Can someone help me understand our health insurance benefits and maternity?

[morkus64]

I don't know why, this is just one of those things that I can never quite figure out. Feeling a little dumb.

So this is our current plan: https://www.mybenefitsnm.com/Docume...NM_PPO_01-01-16 to 12-31-16_2005-07-01_v2.pdf

My wife and I are planning on starting a family later this year, and I'm trying to figure out what I need to budget and also if it makes sense for me to be on a separate plan (my work would cover me, but the cost is the same so we just had us both on hers).

My questions are:

- Is the maximum out of pocket actually less if we're on separate plans, or does the individual rate apply to each individual? That is, if I were to spend basically nothing on healthcare and she spent a ton for her and the future baby, would her maximum be 3500 or 7000?

- Page 3 lists the "if you are pregnant" costs. Is that fairly all-inclusive? And am I understanding that it is really only 1000 + 30 for the first visit? That can't be it, right?

 

[RLGL]

Talk to your agent!

 

[dullard]

Like RLGL said, talk to your HR or insurance agent.

I just want to come in here to point out a trap that some people that I know got into. Your wife is a person, your baby will be legally a person. That is to mean, the instant the baby is born, you are now in family insurance coverage territory. Both your wife and your baby will rack up their own medical bills.

Imagine that you planned on an individual deductible ($500 on your link) and individual out-of-pocket maximum ($3500 on your link) for your wife. Now suppose there is a problem with the baby (say premature birth). Now you are in family territory with a $1,500 deductible and $10,500 out of pocket maximum.

That is a major difference in cost between $3,500 and $10,500 based on an unclear definition. So get it clear before you make critical decisions like choosing insurance or deciding to have a baby.

 

[yuchai]

Under Health Care Reform rules, plans need to make sure that the out of pocket maximum (OOPM) is not greater than $6,850 for any individual in 2016. Given that the linked plan is a 2016 plan, it is very likely that the OOPM is $3,500 for an individual family member within family coverage. That said, yes, ask the question before committing to anything.

The categories of costs are probably pretty inclusive on page 3, but the amounts can be very different because health care costs can vary a lot depending on a lot of factors. Also, this shows a normal delivery scenario which is best case. C-sections and other complications will cost more.

Edit: when I said page 3 above, I actually meant the information shown on page 7. The stuff on page 3 is not comprehensive at all.

 

[JEDIYoda]

w2hyy even bother with ATOT?????? duh

 

[morkus64]

Thanks RLGL, dullard, and yuchai! Really helpful, and I will reach out to BCBS to confirm.

 

[JEDIYoda]

Why ?? You should have just called the company yourself...well duh...........HELLOOOOO......wake up/.......

Please tone it down a little. This was a bit over the top for what is a fairly serious thread. E.g., look at RLGL's post. -Admin DrPizza

 

[quikah]

$30 per pre-natal visit. I forget how many there were, like 10 or 12?

$1000 per hospital admit. Should only be one for normal pregnancy, but can be more if any complications.

Physician service are not included, so you need to pay up to your deductible for that.

 

[sactoking]

Since this is a state-sponsored plan it may not technically be subject to many of the ACA reforms (if BCBS is acting as a third-party administrator for the state's ERISA-regulated self-funded plan, for example).

That caveat aside, under the ACA reforms deductibles have changed slightly. In the past you could see plans with individual deductibles and plans with shared family deductibles. For example, there might be a $500 deductible for individuals and a $1,000 shared deductible for families, meaning that nobody's coverage would start until the $1,000 was met. Under the ACA those shared deductibles are no longer legal.If a plan advertises an individual deductible then all people in the family have their own individual deductibles. You also get the benefit of being subject to family deductibles if total costs exceed them. In other words, each claim accrues toward both the individual and family deductibles and whether or not it is paid is determined by whether EITHER deductible is met.

EXAMPLE: You and your spouse are enrolled in pre-ACA coverage with a $500 individual deductible and a $1,000 shared family deductible. You have $750 in medical expenses and your spouse has $250 in medical expenses. None of these expenses are covered by the plan because they do not exceed the shared deductible of $1,000.

EXAMPLE 2: You and your spouse are enrolled in post-ACA coverage with a $500 individual deductible and a $1,000 family deductible. You have $750 in medical expenses and your spouse has $250 in medical expenses. You have met and exceeded your $500 deductible so the amount above that threshold ($250) is paid by your insurance according to the copayment/coinsurance agreement. Your spouse has not met their deductible but has accumulated $250 toward the $500 amount. However, your family has met the $1,000 family deductible so ALL covered expenses for you and your spouse are now subject to the copayment/coinsurance agreement since your family has met the aggregate deductible.

 

[Cozarkian]

My questions are:

- Is the maximum out of pocket actually less if we're on separate plans, or does the individual rate apply to each individual? That is, if I were to spend basically nothing on healthcare and she spent a ton for her and the future baby, would her maximum be 3500 or 7000?

- Page 3 lists the "if you are pregnant" costs. Is that fairly all-inclusive? And am I understanding that it is really only 1000 + 30 for the first visit? That can't be it, right?

2. Assuming your wife were pregnant today and you have not visited a doctor this yea, you will likely pay:

$500 deductible for 2016.
$500 deductible for 2017.
After the deductible is met you will pay $30 for each prenatal visit, I'd budget for 10 in case there are problems or she is late.
$1,000 for delivery.
$30 for a postnatal visit if c-section.

When baby is born, you add baby to the insurance and you will owe another $500 for the deductible increase, which should cover all baby wellness visits in 2017.

All in all that is about $3,800 to $4,000.

However, if baby comes early or there are complications and spends time in the nicu, that is another $1,000.

I would also plan on $1500 family deductible in 2018 as you will have 12, 15, 18 and 24 month visits in the following year, more if baby is underweight.

That brings the total up to $7,500 over for pregnancy over the first two years. Also don't forget to account for any lost income if you take extended leave.

Congratulations, it is worth it (and exhausting) and if you are already preparing financially that shows you will be a good parent.

 

[Cozarkian]

Sigh, I missed the PPO deductible waiver and coinsurance for tests.

Page 7's $1,800 is close, but add $500 for a second deductible when the year rolls over and $1,000 for a hospital admission if baby comes early, plus the $500 deductible for baby.

I would still try to save up $5,000.

My wife and I looked up daycare costs about $1000 per month in my area and started saving $1,000 per month as soon as we started trying.

That made sure we had a nice fund for medical expenses and baby supplies and that we could afford day care.

 

[Phynaz]

Get a better plan before you have a kid!

Edit:
Actually are going to have to change plans, BCBS is pulling out of the New Mexico plan.

 

[cbrunny]

Good god. Move to Canada.

 

[yuchai]

Since this is a state-sponsored plan it may not technically be subject to many of the ACA reforms (if BCBS is acting as a third-party administrator for the state's ERISA-regulated self-funded plan, for example).

That caveat aside, under the ACA reforms deductibles have changed slightly. In the past you could see plans with individual deductibles and plans with shared family deductibles. For example, there might be a $500 deductible for individuals and a $1,000 shared deductible for families, meaning that nobody's coverage would start until the $1,000 was met. Under the ACA those shared deductibles are no longer legal.If a plan advertises an individual deductible then all people in the family have their own individual deductibles. You also get the benefit of being subject to family deductibles if total costs exceed them. In other words, each claim accrues toward both the individual and family deductibles and whether or not it is paid is determined by whether EITHER deductible is met.

EXAMPLE: You and your spouse are enrolled in pre-ACA coverage with a $500 individual deductible and a $1,000 shared family deductible. You have $750 in medical expenses and your spouse has $250 in medical expenses. None of these expenses are covered by the plan because they do not exceed the shared deductible of $1,000.

EXAMPLE 2: You and your spouse are enrolled in post-ACA coverage with a $500 individual deductible and a $1,000 family deductible. You have $750 in medical expenses and your spouse has $250 in medical expenses. You have met and exceeded your $500 deductible so the amount above that threshold ($250) is paid by your insurance according to the copayment/coinsurance agreement. Your spouse has not met their deductible but has accumulated $250 toward the $500 amount. However, your family has met the $1,000 family deductible so ALL covered expenses for you and your spouse are now subject to the copayment/coinsurance agreement since your family has met the aggregate deductible.

I am pretty sure ACA did not require the change in the way deductibles work as you described. The "aggregate" approach, or what you call the "shared" approach, i.e. family deductible amount applies before coverage begins for any individual within family coverage, is actually a requirement under HSA plans and is still allowed. HSA plans require a minimum deductible of $1,300 single and $2,600 family with individual members in families subject to the family deductible amount. The only implication under ACA is that if you have a plan that uses the "aggregate" approach that the family deductible amount can no longer be greater than $6,850 in 2016 because of the out of pocket limit requirement.

Example 1: a plan that uses the aggregate or "shared" approach as you describe it and has $1,500 single and $3,000 family deductible is allowed before or after ACA. An individual in family coverage has to pay up to $3,000 in deductible before coverage begins. The ACA doesn't have a problem with this because $3,000 is less than the $6,850 limit on individual out of pocket maximum

Example 2: same as example 1 but the plan has $3,500 single and $7,000 family deductibles. This isn't allowed because an individual in a family coverage has the potential to pay up to $7,000 in deductible before coverage kicks in, which is higher than the out of pocket limit allowed under ACA of $6,850 in 2016. One easy way for plans to remain in compliance but have minimal cost impact is to define the deductible as $3,500 single, $6,850 for each member within family coverage, $7,000 family.

Most standard PPOs (non-HSA) don't have this aggregate or shared deductible approach though and works the way as described under your Example 2, with the caveat that the family in your situation actually hasn't met the $1,000 family deductible because the subscriber paid $500 (after that the plan started paying so those don't count towards the deductible) and your spouse paid $250 so the family has only accumulated $750 in deductible.

 

[quikah]

I would also plan on $1500 family deductible in 2018 as you will have 12, 15, 18 and 24 month visits in the following year, more if baby is underweight.

Well ness checks are free under ACA rules (annual checks for 2+ yrs old and the 1, 3, 6, whatever months for babies).

 

[sactoking]

snip

You're right, I was conflating the embedded individual out-of-pocket maximum with the deductible. In no case can an individual's OOP max exceed the stated individual maximum even if the aggregate other-than-individual amount exceeds that limit.

My second example is off, it's not $1,000 to the deductible but it's not $750 either. Technically it's $750 (the first person's $500 deductible plus the $250 applied to the second person's deductible) plus the individual's cost sharing portion of the remainder of the $250 from the first person's costs.

 

[Phynaz]

Well ness checks are free under ACA rules (annual checks for 2+ yrs old and the 1, 3, 6, whatever months for babies).

They are far, far from free.

They are covered at 100%, but they are not free.

We really need to stop thinking of healthcare being free. It isn't, it's expensive.

 

[morkus64]

Thanks for all the information everyone - this is super helpful. We've got a little nest egg saved, but hopefully I can manage to put some more aside before the baby comes!