[Epaphras]

So, we've been married 16 months next Monday. We knew before we got married that we wanted to have a baby by the three-year anniversary. That means we would have to get pregnant by next November (2010).

I am a graduate student and work part-time at the university, and I get a living stipend (modest, but we make it alright) and they pay for my tuition. It goes through April 2010, at which point I'll be one or two classes away from my Masters. We'll have to pay for those last six credits ourselves. She works half- to 3/4-time as a grocery store clerk and is growing a massage therapy practice, slow and steady. She could do both jobs well into the third trimester, and resume them both not long after the baby arrives. Ideally by then I would get a job with my degree and work experience that we would arrange to live on that income alone, so she could be a stay-at-home mom which is her desire. She would still see massage clients but we would not factor that income into our "to live" budget.

We've had private insurance since we got married. It's a high-deductible plan with a Health Savings Account (HSA), so the premiums are very low. There is a maternity rider on the plan that covers 100% after a $10,000 deductible.

If we got pregnant tomorrow, our household income is low enough that we qualify for several of the state-run Medicaid programs available for pregnant women. However, the "best" on that covers 100% of prenatal, delivery, and six months of postpartum care, we do not qualify for because we have private insurance.

We are in a pickle because while we can afford the premiums on private insurance, we would have to structure the payments in the event of a pregnancy under our current insurance, because we could not just write a check for $10,000 to cover the deductible. But, we can't access the Medicaid program because we have the insurance.

Another wrinkle is that, as I'm aware (could be wrong though), when you start a new job it takes 30-60 days to get on the employers' insurance. I can just seeing me getting a new job with my wife ready to burst, and she is due weeks before we'd be covered under the employers' insurance. Is that true, or do they make exceptions for things like that?

Anyway, I know Medicaid programs vary wildly from state-to-state...but has anyone here had any experience with programs for pregnant women in your state? Please share about the quality.

Right now, ideally we'd celebrate my first day at a new job by making a baby lol. But if we get pregnant before that happens (especially if it happens in the next few months), we'll either be on the hook for the deductible on our private insurance, or we'll have to explore the public Medicaid options.

Then again, if this health care reform thing goes through, all this could be irrelevant by the time we have a baby. Any thoughts?

[S.B.Nichols]

I'll jump in here since no one else is...

My wife and I decided to wait until we had adequate insurance before trying. A ten thousand dollar deductible seems ridiculously high, but if that's what you got, that's what you got. If it were me and I new there were a good chance I'd be getting a new job after I finished my degree, I'd wait...

BUT, all that said, people in your situation get pregnant all the time...babies are born and bills get paid. If you can't afford it, the state will pick up the tab, it just depends on what level of prenatal care you want. My pastor has had 4 kids in the last 5 years, with a deductible of 5000, and has been able to swing it. My wife and I's deductable is only $350 (blue cross plan for state workers).

Just a note...something we've learned in our struggles that I hope you won't need to consider...while insurance covers infertility testing, it doesn't cover infertility treatment at all. But, hopefully you won't have any troubles in that department.

[Rach]

When we got married, I always figured that we would be pregnant or new parents by year three as well, though, sadly, a miscarriage two months before our anniversary caused year three to come and go without a child. July 2nd was our 4th anniversary and July 23rd we had our first child (New mommy, whoo hoo!!). Sometimes, God's plans are different than our own, just keep that in mind.

That being said, from the sounds of your insurance, a $10,000 deductible is RIDICULOUSLY high. If your wife has no other health issues that would not be covered under prenatal care that would require her to remain on the private plan, I would suggest taking her off, and going with Medicaid. Unless, for some reason her current OBGYN/PCP does not accept Medicaid (which I am not sure if providers can deny service based on the patient's coverage) then state coverage would be a better option in my opinion. But, if you do stay with your private insurance coverage, and you do end up with the $10,000 deductible, in 99.9999% of cases, you can set up a payment plan with the hospital so that is not a one-time out of pocket expense.

Personally, I would wait until you have completed your schooling and have secured a job with insurance before even trying. If you get a new job and she is a couple months pregnant, you could run into the problem of your new insurance denying all pregnancy related claims because they would consider it a "pre-existing condition". Trust me, after working in the billing office of a hospital for 2 years and working with varying insurance companies, I have seen it.

[darfaz]

Originally Posted by Rach

Personally, I would wait until you have completed your schooling and have secured a job with insurance before even trying. If you get a new job and she is a couple months pregnant, you could run into the problem of your new insurance denying all pregnancy related claims because they would consider it a "pre-existing condition". Trust me, after working in the billing office of a hospital for 2 years and working with varying insurance companies, I have seen it.

Not to thread hijack or anything, but this is serious. I knew a couple who actually ended up having to hire expert witnesses( i.e. OB/GYNs) to testify in a case where they had gotten pregnant on their honeymoon and the insurance company was refusing to pay, declaring that the pregnancy was pre-existing to the marriage and to the point where she would be on his insurance plan.

Anyway, because of an insurance glich with my wife's company during our first pregnancy, we had to pay for most of it out of pocket, and we haven't paid nearly close to $10,000 (we didn't have any pregnancy complications or anything, praise God). Two years later, we are still paying a monthly bill for the amount. It's manageable and a lot of hospitals will even take off a huge chunk of what you owe. Also, they often allow you to say what you can pay back monthly. The hospitals around me will do anything to get paid, even a little.

[Epaphras]

Originally Posted by darfaz

Not to thread hijack or anything, but this is serious. I knew a couple who actually ended up having to hire expert witnesses( i.e. OB/GYNs) to testify in a case where they had gotten pregnant on their honeymoon and the insurance company was refusing to pay, declaring that the pregnancy was pre-existing to the marriage and to the point where she would be on his insurance plan.

Anyway, because of an insurance glich with my wife's company during our first pregnancy, we had to pay for most of it out of pocket, and we haven't paid nearly close to $10,000 (we didn't have any pregnancy complications or anything, praise God). Two years later, we are still paying a monthly bill for the amount. It's manageable and a lot of hospitals will even take off a huge chunk of what you owe. Also, they often allow you to say what you can pay back monthly. The hospitals around me will do anything to get paid, even a little.

So, by this you are saying it's important to wait until we are fully on an employers' insurance, so there are no complications?

[darfaz]

I would think it be important to wait until you know your wife is covered. Unless, of course, you don't mind being on state insurance or paying out of pocket for the pregnancy.

[Rach]

Insurance companies will try to find any way to not pay a claim. Any sort of loophole they can find, they will use against you. Sad to say, they are not looking out for your best interest, so it is ALWAYS better to play it safe when it comes to insurance coverage, and make sure your a star star is covered.

Also, with your private insurance plan, keep in mind that your wife will have upwards of 20 prenatal doctor appointments for standard prenatal care. Also, as was the case with my pregnancy, we had to not only have multiple tests and labwork at the hospital (glucose testing for gestational diabetes, preclampsia/toxemia protein tests, etc...) that came up, but our son was breech, so it meant a procedure at the hospital to try and turn him in-utero, and ultimately a scheduled c-section because he was too stubborn to turn. All that to say that there are ALOT of unexpected claims/costs that may come up in pregnancy, so it is so important to make sure you are good and covered.

darfaz brought up a good point as well (one that I meant to bring up), if you opt to stay on your private insurance and pay the deductible, since you may be considered "low-income" and could qualify for what we at the hospital I worked at in Washington called a "Charity Assistance Program". Basically you had prove to the hospital that you are on a very limited income, and based on the federal poverty guidelines, you could have some to all of the "patient responsibility" (i.e. your deductible) written off by the hospital so you wouldn't have to pay it. But that is not something that you should count on, or is guaranteed to be available.

My best advice is to call the nearby hospital where you would anticipate giving birth and ask them for an general estimate of cost for a hospital stay for both a natural and c-section delivery (hospital stay for c-section is typically longer than a natural birth meaning more cost) and ask about payment plans or if they have an assistance program like I mentioned.

[Leboman]

Our oldest son was both born while we qualified for Medicaid in North Carolina. We paid next to nothing and he was a C-Section with an extended hospital stay for my wife. We had insurance with our other two and are STILL paying for them.

Most company insurance plans have stipulations covering changes in family status. If you add (or subtract) family members you are given a window in which to make those changes. If you miss it, you usually have to wait until the next enrollment period. That has been my experience with every insurance coverage I've had.

[Epaphras]

Rach,

I did a Google search on pregnancy as a pre-existing conditions, and it looks like that under HIPAA or whatever, they are technically not supposed to deny coverage for pregnancy as a pre-ex. However, they said there are a lot of 'buts' with it. For example if you have no insurance, get pregnant, then get a job that offers coverage, the insurer does not have to cover it.

Does our high-deductible catastrophic insurance count as insurance in terms of it automatically having to be accepted by the employers' insurance under HIPAA? Or do only apples-to-apples insurance plans count? Is it something our current insurance agent would be able to answer if I gave him a call?

[Epaphras]

Called our insurance agent and he convinced us to lower our maternity rider from $10,000 to $5,000. I was wrong in that pregnancy expenses are not covered at all without the rider, except for ectopic pregnancy or emergency c-section, etc. I had originally scoffed at the rider as frivolous because those costs could just go toward the general deductible, but not so. I also misunderstood in that we have a $7,500 deductible, period. Not $,7000 each.

Anyway, lowering the deductible on the maternity rider will cost another $35 a month, but since we plan on starting for a baby within 9-12 months, that's only $315-$420 extra in premiums, which last time I checked is less than $5,000 (amount we'd pay out-of-pocket under current rider deductible). So overall a good deal especially if we get accidentally pregnant before we start actually trying under group coverage.

He also confirmed that a group plan can't deny coverage, but could make us wait 90 days.

So worst-case scenario, we pay the the first $5,000 in pregnancy costs out of pocket because we get pregnant before getting on a group plan and/or before the waiting period ends; best-case scenario we wait until I'm on a group plan through my employer and we're covered that way with only co-pays and a smaller deductible.

[OiBoyz]

You might also check with your local hospital. I work at a hospital and they offer a discount if the delivery is pre-paid. It's something like 10-15%. I don't think you have to do it in a lump sum, I think they allow for payments, but because you pre-pay, they cut you a deal. I don't know what happens if your wife were to go into labor and be out of town and deliver somewhere else.

Also something to consider: I live in a very rural area. Our hospital does not handle some high risk pregnancy stuff, if anyone goes into labor before 32 weeks for example. So, while it's rare, we fly those people out to a higher level of care. I don't know if something like this applies to you, but here it's really stupid not to have ambulance/air transfer membership. In fact, it's something my employer offers as a benefit. One airflight can cost upwards of $35,000. With membership (which here is about $90 a year for the whole family) they will take what your insurance pays and not bill you the rest. Or if you have no insurance, they will just eat it.

[Rach]

Originally Posted by Epaphras

Rach,

I did a Google search on pregnancy as a pre-existing conditions, and it looks like that under HIPAA or whatever, they are technically not supposed to deny coverage for pregnancy as a pre-ex. However, they said there are a lot of 'buts' with it. For example if you have no insurance, get pregnant, then get a job that offers coverage, the insurer does not have to cover it.

Does our high-deductible catastrophic insurance count as insurance in terms of it automatically having to be accepted by the employers' insurance under HIPAA? Or do only apples-to-apples insurance plans count? Is it something our current insurance agent would be able to answer if I gave him a call?

It's those "buts" that I was talking about in regards to ways the insurance companies find loopholes. But it looks like you were able to answer your own questions.