Phew… so the insurance conundrum is an ongoing issue here, and really, most of it won’t be resolved until AFTER little man comes, because so much of it is dependent upon when he comes and what my stupid insurance actually ends up covering (if anything). This will be super boring for y’all, but I need to write it all out in one place so I can wrap my mind around it, reference it over the next 6 weeks, and be a little more clear-headed about everything when it comes time to make a decision in the next month or two. I do not expect commenting on this post. 🙂

[Flashback to my pregnancy with Stella]

With Stella, I was due Dec. 22nd, and because of our insurance deductible & tax credit reasons, it literally would have cost us THOUSANDS and thousands of dollars more if she was born in 2012 instead of 2011. Because of this, I had talked to my midwives about a possible induction if she hadn’t arrived by Dec. 29th. I would have been 41w at that point, and since I was having a hospital birth anyway, I figured it was worth it to try induction in order to save us that kind of money. Thankfully it ended up not being an issue since she decided at 38w (Dec. 8th) that it was time to join us. Whohoo!

[Back to now]

This time it’s actually more confusing, not only because am I due on Jan. 8th (so really, I’d have to have him by 38w6d to be in 2013 – not incredibly likely), but also because we’re self insured, planning a home birth (which many plans specifically exclude coverage for, even though it’s SO MUCH CHEAPER than a hospital birth), and needing to switch to an Affordable Care Act compliant plan in 2014… HA, there are a ton of variables.

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Currently Charlie, Stella and I are on a high deductible HSA eligible family policy through Assurant Health ($5k individual deductible with 30% coinsurance up to $12,500 out of pocket max / $10k fam deductible with $25,000 out of pocket max). They contract with bigger companies, and I figured out a couple of weeks ago that they had switched from the Cigna PPO network to Aetna sometime during this pregnancy. Although they claimed “nothing has changed with your policy coverage” – in reality, Aetna specifically excludes home birth, so ya, that’s a big change for me! The billing company my midwife uses did a VOB (Verification of Benefits) for me for $20 and confirmed that Aetna covers nothing related to home birth. However, they did offer this possible loophole:

If you do end up birthing in 2013 we can bill Assurant for the global fee (the large fee that covers both the birth and the routine prenatal and postpartum care).  Since this procedure code covers both the home birth and some office visits, we can legally bill it with either place of service.  This kind of our loop hole for billing insurance companies that will not cover homebirth, with using place of service office instead on the code that technically covers both.  However, this does mean that we cannot bill any other codes that are strictly home codes (labor management, supplies, aquatherapy, etc).  Or the other option would be to itemize bill all of the prenatal care, and just bill everything but the birth.

…

If you do deliver in 2014, it will simply be broken up between insurance companies by the date of service and the plan effective dates (so any care in 2013 will go to Assurant and any care in 2014 will be billed to the new plan). Without billing the global fee to Assurant, we should still be able to bill all of the prenatal visits and labs and have them process, regardless of whether homebirth is covered or not.  Then we would bill just the delivery fee (not the large global fee) to the new insurance company and any further visits would be itemized separately.  The only bad thing about this is paying for 2 separate deductibles.

When I complained to my insurance agent about the Cigna to Aetna network change, he wrote back that we DID have the option of switching back to the Cigna coverage network for the month of December for an additional $30 or so of premium. SOLD! It’s not a guarantee of midwife coverage (and I’ll have to pay another $20 for a 2nd VOB now), but worth the $50 to have a chance of better coverage if this kid comes in 2013. My midwife has been paid by Cigna before, but the billing company told me with a PPO he would be considered an out-of-network provider (which will be paid at lower rates than an in-network provider).  However, just because he accepts the Cigna PPO network does not mean that all plans will cover a midwife or homebirth.

Another note – my global midwife fee is only $4,000. I’ve spent about $1,000 towards my deductible this year, and I have a $5k deductible, so it’s entirely possible that not a penny of this will be covered, even if the kid is born in December. This is something we were aware of going into it – it was just nice to think that if we did decide to transfer to a hospital for any reason that my $4k midwife fee would have already satisfied my deductible and we’d “only” be responsible for our 30% ($2,250) up to my $12,500 max, at which point I’m covered 100%. In reality, the ideal would be that everything goes smoothly, we birth at home, and the $4k is just the $4k that we have already paid up front to my midwife.

FWIW, my non-medicated (so no epidural/drug charges), one night stay, uncomplicated hospital birth with Stella cost roughly $8,000 – so with our current plan, we’d owe roughly $6,000 out of pocket if we had chosen a hospital birth, even though they’re in-network and maternity is “covered 100% — once you hit your deductible and out of pocket maximum.” Gotta love insurance. That’s a huge part of why it didn’t seem like that big of a deal to go with home birth, even though it’s $4,000 out of pocket for us!

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So then there’s the timing issues…

Dec 15th: The deadline to sign up for an ACA plan through Colorado’s health exchange for a January 1st effective start date. Based on rough numbers, we qualify for about $240/mo in APTC (advance premium tax credits), though I’m guessing this number will increase when we’re a family of 4. I just don’t know by how much. The APTC is a credit the feds will apply towards your monthly insurance premium IF you buy through the exchange based on what you estimate your 2014 tax return income levels to be. Because of our family # changing and Charlie being self employed, I really have NO idea what exactly our income will be for 2014 and what the appropriate APTC is. If we guess too high of an income, we’ll simply pay a higher up front premium now and get more money back when we file 2014 taxes. If we guess too low, we’ll owe that difference in premium aid back to the government. Right now, with our estimated APTC of $240/mo, it looks like our insurance premium for a similar health exchange plan for a family of 3 would be about 50% higher than what we’re currently paying (UGH). Again, no clue how that APTC amount would change things once we add an additional person to the family (as well as an additional person to the insurance contract!).

• Benefit of doing this by Dec 15:
  • If the kid isn’t born until 2014, then hopefully a portion of the midwifery cost will be eligible to go towards the deductible of whatever plan I’m on for 2014.
• Con of doing this by Dec 15:
  • If the kid is born in 2013, I’d prefer to sign up for a much higher deductible plan with a lower premium. All of our acute care is done for free by my boss (I work at a family practice medical center) so I’m not worried about incidental acute visit costs, and preventive care visits are covered 100% no matter what plan you’re on. However, I obviously won’t know by Dec 15th if this kid will come in 2013 or 2014.
  • If the kid is born in 2013, I wouldn’t have to worry about choosing a plan that possibly covers home birth. RMHP is cheapest around here through the exchange – and they specifically exclude home birth. Again, I won’t know by Dec. 15th which year little man will make his arrival in, so I won’t know yet if I can choose the cheaper RMHP option or if I need/should go with a more expensive plan through Anthem BC/BS that potentially offers home birth coverage.

*Note: We can also sign the entire family up for an ACA plan through the exchange to start effective February 1 or March 1 if we want because our current plan doesn’t kick us off until March 15. Downside to this is losing out on whatever we pay in January that could potentially go towards our annual deductible.

Dec 27th: The last day my insurance agent can sign us up for an ACA compliant plan through his company, Assurant Health (which is outside of the exchange).

• Pros:
  • Much cheaper plan (premiums comparable to current rates instead of 50% higher – roughly a $2,500 annual savings).
• Cons:
  • Not ACA compliant (though really, I’m not sure how much of a difference this is for really since it’s basically a major medical plan anyway).
  • Not APTC eligible – which might be a big thing if our income is lower than expected in 2014.
  • Baby would have to be born by December 27th for us to all get a family plan together because the insurance agent can’t write Charlie & Stella on a new plan while I’m pregnant. If he has to write me on a separate solo plan and Charlie & Stella on their own plan, the premium would be up in the range of what the exchange plans were above, and then I’d really rather just go through the exchange I think.

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So there ya go… basically, it’s going to be a shot in the dark with deciding which plan to choose and when to switch to it. There’s no guarantee ANY of the plans would cover midwifery care (though there is that possibility for some of them)… so I need to decide if it’s worth choosing a plan based on the CHANCE of coverage on the CHANCE the the kid is born in 2014 instead of 2013. I know that #1 being born 2 weeks early doesn’t mean squat for when #2 will be born though. The research I found showed that second time moms have a 23% chance of the baby being born by 38w6d… so I’m not exactly banking on a 2013 baby. I’m just not sure what to do in the meantime.

After reading all of this back over, I think I’m going to plan to stay on my current plan with my husband and daughter through February 1st and then choose to start an exchange plan for all four of us that is ACA compliant on February 1st and call any January payments towards deductible a lost cause. I just don’t think it makes sense to pay a higher annual premium for a plan that might not cover home birth anyway. Once December 1st hits, I’m going to do a new VOB for $20 on my current plan to see what my chances of coverage are through the Assurant/Cigna network, but really, we’ve already paid my midwifery fees, and I think I need to just pray that all goes smoothly, the deductible won’t matter because we don’t transfer to a hospital, and try to find the best plan that makes sense for us moving forward as a family of 4 post-delivery, probably with a Feb or Mar 1 effective date. This will probably be the cheapest plan available ($6,300 individual / $12,600 family deductible with 100% coverage after that). Also, I probably need to stick with a plan that is HSA compatible, because my work lets me contribute up to the max ($6550 in 2014) with pre-tax income to pay medical bills with, which definitely helps.

The other choice of staying with Assurant if this baby is born before the 27th of December… well, I’ll just have to decide that if that actually happens.

Yikes, insurance in America. What a mess.