Which insurance plan should we choose?

[SageFemme]

Hello everyone!

You may have seen my thread on the Disney For Families board. If not, I'll give you a brief history: DH and I wanted to TTC next year but we're uninsured and was looking for the best route to take: use the Indian clinic for prenatal care and the Indian hospital (free) 1 1/2 hours away or pay for private health insurance. Ultimately, we chose to pay for insurance because we wanted to choose our doctor and deliver at the excellent hospital less than 5 minutes away. I am big on planning (hence why I'm on the DIS ) so I feel the need to ask this.

Due to this insurance having a 365 day waiting period before maternity is covered, we're going to wait till our house is finished building, then I will get "basic" insurance for just me with maternity at $153/month with a $5,000 deductible. I don't go to the doctor but once a year anyway. After the year is up, we will do a different policy with or without DH (not sure). Our house will be finished around Feb. 2010 so that would mean we would start TTC in Feb. 2011 - a long time from now but I guess I will plan our Dec. 2010 trip in the mean time!

Here are what I feel are the best two options for us. Only thing is, I don't know which one would be best. We are completely new to insurance!

FYI, getting it through our jobs are not an option because they are mediocre at best.

These prices will most likely change since we're not getting this plan till Feb. 2011 but you get the general idea.

Plan A:

$1500 Deductible.
$15 copay for office visits.
After deductible, 70% for rx.
All outpatient and inpatient services (incl. maternity) are paid at 80%, meaning we would have to pay 20%.
Prices per month, incl. maternity:
Me only: $326
Me, then after baby is born: $395
Me, DH: $441
Me, DH, then after baby is born: $510

Plan B:

$5,000 Deductible for Family and $2500 for just me.
After ded. is met, everything is paid at 100%.
Prices per month, incl. maternity:
Me only ($2500 ded.): $250
Me, then after baby is born: $285
Me, DH: $318
Me, DH, then after baby is born: $368



Yep, that pretty much sums up how I'm feeling right now!

I'd appreciate any info and thanks if you made it this far, LOL!

 

[JeMarie6]

Hello everyone!

You may have seen my thread on the Disney For Families board. If not, I'll give you a brief history: DH and I wanted to TTC next year but we're uninsured and was looking for the best route to take: use the Indian clinic for prenatal care and the Indian hospital (free) 1 1/2 hours away or pay for private health insurance. Ultimately, we chose to pay for insurance because we wanted to choose our doctor and deliver at the excellent hospital less than 5 minutes away. I am big on planning (hence why I'm on the DIS ) so I feel the need to ask this.

Due to this insurance having a 365 day waiting period before maternity is covered, we're going to wait till our house is finished building, then I will get "basic" insurance for just me with maternity at $153/month with a $5,000 deductible. I don't go to the doctor but once a year anyway. After the year is up, we will do a different policy with or without DH (not sure). Our house will be finished around Feb. 2010 so that would mean we would start TTC in Feb. 2011 - a long time from now but I guess I will plan our Dec. 2010 trip in the mean time!

Here are what I feel are the best two options for us. Only thing is, I don't know which one would be best. We are completely new to insurance!

FYI, getting it through our jobs are not an option because they are mediocre at best.

These prices will most likely change since we're not getting this plan till Feb. 2011 but you get the general idea.

Plan A:

$1500 Deductible.
$15 copay for office visits.
After deductible, 70% for rx.
All outpatient and inpatient services (incl. maternity) are paid at 80%, meaning we would have to pay 20%.
Prices per month, incl. maternity:
Me only: $326
Me, then after baby is born: $395
Me, DH: $441
Me, DH, then after baby is born: $510

Plan B:

$5,000 Deductible for Family and $2500 for just me.
After ded. is met, everything is paid at 100%.
Prices per month, incl. maternity:
Me only ($2500 ded.): $250
Me, then after baby is born: $285
Me, DH: $318
Me, DH, then after baby is born: $368



Yep, that pretty much sums up how I'm feeling right now!

I'd appreciate any info and thanks if you made it this far, LOL!

Does plan A not have an out of pocket maximum? Usually you pay ded, then the 20% coinsurance up to an Out of Pocket Maximum (OPM). If Plan A has a reasonable OPM, I would go with that one since you are going to have known medical expenses with the labor/delivery. You can usually switch to a higher deductible later, but you can't switch to a lower deductible later if you or the baby has any medical issues because you usually have to go through underwriting. Do both policies cover infertility the same way (if at all) just in case its needed?

 

[princessbride6205]

Are you comfortable with possibly having $5000 out of pocket, for basically just emergencies and hospital stays covered? Or would you rather have a more comprehensive care plan where you can go to the doctor? What type of care do you want the baby to have - or will you switch plans by the time you want baby covered? Including well visits and sick, our DD was at the doctor's at least 20 times in the first 2 years. Those visits add up fast! As for your maternity care and childbirth...my completely routine childbirth, after what my insurance covered, was still several thousand dollars. Insurance and medical costs are insane - I hope you can find which option will work for you.

And an aside, my employer health care plan is the pretty much the same as your Option A.

 

[SageFemme]

Does plan A not have an out of pocket maximum? Usually you pay ded, then the 20% coinsurance up to an Out of Pocket Maximum (OPM). If Plan A has a reasonable OPM, I would go with that one since you are going to have known medical expenses with the labor/delivery.

Okay, for Plan A, it says N/A for OPM, yet it says they have a Stop-Loss for $5000. It says "When you have incurred the specified amount [$5,000] in excess of the deductible, the amount of coverage will increase to 100%".

For Plan B, the OPM for an Individual is $2500. For Family it is $10,000. I am sleepy and would appreciate some clarification on this, LOL. Does this mean I need to pay the deductible plus the OPM before 100% of services are covered?

You can usually switch to a higher deductible later, but you can't switch to a lower deductible later if you or the baby has any medical issues because you usually have to go through underwriting.

What is underwriting?

Do both policies cover infertility the same way (if at all) just in case its needed?

Unfortunately, neither policies cover infertility services.

 

[SageFemme]

Are you comfortable with possibly having $5000 out of pocket, for basically just emergencies and hospital stays covered? Or would you rather have a more comprehensive care plan where you can go to the doctor?

Which would save me more money? LOL

What type of care do you want the baby to have - or will you switch plans by the time you want baby covered? Including well visits and sick, our DD was at the doctor's at least 20 times in the first 2 years. Those visits add up fast!

Both plans cover well child visits 100%. I'm guessing sick visits would be under the $15 copay for Plan A and is 100% covered after ded. for Plan B, I believe. Plan B is confusing to me due to the OPM and all that.

 

[SageFemme]

Here's what I'm confused at. Plan B says the OPM is the $5,000 deductible plus $10,000. Does this mean that we need to pay $15,000 OOP before 100% of services are covered? Then the brochure says the OPM includes the deductible!! OMG I'm going crazy. I'm talking to an agent next week but I may shoot myself before then, LOL

 

[SageFemme]

Anyone else have any thoughts?

 

[PoohHappens]

Also you need to figure out what the lifetime benefit is on both of these plans. A preterm infant in the NICU can max that out if it is not high enough. I would also want to see what physicians take this coverage and see if you can get any info from some one who has used it. For a private plan it almost seem too reasonable to me. I would have concerns about things that may not be covered like cancer treatments, physical therapy, psychological treatment etc.
I do not want to sound negative, but why are you not insured now, for us that is a priority no matter what we have to go without. We are insured through my husband with family coverage $3000 deductible (1000 of which is covered by employer) and then 80/20 until maximum out ouf pocket of 10,000 annual. The origional 3000 does count toward the 10 making it technically another 7000. No copays, well visits 100%, maternity is not considered well visits. Even with the employer covering part of the monthly cost this has a higher monthly cost than any of the plans you are showing. You also need to consider things like what happens if you are unable to work for part of your pregnancy. I have currently had to stop working as of July 1 and I am not due until October 27. Because of the way I work, I do not have any disability or pay while off. We however new this and still chose for me to work this way. Good luck as you are looking into all this. I know that insurance can be very confusing. But it in our opinion it is a need a basic must have like electricity, water and food.

 

[SageFemme]

The reason we don't have insurance now is beside the point of this thread. Back on topic:

Also you need to figure out what the lifetime benefit is on both of these plans. A preterm infant in the NICU can max that out if it is not high enough. I would also want to see what physicians take this coverage and see if you can get any info from some one who has used it. For a private plan it almost seem too reasonable to me. I would have concerns about things that may not be covered like cancer treatments, physical therapy, psychological treatment etc.

The lifetime benefit for both plans is $5m. Psych treatment is paid at 50% for Plan A and 100% for Plan B. The rest of the stuff I need to find out.

 

[PoohHappens]

That is a good lifetime max for insurance these days. Sounds like good coverage either way. What we usually do is add up the total monthly cost for the year and add the deductible/MOP and see which totals a higher cost for the year. Then consider how things will get paid. Often we do prefer like the first where there are copays as we know if we are sick we can go to the dr and only pay the $15 instead of knowing we will get a bill for the whole visit. However, if the MOP is only the $5000 on the one with the larger deductible you can sometimes come out ahead if you set that aside for the year, but don't have to use it. It sounds like you are really looking carefully at things and planning well. I hope you are able to find something that works well for your family. Good luck and good luck with your family planning too. I think you have made a great choice to go ahead with the insurance (of course my opinion) but an hour and a half away for Prenatal visits and delivery is really quite far. I am an L&D and high risk OB nurse and would encourage my patients to have closer care if possible. Also as you stated it is nice to be able to choose your provider. It is nice though that you do have that availible to you if you were to happen to become pregnant before your insurance is effective. I know that is not your plan, but we do see it happen sometimes. Another option if you do end up in an unplanned situation is approaching a hosptial with a teaching program. Our residents run a clinic and if you are unisured or underinsured their rates are less and they will make arrangements for payement with you. They are still excellent physiscians at an excellent hospital who work then with more experienced physicians. I can't say that is true of all residency programs though. And of course I am unfamiliar with the other clinic/hospital you mentioned it may be wonderful--just a distance. Again good luck.

 

[PoohHappens]

Sorry I just realized no one answered your underwriting question. It is where before approval they evaluate your current medical status and conditions and then determine what things they may choose not to cover. Like if you have diabetes your new insurance can refuse to cover anything pertaining to diabetes in your coverage. It is a really crummy thing that insurance companies do. Sometimes they will say that they will not cover anything you have seen a Dr for in the last X# of months to years. Most employers offering insurance cannot do this, but when you take out an individual plan they are often free to exclude whatever they want.

 

[sameyeyam]

I think if you have FREE Indian medical care available you should take advantage of it. I don't know all of the particular's of it, but if it will offer free medical care for both of you, then why not use it?

Maybe you could purchase a policy before the pregnancy, as sort of an insurance if something does go wrong and you need medical care outside of the Indian system. Then use the free medical system, if all appears normal then you won't have spent any money beyond the premium amount.

The majority of pregnancies are normal and even though the hospital is 1-1/2 hours away, that is normally enough time to get to the hospital. I don't feel that liking my doctor is reason enough to pay extra. I don't have to like him/her. If they are competent and offer good care then I'm happy.

3 years ago I went thru breast cancer and had a surgeon that I didn't really care for. As a matter of fact he was very arrogant, but after some discussion with my primary care doctor, we both decided that I don't have to like him, basically he was one of the best breast surgeons around. You really won't see your doctor all that much, probably just a few minutes at a time. you will see more of the nurses then anything, the doctor will come in every once in a while and for the delivery...and trust me during delivery you won't really care whether your like the doctor or not!

I will also warn you that you will pay way more then you think with private insurance. Your insurance will find ways to reduce the amount they have to pay. You may go to a hospital on the approved list, but your anesthesiologist is not on their preferred list, so the insurance company will pay less to them and you are stuck with the remainder! Your doctor may order a medicine, but the insurance co. decides that a generic will do better and reduces your amount of reimbursment. Your doctor will order lab tests and the insurance company will call some of them redundant and not pay. Your doctor orders xrays or MRI's...they doctor that reads the films charges more than the insurance company considers reasonable and customary.
The list goes on and on and on....and I've had several different company sponsored insurance plans that sounded great, but in reality the fine print/legalese is there way of reducing payment on everything.

For instance I have a plan that shows $100 for Emergency Room. Recently I ended up paying over $2,000 out of pocket for expenses that the insurance company didn't pay due to some of the above reasons I listed. Trust me I have appealed until I am blue in the face and you will NOT win against a big insurance company.

I'm not really trying to be negative, but I also want you to know that you will likely encounter many of these issues with private insurance. If it were me I would utilize the free medical care that you have available and purchase a plan that would cover you in the event of unforseen complications that required outside medical care.

 

[dis75ney]

I think if you have FREE Indian medical care available you should take advantage of it. I don't know all of the particular's of it, but if it will offer free medical care for both of you, then why not use it?

Maybe you could purchase a policy before the pregnancy, as sort of an insurance if something does go wrong and you need medical care outside of the Indian system. Then use the free medical system, if all appears normal then you won't have spent any money beyond the premium amount.

The majority of pregnancies are normal and even though the hospital is 1-1/2 hours away, that is normally enough time to get to the hospital. I don't feel that liking my doctor is reason enough to pay extra. I don't have to like him/her. If they are competent and offer good care then I'm happy.

3 years ago I went thru breast cancer and had a surgeon that I didn't really care for. As a matter of fact he was very arrogant, but after some discussion with my primary care doctor, we both decided that I don't have to like him, basically he was one of the best breast surgeons around. You really won't see your doctor all that much, probably just a few minutes at a time. you will see more of the nurses then anything, the doctor will come in every once in a while and for the delivery...and trust me during delivery you won't really care whether your like the doctor or not!

I will also warn you that you will pay way more then you think with private insurance. Your insurance will find ways to reduce the amount they have to pay. You may go to a hospital on the approved list, but your anesthesiologist is not on their preferred list, so the insurance company will pay less to them and you are stuck with the remainder! Your doctor may order a medicine, but the insurance co. decides that a generic will do better and reduces your amount of reimbursment. Your doctor will order lab tests and the insurance company will call some of them redundant and not pay. Your doctor orders xrays or MRI's...they doctor that reads the films charges more than the insurance company considers reasonable and customary.
The list goes on and on and on....and I've had several different company sponsored insurance plans that sounded great, but in reality the fine print/legalese is there way of reducing payment on everything.

For instance I have a plan that shows $100 for Emergency Room. Recently I ended up paying over $2,000 out of pocket for expenses that the insurance company didn't pay due to some of the above reasons I listed. Trust me I have appealed until I am blue in the face and you will NOT win against a big insurance company.

I'm not really trying to be negative, but I also want you to know that you will likely encounter many of these issues with private insurance. If it were me I would utilize the free medical care that you have available and purchase a plan that would cover you in the event of unforseen complications that required outside medical care.

I have to agree with the above poster. When I was pregnant with DS, I went to a group of MDs and had appointments with each one, since I didn't know who would be on call when I went into labor. I loved all the doctors in that group but one (I work in the medical field, and while the other MDs knew this and treated me with respect, this one doctor treated me like I didn't know anything - very patronizing). Guess which one was on call when I went into labor? Yep, the one I didn't like...

But honestly, I think I saw her all of ten minutes during my labor and delivery - five minutes for her to confirm with the resident physician that yes, my cervix had dilated from four to ten cm in fifteen minutes and that I was pushing instead of getting a c-section , and five minutes when she caught DS as he came shootin' out (yep, kid decided he was coming out and wasn't going to listen to some chick in a white coat tell him to stay put for 30 seconds while he got suctioned ). The RNs and one of the resident physicians gave me the most care throughout the L&D...

Quite honestly, I'd go for the free health care and purchase a supplemental policy in case something happens outside of the Indian coverage. Or who knows, by that time your job situations may have changed and the insurance they offer would be better than what you have now...

 

[SageFemme]

Well we ended up going to the main office today to talk to an agent and walked out with insurance, LOL. That seems to always be how it ends up, huh? LOL

Of course we haven't "officially" been approved yet...but we got the "Basic" plan for both of us. It's an 80/20 plan with maternity coverage and dental. $275/month. We got the highest deductible ($5000) for this first year for the 365 day maternity waiting period. It's funny, my DH mentioned doing what y'all said: using the Indian clinic but having insurance "just in case".

I'm still needing to decide if we are going to use Plan A or Plan B for the next coverage year of Sept. 2010 so please keep the comments coming!

Thanks!!

 

[squirrlygirl]

In reference to your Plan B...here's how our previous plan worked:

We had a $2500 deductible, so any medical care up to that point we paid all of. Insurance then kicked in..ours paid 90% (so we would pay $10 for a doctor's visit that was charged at $100) You say yours pays 100%...is that 100% minus copays or just 100%?

If/when we had paid $5000 out of pocket in one year (this included the deductible) then they covered everything without copays. Ours included prescription costs towards that, but I've heard many do not count it.

Our new insurance also has an OPM. The kicker is that in the fine print they exclude everything that you pay out of pocket for as not contributing toward the maximum. so there's no way to ever reach it.

 

[SageFemme]

squirrlygirl: The copay is the $5k deductible for Plan B. So basically there are no copays. After the deductible is paid, everything is 100%. Does that sound like the best option for prenatal care and the birth?

That's interesting what you said about the OPM. I'll have to check that out.

Thanks poohhappens for the explanation on underwriting! I wouldn't get pregnant until after I get the coverage and after my 365 day waiting period.

 

[Debbie7452]

Just a warning to check and see if they charge a deductible on baby after it arrives. I've had four kids with four different insurance plans. Only the last one charged a deductible on a normal healthy newborn and that was certainly an unwelcome $1000 surprise (the deductible, NOT the baby,LOL!).

I also never seemed to be lucky and get my "regular" Dr. for the delivery. With the last baby, I drove over an hour each way for weekly OB appointments throughout my pregnancy (I was high risk) because I loved my Dr. She did NOT deliver DS because she had a meeting to go to! I was really upset...I changed Dr's to one closer to home after my post baby check up and I told her why!

 

[SageFemme]

Debbie7452: Thanks for the heads up! I will check into that! Sorry to hear about your Dr.! I had a midwife throughout my first pregnancy except for the end (due to a switch of insurance) and my Dr. did not make it to the delivery. The nurses delivered her.

 

[PoohHappens]

Debbie7452: Thanks for the heads up! I will check into that! Sorry to hear about your Dr.! I had a midwife throughout my first pregnancy except for the end (due to a switch of insurance) and my Dr. did not make it to the delivery. The nurses delivered her.

Congrats on your new insurance, I hope you are happy with it and you find it works well for your family. I think you got a good deal, especially covering both of you. You said BCBS so I thought I would make sure it was explained that you usually get some discount for using your insurance with a participating or contracted provider. So if you go to a reg dr appointment and the charge is 125 your insurance may state that the contracted acceptable charge is 85. You would only have to pay the 85. Then that 85 will count toward your 5000 deductible. Hope that made sense.

I had to smile to myself as an OB nurse about your delivery comment. (although I realize you might not find it funny) You would still have been charged a delivery fee from the physician that did not manage to catch your baby. We as nurses have been trying to figure out how to claim that one or get in on that extra pay for years I have delivered a few over the years. Sounds like everything turned out ok and that is what is truly important with having a baby, that everyone is healthy.

 

[SageFemme]

Thanks poohhapenns!!

As someone who currently works in healthcare and a future RN (DH too, he starts LPN school next month!! ), I know all too well about not getting enough respect for what you do! I envy you but I will fulfill my dream of becoming an RN (L&D or NICU) soon enough! Thank you for all that you do!