Maternity coverage question

[skyline]

I'm hoping someone here might have a quick answer to (hopefully) a quick question:

I'm preparing to FIRE in the next 0-3 years, and have started pricing self-insurance for my family. I currently have one child, and may or may not have another in the same time period. For a variety of reasons, I expect that my family would not qualify for maternity coverage on an individual policy, and if we do have another baby, we would have to pay out of pocket for the pregnancy (unless I keep working and get insurance through my employer, which is the fallback plan).

My question is, do policies that do not provide maternity coverage still fully cover care for new born babies? I'm assuming that they would be covered immediately from birth regardless of whethe the mother is covered?

Thanks,

 

[Rich_by_the_Bay]

...if we do have another baby, we would have to pay out of pocket for the pregnancy (unless I keep working and get insurance through my employer, which is the fallback plan).

Careful - not all pregnancies are uncomplicated. The cost of the few percent with pre-eclampsia, threatened miscarriage, emergency section and a host of other uncommon but not unheard-of issues can decimate most nest eggs.

 

[mykidslovedogs]

Most states require "complications of pregnancy" to be covered under the regular healthplan, regardless of whether or not the maternity option is added to the plan. Take a look at Colorado's rules for coverage for complications of pregnancy -

http://www.dora.state.co.us/Insurance/regs/4-2-6.pdf

Of course, you will have to find out what your own state's, regulations are on that, but the above link should give you a little bit of an idea.

Why do you think that you would not qualify to add a maternity option to an individual plan? Have you had a complicated pregnancy in the past, therefore, making you a "high risk"? If you give me some more detail, I might be able to give you some more specific answers as to whether or not you would qualify for maternity coverage.

Maternity coverage on individual healthplans, at least in the state of Colorado, generally, is not very good. Maternity coverage is a Federal Mandate on group plans, and generally, the coverage is much more comprehensive for maternity on group plans as well. In the individual market, the coverage typically costs just about as much as it costs to pay out of pocket. Your biggest protection that you are buying with a maternity plan is coverage for the cost of a planned C-section, which would not fall under the "complications of pregnancy" regulations.

FYI - Assurant Health has a great maternity benefit where you can purchase a $5000 deductible maternity plan, and what that actually buys you is a cap on your out of pocket AS WELL AS, and this is the most important part, up to 50% discounts towards pre-natal care and labor and delivery. Without the option added to your plan, you DON'T have access to discounted services for maternity. The 5000 deductible maternity option costs around $35/mo in Colorado. I'm not sure about the cost in other states. The biggest disadvantage to the maternity option, is that, per contract, you cannot concieve prior to 9 mo. after purchasing the option. If you do, the coverage is null and void.

Lastly, at least in the state of Colorado, the newborn is granted guaranteed issue on to the parent's health plan, regardless of whether or not the parent had maternity coverage. The law is that you have a 30-day grace period to formally add the baby, but it is immediately covered under your plan from the moment of birth. All charges up until labor and delivery are completed go onto the mother's coverage. After that, the baby's care falls under it's own coverage and it's own deductible. The parent must at least have had health insurance prior to birth in order for the baby to have it's own coverage once it is born.

 

[Martha]

If you buy a policy that has dependant coverage, (rather than each of your family members having their own individual plan) your state likely will require the plan to cover the newborn. Check the insurance guide for your state at www.healthinsuranceinfo.net.

 

[Rich_by_the_Bay]

Most states require "complications of pregnancy" to be covered under the regular healthplan

The OP said, "For a variety of reasons, I expect that my family would not qualify for maternity coverage on an individual policy, and if we do have another baby, we would have to pay out of pocket for the pregnancy."

That's the scenario I was cautioning about: no obstetric coverage at all. This could be well more than a few thousand dollars if all does not go well.

 

[haha]

Think strongly about deciding now about your family size, continuing to work until that issue is behind you and you have taken definitive pregnancy prevention steps. Unless you are quite well off, then I suppose it might be another matter.

Ha

 

[SecondCor521]

This could be well more than a few thousand dollars if all does not go well.

My daughter went from being a $2,000 baby to a $15,000+ baby in under one minute (prolapsed cord). Insurance covered most of that, so our OOP was maybe $3K. I was thrilled to be writing those checks though because I found out quickly (while the emergency C-section was being done) what the possible outcomes were, but in our case she turned out just fine.

2Cor521

 

[mykidslovedogs]

The OP said, "For a variety of reasons, I expect that my family would not qualify for maternity coverage on an individual policy, and if we do have another baby, we would have to pay out of pocket for the pregnancy."

That's the scenario I was cautioning about: no obstetric coverage at all. This could be well more than a few thousand dollars if all does not go well.

In Colorado, again, complications must be covered regardless of whether or not you have maternity. Some of these conditions could happen prior to labor and delivery. The state of Colorado defines "Complications of Pregnancy" as:

1.)Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from
pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute
nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical
conditions of comparable severity, but shall not include false labor, occasional spotting,
physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis
gravidarum, preeclampsia, and similar conditions associated with the management of a difficult
pregnancy not constituting a nosologically distinct complication of pregnancy;

Other complications that must be covered regardless of whether you have maternity or not include: 2.)Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous
termination of pregnancy, which occurs during a period of gestation in which a viable birth is not
possible.

I am not sure how other state laws define "complications of pregnancy" or even if other states have provisions requiring individual plans to cover complications of pregnancy as part of the base health plan, but that would be something that you would want to check into.

All other conditions related to prenancy or conditions listed above that are not considered a "complication" would not be covered unless you have maternity added to your healthplan. Group insurance is going to cover maternity automatically, but individual insurance typically only offers maternity as an additional option that you can add on to your plan. There are also typically waiting periods that apply in the individual market, so you will want to take that into consideration as well.

 

[Bimmerbill]

My daughter cost about $30K, not including prenatal care. She is 14 months old now.

Normal delivery, 2 days in hospital, home for 1 day, 2 more days in hospital due to jaundice. Add in all the breast feeding gear, food, supplies, consultations, visiting nurse visit at home, etc.

BCBS paid it all, thankfully!

 

[skyline]

Thanks to everyone for their feedback. I did some research on my own as well, and I'm starting to get a little more familiar with the whole individual health plan scene. You guys are right, I don't think I want to be out there w/o maternity coverage if we do decide to have another kid.

In the meanwhile, here's a couple more questions I'm hoping to get feedback on:

Based on info from http://www.healthinsuranceinfo.net/ca03.html, I see that in California, insurance companies are not allowed to hold any preexisting conditions against you if the condition existed more than 6 months prior to applying for insurance:

"The definition of pre-existing condition is different under individual health policies than under group health plans. Individual health policies can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice in the 6-month period (if the policy covers 3 or more people) or 12-month period (if the policy covers 1 or 2 people) prior to obtaining the individual health policy. Individual health policies can apply pre-existing condition exclusion periods for pregnancy, but not for genetic information. In addition, if enrolled within 30 days newborns, newly adopted children and children placed for adoption can avoid pre-existing exclusion periods."


Anyone have any personal experince that can attest to this? My wife did have complications in her last pregnancy, but that was at least a year ago, and if I read the above correctly, it sounds like her prior condition wouldn't count? Sounds too good to be true?

The second question is whether insurance companies are allowed to charge extra for having pre-existing conditions that were prior to the exclusion period. Say I have a condition that went away 2 years ago. Insurance company can't hold it against me as far as issuing the policy, but can they then screw me on the rates so I wouldn't want it anyways?

Thanks in advance for your feedback...

 

[mykidslovedogs]

The exclusion period you referenced in italics, in my experience, only applies if you are actually accepted for coverage and weren't given a specific "exclusion rider" for any pre-existing conditions. What that paragraph really means is that if you are accepted for coverage, the insurance carrier has the right to exclude coverage going forward, for a defined period in time, any conditions that you may have rec'd treatment, advice, diagnosis of in the 6-12 months prior to being accepted. This is kind of a protection that's built in for insurance carriers to protect themselves from people who may lie about or mistate their health status during the application process.

On the other hand, the insurance carriers still have the right to look back as far as they want to (and it's usually 5-10 years) when they are UNDERWRITING your application, and during underwriting, they can decide at that time if they want to accept you, decline you (if the State allows that), exclude pre-existing conditions (if the State allows that) for a lifetime or a defined period of time, or even rate you higher (if the State allows that) based on any of those pre-existing conditions.

In my experience, people who have had a c-section are usually prohibited from adding a maternity option to a new, individual health insurance policy. On the other hand, if it wasn't a C-section, then it depends on what kind of complication she had as to whether the insurance carrier is going to allow you to add maternity coverage to your policy or not.

Newborns, in my experience, are always granted guaranteed issue during the first 30 days after birth, onto the parent's healthplan regardless of whether the parent, mother or father, had maternity coverage on their healthplan.

 

[skyline]

...if you are accepted for coverage...

Sounded too good to be true! I guess I need to make it work with HIPAA guaranteed plans or keep working until the family building is done...

Thanks for your clarifications

 

[mykidslovedogs]

Sounded too good to be true! I guess I need to make it work with HIPAA guaranteed plans or keep working until the family building is done...

Thanks for your clarifications

If you can afford the premiums, you are going to get the best coverage for maternity on a group or guaranteed plan.

Tip: If your employers don't pay for dependent coverage, you might check into pulling your child(ren) off of the group policy and purchasing individual coverage for him/her/them. If your spouse has access to group coverage via an employer, perhaps she could be the one to keep group coverage while the rest of the family goes with individual coverage.

I don't know how it is in CA, but in CO, family level coverage is usually the same cost on small group plans and even sometimes on large group plans whether you have one or 10 kids, so if you only have one or two kids, sometimes it's much less expensive to put the kids on individual plans, while the adults or female adult remains on a group plan until done having babies.