Health Insurance

We're in the process of changing health insurance at work. In our
group, we have my parents, me, Allyson, and Caterpillar. Neither my
parents nor Allyson ever go to the doctor, and have probably had less
than $1,000 in medical expenses combined over the last 10 years.
Caterpillar and I need health insurance - I because I'm not done having
kids, and she because I want more treatment than we can afford if she
were to become seriously ill or be in a bad accident.

We currently have a small group policy, which is hideously expensive and
gets more so every 3 months. The advantage is that if we switch,
there's no pre-existing condition wait. If I go to an individual
policy, and we ever need to switch, there's a 12-24 month wait before
anything we'd had treatment for in the prior year was covered. We also
can't find an individual policy with maternity coverage, and
complications of pregnancy are the most likely expenses our family will
have.

For Caterpillar, we had a homebirth with a midwife, and none of it was
covered by insurance. That's the plan for #2, but I'm unwilling to risk
having complications that run up a huge bill. The insurance agent I'm
talking to has faxed me a page from the individual policy that says:

"Limited coverage for specific conditions of pregnancy includes only
spontaneous miscarriage, ectopic pregnancy, Medically Necessary
caesarean section, gestational diabetes mellitus, and medical conditions
whose diagnoses are distinct from pregnancy but are adversely affected
by pregnancy."

Insurance agent says that means everything except routine prenatal care
and normal vaginal delivery are actually covered by a policy that has no
maternity coverage.

Has anyone been in the situation where they had insurance with no
maternity coverage, got pregnant, and had complications? Did you have a
good experience? Any other things I should consider?

Phoebe

Phoebe & Allyson wrote:

For Caterpillar, we had a homebirth with a midwife, and none of it was
covered by insurance. That's the plan for #2, but I'm unwilling to risk
having complications that run up a huge bill. The insurance agent I'm
talking to has faxed me a page from the individual policy that says:

"Limited coverage for specific conditions of pregnancy includes only
spontaneous miscarriage, ectopic pregnancy, Medically Necessary
caesarean section, gestational diabetes mellitus, and medical conditions
whose diagnoses are distinct from pregnancy but are adversely affected
by pregnancy."

Insurance agent says that means everything except routine prenatal care
and normal vaginal delivery are actually covered by a policy that has no
maternity coverage.

I wouldn't interpret the quoted policy as saying that
at all. What if you had complications during the homebirth
that ended in a hospital transfer, an epidural, and an
instrumental birth? Doesn't sound like that would be
covered to me, but it would likely be pretty pricey to pay
out of pocket, especially since you'd likely be paying
your midwife on top of it.

Best wishes,
Ericka

Has anyone been in the situation where they had insurance with no
maternity coverage, got pregnant, and had complications? Did you have a
good experience?

After William was was born, I had to be readmitted to the hospital because I
had an awful headache, my chest hurt, and I just felt terrible. When I got
there they began to run all sorts of tests on me, and because one explanation
for the symptoms could have been post-partum cardiomyopathy, I had to have a
lot of tests done includint, IIRC, an dkg, an electrocardiogram, a CAT scan, a
VQ scan, and some kind of ultrasound, bloodwork, and God only knows what all
else. Turns out that I had just bled a lot, lost half my blood, and needed two
pints.

My major medical, non-maternity insurance wanted to call this a maternity
expense and stick us with the well over $10,000 bill (in addition to the money
already owed to the doc, hospital, anesthesiologist, and neonatologist for the
birth!). I was able to get my doctor to convince them that they should cover
it--but it was 80-20 with a $2,500 deductible, so it was still pretty bad (and
still mostly unpaid . . .). Anyway, I wouldn't count on insurance covering
anything they don't explicitly say they will cover, not without a fight anyway.

Leslie

Ericka Kammerer wrote:
What if you had complications during the homebirth
that ended in a hospital transfer, an epidural, and an
instrumental birth? Doesn't sound like that would be
covered to me, but it would likely be pretty pricey to pay
out of pocket, especially since you'd likely be paying
your midwife on top of it.

A $10,000 hospital bill doesn't worry me. A $50,000 hospital bill worries
me, and it's fear of a $50,000 hospital bill that is leading me to want
insurance at all.

We have a high-deductible plan, so the first $5,000 of expenses are out of
pocket regardless. I'll get $5,000 into a savings account from my employer
every year for 2004, 2005, and 2006, and we aren't anticipating that #2
would be born before 2006. We'll probably use some of that $15,000 for
routine stuff, and some for TTC#2, but we've also got savings that could be
dipped into. So $10,000 for a complicated vaginal birth and $5,000 in
deductible doesn't worry me so much. Plus we're saving $500 a month in
premiums (and getting slightly better coverage), which for 24 months is
$12,000 that could be used to defray any birth expenses.

Phoebe
--
yahoo address is unread; substitute mailbolt

Phoebe & Allyson wrote:

A $10,000 hospital bill doesn't worry me. A $50,000 hospital bill worries
me, and it's fear of a $50,000 hospital bill that is leading me to want
insurance at all.

I should think so. I think going without insurance
is terribly risky, even if you're quite healthy. My SIL
went without insurance for a single month when switching
between her employer's insurance and insurance through her
husband. She figure no problem, she'd pay for the baby's
six month well baby visit out of pocket since it wasn't
that expensive. Wouldn't you know that was the visit her
baby was discovered to have cancer. The financial
implications for them were staggering.

I'll keep thinking in case I can come up with a vaginal
birth situation that might get out of hand financially. I assume
that something strange like serious complications from an epidural
would be covered. If there were complications from a vaginal
delivery that required you to stay in the hospital for quite
a few days, would that be covered?

Best wishes,
Ericka

Ericka Kammerer wrote:
I think going without insurance
is terribly risky, even if you're quite healthy.

I agree if you've got kids involved, but if you've got no one dependent on
you and no one responsible for you, there's always bankruptcy, or payment
plans. Since I've been uninsured most of my adult life (and I suspect for
most of my childhood), the vague possibility of catastrophic illness or
injury weighs less heavily on me than the tremendous cost of health
insurance.

Your SIL's situation is covered by HIPPA now; you can have a 63-day break in
group coverage without getting hit with a pre-existing condition period.
But childhood cancer is really the only reason I care about insurance for
Caterpillar. (For #2, I'd want insurance from birth, in case there were any
birth-related issues, but we're past that point with #1.)

If there were complications from a vaginal
delivery that required you to stay in the hospital for quite
a few days, would that be covered?

Heck if I know. Part of my problem is that even with the policy in front of
me, I don't know enough about how any pregnancy-related complications would
be coded to tell whether they'd count as a distinct diagnosis complicated by
pregnancy, or a subset of pregnancy.

Phoebe

--
yahoo address is unread; substitute mailbolt

Phoebe & Allyson wrote:

If there were complications from a vaginal
delivery that required you to stay in the hospital for quite
a few days, would that be covered?

Heck if I know. Part of my problem is that even with the policy in front of
me, I don't know enough about how any pregnancy-related complications would
be coded to tell whether they'd count as a distinct diagnosis complicated by
pregnancy, or a subset of pregnancy.

Yeah, that's the tough part :-( I wonder if you
could take the policy statement to a medical professional
in a childbirth-related field and ask them what they thought?
Do you have an OB that you have any sort of relationship
with that you could go to the office and talk to the person
there who handles their insurance issues? Most offices have
someone who specializes in insurance issues on staff these
days. I suspect that person might know better than anyone
else where the pitfalls might be.

Best wishes,
Ericka

Ericka Kammerer wrote:

Most offices have
someone who specializes in insurance issues on staff these
days. I suspect that person might know better than anyone
else where the pitfalls might be.

I think you're right. I suspect if something did come up, I'd have a
situation like Leslie's - whoever was doing the coding of the bill would
need to find a diagnostic code that made it covered, then advocate for
it to be covered. If we were planning a hospital birth (or risked out
of homebirth before I went into labor), then I'd just find a sympathetic
OB, and I think it would be fine. In a situation where we'd only need a
sympathetic person if we needed to transport (and take whoever was on
call), we're more likely to have problems.

You don't happen to have any stats on likelihood of intrapartum and
postpartum complications in subsequent pregnancies vs. initial
pregnancies, do you? I know first babies are much more likely to
transport, but I don't know what the odds are for complications that
would cause a hospital stay after a homebirth, for instance.

Phoebe

"Ericka Kammerer" wrote in message
...
Phoebe & Allyson wrote:

If there were complications from a vaginal
delivery that required you to stay in the hospital for quite
a few days, would that be covered?

Heck if I know. Part of my problem is that even with the policy in
front of
me, I don't know enough about how any pregnancy-related complications
would
be coded to tell whether they'd count as a distinct diagnosis
complicated by
pregnancy, or a subset of pregnancy.

Yeah, that's the tough part :-( I wonder if you
could take the policy statement to a medical professional
in a childbirth-related field and ask them what they thought?
Do you have an OB that you have any sort of relationship
with that you could go to the office and talk to the person
there who handles their insurance issues? Most offices have
someone who specializes in insurance issues on staff these
days. I suspect that person might know better than anyone
else where the pitfalls might be.

Best wishes,
Ericka


I had possibly one of the worst insurance situations known to man in my
first pregnancy-the company I was with changed on January 1st, having been
bought out by another company. All subscribers under company A were
immediately covered under company B, however, on January 1st, I ended up
having an emergency C-section. Of course, all offices were closed on January
1.

Officially, company B didn't even know I was pregnant. We ended up with all
sorts of mess because I had ended up having a C-section w/o pre-approval or
authorization.

Luckily, both the women's hospital and the perinatologist were more than
willing to argue with the company-and the medical records were clear that
all the steps had been followed, just under the old insurance company. But
you'd better believe I changed insurance ASAP after that!

When I had a chance to change insurance, I spent quite awhile talking to the
person who handles insurance for the perinatal practice, and went with the
one that, according to her, had the best record of ACTUALLY covering high
risk pregnancies and after care. We plan to keep my insurance on Cobra for
the last few months of this pregnancy (I'm covered until Aug 1 because of
the school district calendar, and will be covered at a reduced rate for the
first 3 months of next school year for my normal "maternity leave", but
after that I'm stuck for the full bill) just to avoid insurance hassles (my
husband's company tends to change its insurance each fiscal year, so if I
went with his, it would be switching mid-pregnancy again).

Anyway, I second talking to the OB's billing office-they know quite a bit
about which insurance companies are reasonable and which aren't, which are
willing to pay for stays longer than the minimum if needed, will pay for
extra pre-natal visits, etc. If you're considering a midwife instead of an
OB, it would be good to check with that practice about whether or not
they're covered, and for what.

Donna Metler wrote:

If you're considering a midwife instead of an
OB, it would be good to check with that practice about whether or not
they're covered, and for what.

Even if we had maternity coverage (which I currently do), they covered
*nothing* for Caterpillar's pregnancy and delivery. They would have
covered a birth center birth (I know because I read the policy and
argued until they gave in), and prenatal care by a CNM. Our midwife is
still finishing up her CNM work, so she won't have any real-world
experience on dealing with insurance. The birth center near us closed
down, so isn't an option.

Phoebe