy, but I can explain how we used an Excel spreadsheet to figure out the different outcomes, total payments for the year under each plan calculated for a range of different medical bills.

Generally each plan has:
a. a total premium for the year (A)
b. a deductible (B) and a formula for applying the deductible
c. a coverage schedule once the deductible is met, for example C=20% copay.
d. an out-of-pocket maximum (D).

So make a column that's possible doctor bills, 0 though somethousand (I have no idea how much a baby costs), call that expense X.
Then each column is an insurance plan with spending for the year calculated as: A+MAX(D,IF(X>B,D+C*(X-D),X))

Of course, that's oversimplified. You have to look at the words in the plan and see what other differences there are - any special rules for preventative care, maternity care, hospital stays, etc.
In my case there was none of that that was dramatically different, but plans applied the deductible differently: per individual or per couple (That ended up working against us, as my husband got sick and immediately spent "his" $B, but we still hadn't made the deductible because we hadn't spent "my" $B). So we had, instead of one column of expenses, a big table with my expenses in the first column and his expenses in the first row, and the formula filling in the grid, and to compare the plans we just subtracted on table from the other, and saw that it was positive in one corner (the "low expenses" corner) and negative in the other (the "high expenses" corner) with an unexpected even bigger negative in the two "uneven expenses" corners. In your case, you might need to do that kind of table action to distinguish between maternity expenses and regular expenses, if different plans have different coverages.

So in short, my gut instinct is, you know you'll have high expenses, get the poshest plan your employer offers. But if you want to see all the numbers, it's perfectly feasible to make yourself a spreadsheet that lays it all out.
posted by aimedwander at 6:51 PM on October 29, 2011

Wish I could find the reference now, but I learned from an expert on the internet that HMO is typically the best choice, since they provide the most coverage for delivery, etc.

When my HR rep learned I was pregnant, her response was that it's good I chose the HMO.

Bonus for me is that I chose all my specialists while on a PPO, before being pregnant, and they were all in-network for the HMO plan, so I got great doctors and great coverage.
posted by nadise at 7:47 PM on October 29, 2011

I have a 100% PPO plan. My wife just gave birth to a daughter, and it cost us nothing at all beyond our regular insurance premiums. We got many bills in the $3000-$5000 range, all of which were already paid in full. The only thing we ever paid for at all was $15 co-pays for office visits.

But, and it's a big "but", I pay almost $600/month for this plan (now that I have "family" coverage instead of "insured+1"). My employer pays another $1100/month on top of what I pay, too.

It's expensive, but I think it's worth it. My neighbors just had a baby a few months before we did. He had a heart issue and needed to have open heart surgery shortly after birth. Any guesses as to what 20% of neonatal heart surgery and a stay at Stanford Medical Center for a week costs? I bet it's more than a year's worth of the more expensive premiums for the better plan.

My neighbors' son is fine now, BTW.
posted by tylerkaraszewski at 8:24 PM on October 29, 2011 [1 favorite]

Go for the plan that covers the most, period. I don't want to scare you with horror stories, because the vast majority of pregnancies and deliveries go just fine, but I know more than one literal million dollar baby -- the cost of their care exceeded one million dollars before they came home. 30% of a million bucks is more than you want be vulnerable to spending. My husband lost his job when I was 29 weeks pregnant, and we elected to pay $1700 a month in COBRA instead of $450 a month private insurance for the remainder of the pregnancy for exactly this reason.
posted by KathrynT at 10:13 PM on October 29, 2011 [1 favorite]

Make a decision for this year based on maternity coverage.

This.
Specifically, make sure none of the plans specifically exclude maternity coverage if you are already pregnant, or place a 1-year exclusion rider on maternity. Maternity is amazingly expensive, more-so if there are any complications.
posted by Thorzdad at 6:07 AM on October 30, 2011

IANAExpert Talk to your benefits coordinator. I think you should optimize for maternity coverage, because I think the birth of a child is an event that allows you to make new insurance choices, so you can change your choices when your child is born. But you have to get this info from your employer, as it may vary from state to state.
posted by theora55 at 7:08 AM on October 30, 2011

You really do not want to choose a high deductible plan when you know you're going to have high medical expenses, which are inevitable with the easiest pregnancy. They're really more for young healthy people who don't have any health problems but want to hedge against freak high-cost occurrences. There are usually 8-10 routine prenatal visits in a normal pregnancy and at least six well-baby visits the first year, not including any extra testing, sick visits, the delivery, etc. I had a one-night stay in the hospital for an uncomplicated vaginal delivery and I think the hospital bill was $12,000.

Plans in which you elect a PCP are unlikely to affect your maternity coverage significantly--in most HMOs OB/Gyns are considered primary care providers rather than specialists so you don't have to be referred to your OB, and your OB becomes your PCP for the purposes of ordering prenatal tests, etc. It becomes more of an issue if the baby or you have health problems that require specialty care--you'll need referrals from the PCP to see specialists, and the choice of specialist will be restricted to those participating in the HMO.

Yes, make this year's choice entirely about maternity coverage, and do your homework, because they vary a LOT. In general the birth of a child counts as a "qualifying life event" for HR purposes, so you can change insurance (usually within 30 days) after the baby is born. (If you do this you should make sure your pediatrician takes both plans, since there are a bunch of early well-baby checks and you don't want to have to switch peds in the middle of that).
posted by The Elusive Architeuthis at 9:07 AM on October 30, 2011

I believe new laws prohibit your employer from barring you because of your preexisting pregnancy, unless you already have coverage elsewhere, but check on that.

The HMO at my work has been best for us and our kid, because there's no yearly maximum and no deductible. Not having to shell out 500 to 2k of my own cash before I could get stuff paid for was a lifesaver. It's a pain getting referrals, but an OB is usually considered something you *don't* need a referral for, and your well woman visits and well child/vaccinations are covered.

Basically there are three opportunities for expensive complications to happen: pregnancy, birth, and during the first year of the child's life. Get as much coverage as you can. Just in prenatal/baby checkups alone, it will be worth it.
posted by emjaybee at 8:08 PM on October 30, 2011

We are currently pregs with a kid and when we were asked to make a choice earlier this year between HMO (w a hefty coinsurance) and a HDHP with a linked HSA account, we chose the latter. However, the big factor for us was that our employer helps contribute to our HSA account throughout the year, and by doing some quick math with the money we already had in the HSA we could tell that once we met the deductible (which we most assuredly will with a hospital birth, even an uneventful one), it will still be much cheaper than us paying for the copays for EVERYTHING afterwards, from well child visits to preventative care to flu shots. This all really depends on the details of each plan in question. Some HDHP plans (like ours) only charge services to the deductible that are not preventative care as long as you stay with their in network providers (which may not be a hard thing to do - many ins companies have larger networks than you might think). In other words, all routine OB visits throughout y pregnancy don't accumulate towards our deductible so we don't pay anything from the HSA/out of pocket for those. Same goes for routine care for our kids - the only time a visit charges toward the deductible is when we take them for a sick visit or a specialist. We do end up having to do those things, but in the long run, throughout the year, even paying into the HSA towards our deductible expenses, we still save money when we compare the monthly cost of the HMO plus all the coinsurance and copays we'd HAVE to pay for each and every visit if we were on the HMO.
posted by takoukla at 10:21 AM on October 31, 2011