Ugh...picking insurance and not sure what to do

[ktgrok]

So, we have several options. For the most part the plans are identical, other than premiums. All my doctors are covered by all the plans. The difference is out of network benefits. One plan has a 5K out of network deductible, and then covers 70%. The other has a $500 deductible, then covers 70%. The one with the lower deductible for out of network costs $1,643 more in premiums for the year. 

 

The reason I'm looking at this is that we are hoping to get pregnant, and have a home birth. No home birth midwives are in network with any of the plans. Actually....one is, but they don't do VBAC's. (I've already had 2 VBACs at home already....don't want to debate that choice...trust me that the only way I'm giving birth in a hospital is if I risk out of home birth). The midwife I want to use charges about $5K I believe. Close enough, anyway. Any lab work, ultrasounds, etc would be covered as long as I went to an in network provider for those. 

 

Another factor is that Florida law specifies that any insurance company that offers maternity care must cover CPMs (licensed and regulated in my state). They also must cover homebirth. And theoretically must offer a network gap exception if there is no in network provider for a service. So theoretically, I SHOULD be able to get a home birth covered at in network rates, or no more than 10% below what they pay for in network. Both plans cover in network births at 100%. But, I know in actuality it can be hard to get all this to work. My last two births we had self funded insurance so they were not legally required to follow state law. One did pay (Aetna) but they now have a home birth exclusion so when I was pregnant again they refused. We switched to another plan, I think BCBS who had my midwife at that time as in network, but she is no longer practicing. (she went off the deep end and I ended up filing complaints against her, as did many others...it is VERY good she no longer has a license). 

 

So, from what I can tell, if I don't manage to get a Gap exception, after deductible, coinsurance, and premium costs the more expensive plan with the lower out of network deductible would save me $1,500. But if I can get a gap exception I would save $1,643 by going with the less expensive plan. 

 

And I can't figure out how to make that call. It's a gamble. Oh, and I need to decide by Monday at the latest, as we have medical apps next week!!!! 

[BlsdMama]

We have essentially the same decision every year - one policy with a high family deductible (almost $7k) and then the other option, high deductible, low premiums.  Do you know what your costs will be if everything goes according to plan?  Prenatal and delivery and baby care?  Is the $5k a family deductible or individual?  I ask because each you and the baby will have different care costs via insurance.

 

At the end of the day I'd say a lot depends on how much you have set aside for healthcare costs.  If you are great at socking away a medical health nestegg sufficient to cover surprises, a.k.a, your full deductible, go with the cheap plan - then you only pay for what you actually use.

 

However, for us, after two years of "surprises" this year I *really* wanted the more expensive plan with low deductibles. I figure, really, in a family of 13, when do we NOT have some kind of medical mishap?  So we pay the higher premium for the peace of mind.  I get anxious over medical bills - they really stress me out and it just makes me happy when bills come in and only 20% is my responsibility.

[ktgrok]

The in network deductible is ZERO, for both plans. The only difference is the out of network deductible. And yes, the out of network deductible is per person. 

 

Honestly, I just turned 40. There is a decent chance I won't even be able to get pregnant. Paying more all year to maybe save on a birth that might not happen seems kind of crazy, now that I think about it. 

 

And yes, we COULD swing the 5K birth costs if we need to, between bonuses and my advances from writing. We also have investments we could pull from if need be (not 401k, but other investments). 

[kewb]

Ny experience with out of network deductibles is that they nickel and dime you with "customary and reasonable" costs. For example - your doc charges $500 for office visit. Insurance says it is customary and reasonable to charge $150. So they apply $150 to your deductible. I now use a less expensive health insurance plan and pay out of pocket for specialists.

[ktgrok]

Ny experience with out of network deductibles is that they nickel and dime you with "customary and reasonable" costs. For example - your doc charges $500 for office visit. Insurance says it is customary and reasonable to charge $150. So they apply $150 to your deductible. I now use a less expensive health insurance plan and pay out of pocket for specialists.

 

Another good point. Honestly, I think we will do the better plan for us overall, and anticipate paying out of pocket for a birth. I did just see that the $5k she charges includes labs, so I can probably do those in network and save some there. 

[ktgrok]

Ugh, and now to pick vision insurance. NONE Of the plans cover the place we've been going to. NONE. One covers a place that is kind of okay, and nearby. It at least has a lot of selections for glasses and my daughter is picky. The other covers the husband of my friend, who I trust and is good, but is nearly an hour away. Other than that they cover costco, sears, target, etc. Not sure how good the glasses selection is at those places, and I know the glasses selection at the husband of my friend is NOT good. 

[BlsdMama]

Ugh, and now to pick vision insurance. NONE Of the plans cover the place we've been going to. NONE. One covers a place that is kind of okay, and nearby. It at least has a lot of selections for glasses and my daughter is picky. The other covers the husband of my friend, who I trust and is good, but is nearly an hour away. Other than that they cover costco, sears, target, etc. Not sure how good the glasses selection is at those places, and I know the glasses selection at the husband of my friend is NOT good. 

 

We like Costco.  Not a huge selection but generally something there we love.  Less selection for kids but frankly it's for the kids to see so they just need to pick something.  Between insurance + Costco, glasses become downright affordable and we have seven kids (so far) that require glasses, plus me and DH, and  two of us also use contacts.  But, keep in mind, you could always have them do your exams and glasses at Costco and if you want variety then pick up a couple Zenni glasses for fun.

[ktgrok]

We like Costco.  Not a huge selection but generally something there we love.  Less selection for kids but frankly it's for the kids to see so they just need to pick something.  Between insurance + Costco, glasses become downright affordable and we have seven kids (so far) that require glasses, plus me and DH, and  two of us also use contacts.  But, keep in mind, you could always have them do your exams and glasses at Costco and if you want variety then pick up a couple Zenni glasses for fun.

 

Yeah, my 6 yr old is the one that is so picky. And she's SO good about everything else I have a hard time not letting her have glasses she loves. She gives me no trouble for most things, so when she was crying that she couldn't find glasses she liked it broke my heart. She ended up keeping the pair she has and just getting new lenses, but that was because we could go to the one hour place near us and get it done quickly. I don't know that Costco can do the one hour thing, and she can't go a week without her glasses if they have to send them off like one other place did. 

 

I think I'll go with the one that covers Eyeglass World, the place I've been to, even if it isn't my favorite for exams. They have the biggest selection of kid frames, and that insurance also covers Sam's Club and Walmart, both of which are cheap and  around the corner. I think that makes the most sense, rather than driving 2 hours round trip for an exam, friend or not. 

Edited April 30, 2016 by ktgrok

[Rachel]

As far as vision, you don't have buy glasses from the same place you get your exam.

 

When is open enrollment for your husband's company? Maybe you can make selections now and change in 6 months (or whenever open enrollment occurs) if you picked a plan you aren't happy about.

[plansrme]

Keep in mind that the extra premium is pre-tax, while the extra OOP is after-tax unless you have an HSA or FSA. That is probably a 30% difference, minimum.

[ktgrok]

I realized, I can choose the one with the lower premiums, and if I get pregnant apply for the gap exception. If I don't get it, I can switch to the plan with the lower out of network deductible at open enrollment which I THINK is in December, so would be before I'd have the baby,and the midwife could bill it as a global fee then (which is exactly what we did with kid number 3, now that I think about it..or maybe number 2..I forget). 

[cjzimmer1]

One other thought, when does his heathcare year run for.  If they run on a January - December year, you could pick the cheaper plan now and then when open enrollment comes around, switch to the more expensive plan for next year for the delivery if it still make sense to do so.  Even if you got pregnant immediately baby wouldn't be due until next year.  If their plan year runs on a different schedule than that option may not work for you.

 

Edit: if I read through the whole thread before posting I see you basically said the same thing.  My bad.  But going that option would give you some time to find out details before spending the extra money.

Edited May 1, 2016 by cjzimmer1