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The Pregnant Community
insurance questions 
2nd-Jul-2007 12:26 pm [insurance, ttc]
pic: glasses
I'm not pregnant yet, but my FH and I are planning to start TTC this winter. In preparation for that, I need to make some decisions regarding insurance and midwives vs. OBGYNS.

I am currently signed up for the PPO offered by my job. I work at a psychiatric hospital which is affiliated with one of the major hospitals in town. With the PPO, I pay for 20% of office visit costs to doctors who are in the network (St. Francis) and 50% if I go to someone out of the network. For all practicality, I prefer the PPO to the HMO - even if it does cost a little more in the long run.

The HMO's network, on the other hand, includes 3 major hospitals in this city. St. Francis, St. Johns, and Hillcrest. Normally, I'm fine with St. Francis. But they offer the fewest options when it comes to childbirth. They list on their website that you can hire your own doula (gee, thanks for allowing it) and you can have a 'pavillion room' for an additional $135/night. A friend of mine just had a baby there in May, and when I went o visit her I felt like we were all in a closet.

Hillcrest has BirthCare suites so you feel more at home than in a cramped up little hospital room. They also provide a volunteer doula.

I also found this practice (http://www.awstulsa.com) which offers both midwives and obgyns. They are associated with St. Johns.

I have a couple of opprotunities to change my insurance plan. One is when I get married in October ("change of status") and add my FH to my plan. That is effective the day I hand in the paper work. Then, open enrollment is in November and becomes effective in January.

I have some things I want my FH tested for as soon as he's on my insurance. Like I want him to go to the sleep clinic because he has sleep apnea and isn't being treated for it. If I switch to HMO right away, he'll have to FIND a PCP, go to him, get his referal, THEN make an appointment.. HMOs can just be a huge fricken mess. Especially when you're looking at something that isn't a quick fix and may require multiple visits.

ACK. I'm just really unsure of what I want to do. Or when. Or the benefits of each option.

I think right now, my plan is to add my FH when we get married in October, change to HMO during open enrollment, then change back to PPO after having the baby ("change of status" so it'd be effective immediately without waiting for open enrollment)

I'm new to this whole 'choosing my plan' thing. And definitely new to the idea of pregnancy. Any advice is very welcome.
2nd-Jul-2007 06:31 pm (UTC)
Insurance plans always leave my head spinning. But at 39 weeks of pregnancy I can offer this advice: get whatever plan gives you the most freedom. As wonderful and beautiful an experience pregnancy is, it is also a time of great stress and worries. The more flexibility you have and the more options for your care, the better for you and your baby mentally and physically. If you are already thinking you might like to have a doula and a birthing suite, then you definitely should not go with a plan that will not provide for that. Because the farther alone in pregnancy you get, the more support and comfort you will likely want.
2nd-Jul-2007 06:33 pm (UTC)
alone = along, sorry
2nd-Jul-2007 06:45 pm (UTC)
Why don't you just keep your work's insurance and just pay for a midwife out of pocket? Homebirth midwives aren't very expensive in terms of a hospital birth. Most offer some type of payment plan.
2nd-Jul-2007 07:05 pm (UTC)
It sounds like she might even get reimbursed for 50% of the midwife's cost if she goes out of network.
2nd-Jul-2007 07:34 pm (UTC)
That's true I didn't think about that. My insurance won't cover the midwife or birth unforunately so I didn't really think about it.
2nd-Jul-2007 07:27 pm (UTC)
How much do they usually charge? I know you probably can't tell me exactly - but a ballpark estimate would be helpful
2nd-Jul-2007 07:29 pm (UTC)
Anywhere from 3k-5k depending on where you are at. I live near Seattle so it's on the higher end, but with monthly payments it isn't so bad. That's what I plan to do for my next kid.
2nd-Jul-2007 07:36 pm (UTC)
Regarding the size of the rooms-- although some hospitals have really nice birthing suites, you don't usually get to stay in them after the baby is born. With my hospital, you get to give birth in the nice birthing suite, but 1-2 hours after delivery you are moved to the 2-bed recovery room. 2 beds, so potentially 2 people, in the space of the size of one of the birthing suites. So you may want to double-check both the facilities for giving birth and for the recovery, so you have a complete picture.

Basically, do your homework and see if you can get a quickie tour of the rooms in all three of the hospitals. Keep in mind that it can change, though. My hospital used to have private recovery rooms, but during the full moon they found that they were super-busy with births, and so had to switch to the two-per-room layout about 6 months to a year ago. It's still 75% likely that one won't end up with a roommate, but... They're also building more birthing suites. So things may change between now and when you get pregnant and when you actually deliver.

I'm pretty happy with my HMO. It's good to keep things in mind for the pregnancy, but it's also good to keep things in mind for your entire lifestyle. I had several surgeries and procedures and treatments and tests a few years ago, and pretty much all $20,000 of those (within one year!!!) were covered by my HMO. If I'd been on my PPO, I would have been completely financially drained.

Not saying that you have to let the money rule... but it may be something for you to keep in mind, depending on what your overall financial picture is.

You may also find that you start work with your husband's sleep apnea while on the PPO, but the doctors may not take the HMO insurance, or may not be accepting new HMO patients within a particular plan. You should call around and see who in your area will take *either* plan.

2nd-Jul-2007 07:42 pm (UTC)
Yeah, things like the surgeries scared me for awhile too. That was *the* fear that kept me leaning toward HMO for awhile. I actually took my options to my dad (he's a lawyer) and he called some of his friends who specialize in insurance.

My PPO has a maximum out-of-pocket per calendar year limit. For an individual, its $2,500 in network. So even if I had $20,000 in surgeries, I would never pay more than $2,500 in one year. For a family (whether its a family of 2 or 10) its a $5,000 limit.
2nd-Jul-2007 09:31 pm (UTC)
I work in Benefits and HR, and I'd have to say, go in and talk to your Benefits and plan administrator. Call or e-mail if you don't like to just drop by, but they should be able to answer some questions, or at least give you the number to the plans so you can call them and find out more details about coverages and plans.

Your plan administrator may even have some first hand experience with pregnancy and the issues you are thinking about with your added FH. Ask how much an average birth costs out of pocket on both plans. Find out what kind of coverage the baby will have, too.

Most plans will automatically cover your baby for the first month of birth, then require you to enroll/add them in your plan after that.

Check and make sure you CAN change your status, from one kind of plan to the other, as even with enrolling a new baby, (which is considered a status change) it all depends on the rules if you can make any plan changes.

Good luck!
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