I've been thinking again about what we'll do about health insurance if we decide to have another baby. It's complicated, because we purchased an individual plan since we're self-employed, and the
individual plans in the United States where I live don't have (yet) a lot of the safeguards group health insurance plans have (the kind you get through a "real" job). Health care reform's tantalizing protection against treating pregnancy as a pre-existing condition (with a nine-month waiting period, natch) won't go into effect for me until 2014, and we won't be waiting that long.
We chose our current health insurance plan by virtue of its being just about the cheapest our family of three could find. It has a big deductible ($6,000) and no maternity coverage, at all. So we pretty much just never use it, but it's there if we need it. Except, you know, if what we need it for is a pregnancy and birth.
So. Here are my options:
- Upgrade our health insurance ahead of time to a plan that includes maternity coverage.
- Pay out of pocket for all our prenatal, birth, and postpartum expenses.
Here's where I crunch actual numbers and hope that's not too crass. I know it's boring,
so you can skip ahead as you wish. I wanted to write it out for my own ruminating, but I decided to post it publicly in the hope it helps someone else going through the same calculations.
Our current plan (no maternity coverage) is $256/month for the three of us. It has a $6,000 family deductible, up to $300 a year (combined for all of us) in preventive care, and it's HSA eligible, so we can (theoretically) store money away pre-tax that can be used toward medical expenses. (I say "theoretically," because our most recent HSA money disappeared when it turned out the bank managers had been embezzling, but that's neither here nor there.)
PLAN A: If we upgraded with our current insurer, it would be $516/month for the cheapest plan that includes maternity. (At least they have a choice this time — last time I checked, they had had exactly one plan that offered maternity coverage. Now they have a whopping two.) That's a $9,000 family deductible at $3,000 per person, $30 copays for preventive care (including well-baby) visits, 30% coinsurance after deductible for all maternity care (prenatal, delivery, postpartum).
Definition break: If you don't shop for insurance a lot, a deductible is what you have to pay out of pocket before an insurance company will step in and pay out any benefits. Coinsurance is the percentage you have to pay of any expenses. So, if the coinsurance is 30% and the expense is 100, we pay $30 and the insurance company pays $70 — but only if our deductible has been met.
Website plug: I'm getting all these numbers at eHealthInsurance.
PLAN B: If we moved to a different health insurance provider, we could get cheaper maternity coverage that would be in the realm of catastrophic coverage without technically being considered that. There's a plan for $385/month that has a monstrous $22,500 family deductible! No, seriously. Ignoring that one, there's a plan for $424/month that has a $15,000 family deductible. The point of these type of plans would be that they're there if anything really, really expensive went down, like an emergency C-section and a NICU stay. Otherwise, I'd be paying everything out of pocket. Preventive care is covered at 20% coinsurance with the deductible waived. Prenatal care is $25 each for the first four visits, then subject to deductible and 20% coinsurance. Labor, delivery, and hospital stay are 20% coinsurance after deductible.
Care providers: The midwives we used with Mikko, if someone didn't have insurance, offered a flat cash rate of about $2,000 that covered prenatal care (hour-long office visits), labor and delivery, and postpartum care, including lactation consulting and at least two home visits. I know — nice, right? They're not currently practicing (I shed tears just thinking of this), so I don't know if whatever midwives we go with (and we will be using midwives again if all goes well) will have the same sort of deal or a more expensive one, and how much more expensive.
Our medical plans for the next pregnancy and birth: We would like to have prenatal care but nothing too fancy. Last time, we had the most highly recommended tests and skipped the rest (including ultrasounds). We would like a home birth. However, we wanted a home birth last time, and we ended up transferring to a hospital for a non-medicated vaginal birth. I still have no idea how much that cost, because we had a different health insurance plan then with $0 deductible that covered maternity (the only one then available that did). If all goes as planned and we can use a midwifery care flat-rate plan, our expenses could remain under $3,000, including lab tests.
But, we all know things do not always go as planned, and if things went really pear-shaped, we could be out of pocket for tens of thousands of dollars in a flash. We are unfortunately (?) no longer poor enough to qualify for much or perhaps anything in the way of financial aid from a hospital, though I'm sure we could work out a long-term payment plan. That wouldn't be much consolation, though, if they took all our retirement savings and then some. According to WSHA Hospital Pricing, the average price in Washington State for a delivery is somewhere in the range of $8,193 for uncomplicated vaginal birth to $20,224 for a complicated cesarean. That doesn't include charges for the physicians, surgeons, or anesthesiologists, or any emergency ambulance service. I'm not sure if it includes any medications used before or after birth, and I believe the newborn's hospital stay is a separate charge.
I have considered an unassisted pregnancy and birth — but more so before Mikko's birth. There were some complications (excessive postpartum bleeding, for the most part) that made me appreciate having qualified attendants. I'm not judgmental against those who choose unassisted births, but I'm in a headspace where I'd rather have midwives present.
So here's a little chart breaking down the price difference between our current insurance, Plan A, and Plan B:
So, if we upgrade, we're talking at least $2,000 more a year in insurance premiums. Plus, neither plan covers all of our increased health costs. In Plan A, we'd be paying all our prenatal care out of pocket and hit the deductible only if we had unforeseen expenses relating to prenatal care, the birth, or postpartum care. However, if we did hit a complication, it wouldn't be long till we hit the deductible, and then things would be covered at 70%. In Plan B, only four prenatal visits would be covered at $25 apiece, and even a vaginal hospital delivery would be out of pocket, with a $15,000 deductible. Only if there were more severe complications would the benefits kick in.
So: Is $2,016 with Plan B a fair price to pay for peace of mind in the event of any catastrophic complications? Is paying $3,120 more a year for Plan A better to have less out-of-pocket worry in the case of even mild complications (like my previous, non-emergency hospital transfer for a natural vaginal birth), when with an uncomplicated pregnancy and home birth under midwifery care, we could get away with paying over $1,000 less without upgrading? Remember that we're paying the cost of prenatal, birth, and postpartum care mostly out of pocket in all three cases if it's an uncomplicated pregnancy and home birth, and we'll say that's $2,000 since that's what our old midwives charged.
Here's another chart to illustrate the options:
|MATERNITY CARE||No maternity coverage||Plan A||Plan B|
|Uncomplicated (annual cost)||$2,000||$5,120||$3,800 (taking off some for the first four prenatal visits being partially subsidized)|
|Complicated additional expenses (annual cost)||100% of costs (potentially $$$$$)||$3,000 deductible, then 30% of costs||$15,000, then 20% of costs|
It's a risk-benefits game, but the potential losers are my baby and my health.
A couple other factors to keep in mind:
- Every month I've upgraded to the higher price but don't get pregnant, I lose even more of the benefit of the higher-priced insurance. Ideally, I'd time it so my coverage kicks in the month before we conceive, but I can't guarantee anything like that. Note that this also doesn't allow for any spontaneity in our planning (no let's just go for it, honey! moments), as you can see from all the dull, dull, dull, deadly dull html tables.
- Both Plan A and Plan B do not have the HSA option for paying medical expenses with pre-tax dollars. For instance, that $2,000 under our current plan would actually be $2,000 minus our tax bracket, so let's say $1,700. This is assuming no embezzling of HSA funds happens, again. Beyond that, our HSA money gets us this discount* on anything medical, including things our insurance doesn't cover, such as vision and dental care as well as prescription and over-the-counter medication. I'm just not sure how to factor this into the charts since I'm not sure what the yearly average HSA benefit is to us. (*I say "discount," but it's actually a more complicated process of getting a tax deduction after the fact. I guardedly recommend HSA-eligible plans to self-employed families who are willing to manage their own healthcare spending — just try to choose an HSA manager who's not a crook. Ha.)
- Both Plan A and Plan B offer vision coverage, and our current scheme doesn't. However, an eye exam and some glasses every couple years is not worth so very much that I throw that into the consideration.
Philosophically speaking, assuming I've lost 90% of you with all these #%*$!@ numbers, why do I have to make decisions like this?
- Why is my baby's health and my health dependent on some number-crunchers who decided pregnancy was too much of a financial risk for them to bother making maternity coverage standard or easily obtained?
- Why is maternity care so expensive in this country, with the overzealous medicalization of prenatal care and childbirth?
- And how does even an uncomplicated hospital birth cost over $8,000?
- Does anyone think it's a teensy bit sexist not to cover a condition that half the people of childbearing age are subject to? (And you know which half I'm talking about.)
- Knowing that I am extremely privileged to be having this decision to make, how do unemployed or self-employed people without the financial resources to purchase individual health insurance and no access to group health insurance afford to give birth?
I don't understand it, and I don't appreciate making decisions about expanding my family based on finances.
But there it is.
And this is not meant to be a political post, but I will say that I've gotten very offended when family members have talked about health care reform disparagingly, as if it's affecting those people. Nuh-uh. It's affecting me, and my partner and their grandchild(ren), their loved ones. This is an untenable situation for us to be put in, and I'm so conflicted about what sort of risk I'm willing to take vs. how much of my hard-earned money I want to hand over to the insurance companies.
So what would you do? Plan A, Plan B, or brave it without maternity coverage at all? Have you ever or would you ever consider forgoing insurance coverage for pregnancy and childbirth?
I wrote this last night as I was cogitating, and today I called the health insurance company just to confirm that, yes, pregnancy is a pre-existing condition on my plan, and it is. She did inform me of a few more facts:
- For pre-existing conditions, they look back six months from the date of the new plan application for any medical diagnosis, care, or treatment.
- Therefore, the "pregnancy" starts when I first seek medical care. According to that, I theoretically could buy the upgraded insurance at 8 months pregnant as long as I sought no prenatal care before then and that would be the first record that I had the condition. I'm not saying this is my plan, just that it's kind of ludicrous. I'm not sure how much to trust that, though, since I don't have it in writing. My concern was more specific: If pregnancy is dated from last menstrual period and my plan went into effect before conception but after LMP, is it covered? According to the woman on the phone, it would be.
- If I get pregnant on my current plan and upgraded, she said prenatal care would be covered under the new plan immediately but not delivery. (Big whoop, I know, but at least it's something.)
- I could upgrade just myself to an individual plan with maternity and leave the boys where they are, which would be $354/month for our family total. I know — more numbers. That actually sounds much more doable to me, but I have to look into the tax implications of that, because I thought we had to have a family plan to deduct the cost from our business taxes. It would be a blow to lose that. More thinking and researching to do!