possibly dumb question

lifeonthehill · June 2014

Reading a previous post got me thinking. Do the max OOP costs and your annual deductible combine? I am not sure if that questions make sense so here is the example from our ins.

Deductible $1,500 and Max OOP $5,500

We want to save up all the ins. costs before/during TTC does that mean we should be saving $5,500 or $7,000

hoffse · June 2014

alyssa32713 said:

Reading a previous post got me thinking. Do the max OOP costs and your annual deductible combine? I am not sure if that questions make sense so here is the example from our ins.

Deductible $1,500 and Max OOP $5,500

We want to save up all the ins. costs before/during TTC does that mean we should be saving $5,500 or $7,000

Pretty sure it's $5,500. I just overlooked that when writing that post - that's why it's bad to do math in public after a long day at work!

EDIT: And yes, I just put myself out there again. So if I'm wrong, forgive me. Health insurance is NOT my area of expertise.

jjbmstinco · June 2014

I think its $5,500 but clearly from my question, IDK what I am talking about.

Xstatic3333 · June 2014

I vote $5,500 as well-but I'd save a little more in case you're pregnant during 2 calendar years.

brij2006 · June 2014

I believe now with ACA your deductible and co-pays apply toward your max OOP expense. So max per year you would be paying $5,500.

However, make sure your plan is not grandfathered in. Before we changed insurance companies our deductible was $1,000, max OOP $3,000, and we had to pay a $20 co-pay for each maternity Dr visit. So we saved $5k to pay for the birth of a child. The deductible also reset on March 1st, so we could have potentially paid even more than $5k.

So I would call the 800 number to make sure.

jjbmstinco · June 2014

For our plan B (we get a choice of A or

-plan B does not have co pays go to the deductible. Plan A does.

formerlyGDaisy09 · June 2014

Definitely $5,500. $1,500 is the most you will pay for an episode of care (ER visit, hospitalization, etc.)

formerlyGDaisy09 · June 2014

This also goes back to that whole bundled payment "issue", I *believe* that prenatal care (standard of care prenatal care) and delivery are bundled together.

that would mean OB/CNM appointments every 6 weeks through the 2nd trimester and then every 4 weeks until 36 weeks, then 38w, 39w, 40w...and a 6w post partum visit. That timeline is considered standard...that does not mean that is what the practice you see follows. for a long time motivation by DRGs and Fee-for-service payment models motivated providers to see more patients more often, which in turn leads patients to believe that they need to be seen more often. Hopefully with capitated payments there should be a shift in practice back to the Goldielocks "right treatment at the right time" opposed to just more treatment.

I also learned recently that ACOG considers one ultrasound per-pregnancy "best practice" for normal pregnancies....insurance companies LOVE that, it doesn't surprise me that the cost of more ultrasounds gets passed on to the patient.

KatieCutie05 · June 2014

If your Deductible is 1,500... that means ALL of your medical care that is "covered" by insurance will be 100% handled by you. (except what they consider "preventative care" which insurance pays 100% of no matter what) insurance pays nothing but it does count toward your deductible. Then once you've spent 1,500 in medical care covered by insurance the discount kicks in. For examle my plan pays 80% so my cost is 20%. Then after that you will have to spend 4k out of pocket to reach your 5,500 out of pocket maximum. Note tho that most people will not hit that out of pocket maximum. You'd have to have over 20k in medical care to hit that. Which you won't in a "normal" pre/post natal and delivery hospital visit. However if something were to go wrong where you had to stay in the hospital for a long amount of time, needed surgery etc, then you might and then after that OOP max, your insurance will pay 100% of everything. But remember that this starts over in January, so even if you deliver on January 10th, it will all come out of next years insurance where you'll then have to hit that 1,500 deductible all over again.

lifeonthehill · June 2014

Seeing as it its very likely to be pregnant and give birth in two separate calender years would it be smarter for us to save up $11,000 to cover pregnancy, labor and delivery rather than just $5,500?

vlagrl29 · June 2014

definitely $5,500 is the most you would pay. Don't forget though that once that baby is out of you, he/she will have to fulfill his own deductible and co pays as well. No one told us that and we learned the hard way because we didn't have money saved for that.

I was pregnant in June and Delivered in March of the next year. The OB office didn't bill the insurance until after the baby was due which meant we didn't have to start over in deductibles thank god. Ask you OB if they do the same thing.

brij2006 · June 2014

alyssa32713 said:

Seeing as it its very likely to be pregnant and give birth in two separate calender years would it be smarter for us to save up $11,000 to cover pregnancy, labor and delivery rather than just $5,500?

I would also check with this too. According to ACA, maternity is supposed to be covered under 1 deductible and OOP expense even if it falls under 2 policy periods.

One other thing to look at.... If this deductible and max OOP is for an individual, then the regular care is usually covered under mom for baby. However, any extra time in the hospital for mom or baby, or time in the NICU can bump it to the family deductible and OOP expense.

vlagrl29 · June 2014

brij2006 said:

I believe now with ACA your deductible and co-pays apply toward your max OOP expense. So max per year you would be paying $5,500.

However, make sure your plan is not grandfathered in. Before we changed insurance companies our deductible was $1,000, max OOP $3,000, and we had to pay a $20 co-pay for each maternity Dr visit. So we saved $5k to pay for the birth of a child. The deductible also reset on March 1st, so we could have potentially paid even more than $5k.
So I would call the 800 number to make sure.

This has me curious now. I'm going to call my provider today and ask about that. If true, that would be amazing!

vlagrl29 · June 2014

Also, is your plan 80/20 or 70/30. Once you hit the $1500, you will pay 20% of all other medical costs until you hit $5500. Assuming its a 80/20 plan. I consider myself very educated at insurance because I had to deal with a lot of crap regarding it over the last few years.

brij2006 · June 2014

vlagrl29 said:

brij2006 said:

I believe now with ACA your deductible and co-pays apply toward your max OOP expense. So max per year you would be paying $5,500.

However, make sure your plan is not grandfathered in. Before we changed insurance companies our deductible was $1,000, max OOP $3,000, and we had to pay a $20 co-pay for each maternity Dr visit. So we saved $5k to pay for the birth of a child. The deductible also reset on March 1st, so we could have potentially paid even more than $5k.
So I would call the 800 number to make sure.

This has me curious now. I'm going to call my provider today and ask about that. If true, that would be amazing!

It is most definitely worth looking into. We had no clue until we switched insurance providers in March. Then they said that the Max OOP is officially now the maximum you would have to pay. Except for prescriptions. Um yeah, that saves us almost $2k when having a baby and makes it much more feasible.

vlagrl29 · June 2014

brij2006 said:

vlagrl29 said:

brij2006 said:

I believe now with ACA your deductible and co-pays apply toward your max OOP expense. So max per year you would be paying $5,500.

However, make sure your plan is not grandfathered in. Before we changed insurance companies our deductible was $1,000, max OOP $3,000, and we had to pay a $20 co-pay for each maternity Dr visit. So we saved $5k to pay for the birth of a child. The deductible also reset on March 1st, so we could have potentially paid even more than $5k.
So I would call the 800 number to make sure.

This has me curious now. I'm going to call my provider today and ask about that. If true, that would be amazing!

It is most definitely worth looking into. We had no clue until we switched insurance providers in March. Then they said that the Max OOP is officially now the maximum you would have to pay. Except for prescriptions. Um yeah, that saves us almost $2k when having a baby and makes it much more feasible.

The fact that maternity is no longer a pre existing condition is just amazing to me. We have to buy our own insurance and it was never covered before

So it will save us thousands next time

formerlyGDaisy09 · June 2014

You're right on how the deductible works, my bad.

the calendar year thing is partially why maternity care is now "bundled" so your prenatal care and delivery care count as one medical episode, and now a lot of the care is considered preventative. (this is why OB/GYN departments are "loss leaders" in most hospitals....they make-up for it with refferals to radiology and pediatrics)

lifeonthehill · June 2014

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

hoffse · June 2014

alyssa32713 said:

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

That's our tentative timeline too - but I don't think it's too early to figure this stuff out. I have an HSA, and I've been just budgeting to pay for health expenses (basically just an annual exam and BC) OOP up until we start TTC. The HSA is funded about 80% by my employer, and I'd like to get it built up so that we can use it for the expenses of having a baby. As far as I'm concerned, that's basically free money.

But it does take some planning to figure out how much we will need and how long it will take until my HSA has grown to that level. Starting to think about it a couple years out is not too early. Then when the time comes you will be more than prepared.

lifeonthehill · June 2014

hoffse said:

alyssa32713 said:

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

That's our tentative timeline too - but I don't think it's too early to figure this stuff out. I have an HSA, and I've been just budgeting to pay for health expenses (basically just an annual exam and BC) OOP up until we start TTC. The HSA is funded about 80% by my employer, and I'd like to get it built up so that we can use it for the expenses of having a baby. As far as I'm concerned, that's basically free money.

But it does take some planning to figure out how much we will need and how long it will take until my HSA has grown to that level. Starting to think about it a couple years out is not too early. Then when the time comes you will be more than prepared.

That is my logical end of things. His problem is that we work for a small boarding school. We live, eat and work with the same 75ish people every day and everybody knows everything. They all comment on how we need to have kids and he is worried if it gets out that we had a meeting based around this with HR people will jump to conclusions.

Mom987 · June 2014

Every plan is different, but if it is a new ACA plan in 2014, the ded. should count towards the OOP max. Some small companies have the option to continue with their current plan, though, so it may not change for everyone.

hoffse · June 2014

alyssa32713 said:

hoffse said:

alyssa32713 said:

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

That's our tentative timeline too - but I don't think it's too early to figure this stuff out. I have an HSA, and I've been just budgeting to pay for health expenses (basically just an annual exam and BC) OOP up until we start TTC. The HSA is funded about 80% by my employer, and I'd like to get it built up so that we can use it for the expenses of having a baby. As far as I'm concerned, that's basically free money.

But it does take some planning to figure out how much we will need and how long it will take until my HSA has grown to that level. Starting to think about it a couple years out is not too early. Then when the time comes you will be more than prepared.

That is my logical end of things. His problem is that we work for a small boarding school. We live, eat and work with the same 75ish people every day and everybody knows everything. They all comment on how we need to have kids and he is worried if it gets out that we had a meeting based around this with HR people will jump to conclusions.

Ah that makes sense. Any chance you can call the 800 number on your card to start? I've done that before, and the people on the other end of the line were able to look up the plan and give me info on costs. I wanted to avoid HR for a similar reason.

Xstatic3333 · June 2014

Just wanted to say that I learn so much from threads like this! Thank you all

lifeonthehill · June 2014

hoffse said:

alyssa32713 said:

hoffse said:

alyssa32713 said:

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

That's our tentative timeline too - but I don't think it's too early to figure this stuff out. I have an HSA, and I've been just budgeting to pay for health expenses (basically just an annual exam and BC) OOP up until we start TTC. The HSA is funded about 80% by my employer, and I'd like to get it built up so that we can use it for the expenses of having a baby. As far as I'm concerned, that's basically free money.

But it does take some planning to figure out how much we will need and how long it will take until my HSA has grown to that level. Starting to think about it a couple years out is not too early. Then when the time comes you will be more than prepared.

That is my logical end of things. His problem is that we work for a small boarding school. We live, eat and work with the same 75ish people every day and everybody knows everything. They all comment on how we need to have kids and he is worried if it gets out that we had a meeting based around this with HR people will jump to conclusions.

Ah that makes sense. Any chance you can call the 800 number on your card to start? I've done that before, and the people on the other end of the line were able to look up the plan and give me info on costs. I wanted to avoid HR for a similar reason.

We aren't on the Ins! We are both on our parents still. H will turn 26 next year and he will be getting on it then I will the next year for when we start TTC. We are incredibly lucky to have parents who are allowing us to stay on until we are 26. I just don't want to have a kid on my parents insurance.

brij2006 · June 2014

alyssa32713 said:

hoffse said:

alyssa32713 said:

Thank you all!

Pretty sure the ins. is 80/20. I will make an appointment with HR soon to learn some more. H is nervous about doing all of this so early because we are not planning to be TTC until Spring 2016 but I really want to have all of our ducks in a row so when we start saving for these specifics we know 100% what we are being faced with.

That's our tentative timeline too - but I don't think it's too early to figure this stuff out. I have an HSA, and I've been just budgeting to pay for health expenses (basically just an annual exam and BC) OOP up until we start TTC. The HSA is funded about 80% by my employer, and I'd like to get it built up so that we can use it for the expenses of having a baby. As far as I'm concerned, that's basically free money.

But it does take some planning to figure out how much we will need and how long it will take until my HSA has grown to that level. Starting to think about it a couple years out is not too early. Then when the time comes you will be more than prepared.

That is my logical end of things. His problem is that we work for a small boarding school. We live, eat and work with the same 75ish people every day and everybody knows everything. They all comment on how we need to have kids and he is worried if it gets out that we had a meeting based around this with HR people will jump to conclusions.

Don't feel like you can't have this conversation with HR because of people's assumptions. I work in an office of 11 people and our "HR department" are my 2 main bosses and 1 partner (same age as me). Back in October they sent out a questionnaire on our health insurance coverage and what we would like to see covered that currently is not. I'm the only one of child bearing age without children, and we did not have fertility coverage on the plan. The questionnaire was unanimous, but they would know it was me who answered to have fertility coverage. There is likely talk about how H and I are having trouble to have children, but in the end we now have a policy that gives us fertility coverage and makes having children with assistance a possibility.

Yes, they may start rumors or talk about it, but when you aren't having a baby over the course of the next 2 years, then they will be proven differently. It's definitely worth a visit with HR to know exactly what you will be expected to pay, and at that time you could ask if there is any maternity/paternity leave too.

vlagrl29 · June 2014

It's good to be prepared. 2 years give you enough time to plan for the $$ aspect. Things can change but you are planning on the current coverage you do have. We didn't expect to TTC as soon as we did, but loosing my corporate job back in 2009 and only being able to be on Cobra for 16 months pretty much determined for us to TTC right away because DH's insurance at that time didn't cover maternity.

vlagrl29 · June 2014

brij2006 said:

vlagrl29 said:

brij2006 said:

I believe now with ACA your deductible and co-pays apply toward your max OOP expense. So max per year you would be paying $5,500.

However, make sure your plan is not grandfathered in. Before we changed insurance companies our deductible was $1,000, max OOP $3,000, and we had to pay a $20 co-pay for each maternity Dr visit. So we saved $5k to pay for the birth of a child. The deductible also reset on March 1st, so we could have potentially paid even more than $5k.
So I would call the 800 number to make sure.

This has me curious now. I'm going to call my provider today and ask about that. If true, that would be amazing!

It is most definitely worth looking into. We had no clue until we switched insurance providers in March. Then they said that the Max OOP is officially now the maximum you would have to pay. Except for prescriptions. Um yeah, that saves us almost $2k when having a baby and makes it much more feasible.

Just called our provider and it's true in our case that co pays go towards ded.

Although our family doc co pays are only $5, but specialist is $40 if we ever go to one. I'm only $100-ish away from meeting my individual ded. of $2250, after that everything is covered 100%. Sweet! Thanks for mentioning this.

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