NJ marketplace insurance, what did pregnancy cost

Amarante ↓

Tue, Aug 27 2024, 12:08 pm

You are leaving out some critical information

Are you currently insured?

Do you have the ability to get insurance through your employer?

What is your income? The income cap for Medicaid for pregnancy is higher than standard Medicaid so you might be able to get coverage through Medicaid. When you are pregnant, your fetus is counted so you have "two"

Assuming there is no Qualifying Event which triggers Open Enrollment for you - loss of coverage; marriage; move.

If none of this applies to you, you would not be able to get ACA compliant coverage until November when Open Enrollment starts for coverage beginning in January 2025.

If you know you are will be giving birth in 2025, it is pretty simple to figure out what is the best plan. You will almost certain reach your out of pocket maximum regardless of what plan you take as well as your deductible.

So you just add up premiums plus out of pocket cap on costs and this will provide you with a reasonable approximation of what it will cost you.

If you go to the official government marketplace for New Jersey, you can plug in your income which will provide you with the amount of the subsidy based on income. Then you can factor that in and explore all your options from Bronze Tier to Platinum Tier.

Make sure you visit the official site as there are a lot of scam sites out there with deceptive keywords.

amother

↑ OP ↓

Tue, Aug 27 2024, 12:24 pm

Amarante wrote:

As far as I understand, pregnancy is a qualifying event. We also are counting recent move. Currently I am insured but in a different state, as we are in the process of moving and thus getting insurance.

Now I'm not asking what premiuim rates are, those I can see on the marketplace website. I'm asking for people's personal experiences of what the oit of pocket costs were. Yes I understand that different tiers will result in different costs. I want to get an idea of the practical costs involved.

Was thinking if people can provide their practical experiences. Between the deductibles, copay ans coinsurance these things get confusing for someone who has had medicaid, for which I'm currently not eligible in nj, and cannot get insurance through the workplace.

Most plans have a out of pocket max of about 8-9k can I expect the co-pays plus coinsurance to reach that amount?

↑ Amarante ↓

Tue, Aug 27 2024, 12:36 pm

amother OP wrote:

Your move is a Qualifying Event.

Pregnancy is not a Qualifying Event except to the extent that higher income caps apply.

Giving birth is a Qualifying Event but delivery wouldn’t be covered since coverage would begin after birth.

All ACA plans have an out of pocket maximum which means once you have reached that amount, you don’t owe more if you have used in network providers.

Presumably your spouse will also be needing insurance so that would also be a factor. If you have children that will be a factor.

Keep in mind that even plans with the same company can be very different and have different networks and benefits. Many people get plans from their employers and so their Blue Cross or Aetna Plan will be very different than someone else’s plan.

I tried to simplify your decision by giving you the reality which is that pregnancy is expensive and so realistically you are going to meet and probably exceed your out of pocket caps with whatever plan you select.

If this is overwhelming, you can use an agent at no cost to you to help you decide which of the specific plans is best for your situation which would factor in all of your specific contingencies.

amother

↑ OP ↓

Tue, Aug 27 2024, 12:44 pm

Amarante wrote:

Thank you. This is actually very clear.

Are you an agent? You seem very knowledgeable.

Although there is a spouse involved, we may not include him, as he does currently have a healthshare, and the additional premiuim cost adds up. (When having a spouse on a plan, does that double the deductible? That is another factor) we have a kid but he's eligible for free insurance

Yes I understand that pregnancy is expensive, so we're trying to ger a feel of what the total will cost us. However, maybe I'm naive I'm not getting how a pregnancy and birth will equal to 9k out of pocket?
If I dont have a huge deductible, how would I hit the out of pocket max so easily? Just with co-pays and coinsurance on a hospital stay? If co-pays are 50-100 a visit. Add in 500 a day on the hospital stay coinsurance. I do know that there are numerous different visits and tests that will have separate co-pays, but even with that?

↑ Amarante ↓

Tue, Aug 27 2024, 1:44 pm

amother OP wrote:

I am not an agent but handled health insurance for the employees of my HOA. Also since I need health insurance and have to buy it, it was important for me to be a knowledgable consumer.

The out of pocket maximum will depend on the insurance plan you purchase. Generally a Bronze Tier plan HMO will have the lowest premium but will have highest out of pocket and deductible.

This is because there are a few factors. First it is intended to cover catastrophic medical costs that would lead to financial ruin and not cover the cost of day to day medical care. Also, it makes a person eligible for a health savings account which can be a significant tax benefit since you do not pay taxes on the amounts it appreciates and many people use this as an excellent form of tax sheltered savings. You should speak to your tax preparer or expert in terms of whether this is a benefit to you.

A Platinum which is the highest level of coverage will have high premiums but generally lower out deductible and lower maximum out of pocket costs.

For most people the cost of a pregnancy - including prenatal care, delivery and after care is going to exceed the out of pocket costs even for a Bronze Plan with a relatively high out of pocket cap.

The cost of insuring your husband wouldn't necessarily double the premium. Keep in mind that you will be eligible for a premium credit which brings down the cost of the premium. You haven't mentioned what your income is but I will make a "guess" that if you previously qualified for Medicaid where you lived, your income is low enough so that you would get a generous premium subsidy for both you and your husband. If your income is low enough there are Silver Plans which are even better deals because they offer subsides towards actual medical expenses.

I can't recommend any Health Share to a person because they aren't health insurance. They aren't subject to the same kind of protections that real health insurance offers. You say that you are satisfied but the true test of need is when you have catastrophic medical expenses and you are dealing with inadequate health share.

For starters, when you get a plan that is ACA compliant, it covers all pre-existing conditions. Also there are no networks with a health share. The benefit of using doctors who are in a health insurance network is that you can't be balanced billed. Doctors in a network have agreed by contract to accept the rate negotiated with insurance. You will pay according to your plan but the amount will be the amount negotiated with the insurance company.

For example - a doctor bills $10.000 for a procedure. But the doctor is in your network so the amount negotiated with insurance is $3000. Your co-payment or co=insurance is 20% and so you owe $600.

If the doctor is not in your network, they can balance bill. Insurance will bay them $3000 as a maximum but the doctor can bill you for the $7000 which is balance billing because they have no contract to accept the amount insurance will pay.

amother

↑ OP ↓

Tue, Aug 27 2024, 1:57 pm

Amarante wrote:

We actually previously qualified under essential plan, whcih is not an option in nj and has higher income limits compared to nj medicaid. We also recently had an increase in income
Our annual income is about 102,000, family of 3 plus a pregnancy.

When researching marketplace plans, plans start at approximately 250 for myself, and 500 for both me and my husband. Thay is exactly double. The deductible and maybe oop max gets doubled as well. Which means I'm much more likely to spend that much more on the pregnancy medical expenses.

I understand the downsides of a healthshare, but currently it may be what we are sticking with for him.

Do you know which plans offer medical subsidies?
Also what is the difference between hmo and epo?

I should really reach out to an agent to get clarity on all this

↑ Amarante ↓

Tue, Aug 27 2024, 2:02 pm

amother OP wrote:

Thank you. This is actually very clear.

Yes I understand that pregnancy is expensive, so we're trying to ger a feel of what the total will cost us. However, maybe I'm naive I'm not getting how a pregnancy and birth will equal to 9k out of pocket?
If I dont have a huge deductible, how would I hit the out of pocket max so easily? Just with co-pays and coinsurance on a hospital stay? If co-pays are 50-100 a visit. Add in 500 a day on the hospital stay coinsurance. I do know that there are numerous different visits and tests that will have separate co-pays, but even with that?

Benefit reimbursement is very complicated so this is not intended to be an exhaustive explanation.

Generally a co-payment only covers your actually going to the doctor. Every test or procedure that is performed is an additional fee which is billed and so that is generally billed as your coinsurance amount (after meeting deductible).

For example - visit to OB/GYN - your co-pay is $50 but tests are ordered. The tests are billed and the amounts you owe are in addition to this. All of these tests are generally expensive and are in addition to the co-payment for the visit which includes your talking and a minimal exam.

Some pregnancies are billed as what is called "global" so you pay a rate which includes prenatal and through delivery but then hospital charges are additional.

Keep in mind that the co-pay for the hospital doesn't include tests or other stuff that is done in the hospital

And be very aware that maximum coverage is going to depend on whether your doctor is in network for your particular plan. You can NOT rely on the office for this information since a doctor can be "in network" for some Blue Cross or Aetna Plans but not for others. Always verify with the insurance company and also verify with a CYA email that you were told the provider is in network.

amother

Seablue ↓

Tue, Aug 27 2024, 2:06 pm

Amarante wrote:

Pregnancy is actually a qualifying life event in NJ

↑ Amarante

Tue, Aug 27 2024, 2:08 pm

amother OP wrote:

Some plans differentiate between individual out of pocket and "family" out to pocket - you need to check the plan.

The difference is that the individual out of pocket or deductible can be $3000 and the family can be $5000. When an individual has hit their deductible, their individual medical costs will be covered. The rest of the family will be covered when they hit $5000 so they don't each have to hit $3000.

Again depends on the wording of the benefits.

Only the Silver Tier Plans offer subsides towards cost of medical care. You would have to check when you go on the New Jersey official site and see if your income qualifies you for that.

Here is a good explanation of difference between EPO, HMO and PPO

What’s the difference between an HMO, PPO and EPO?

Health plans sold through Covered California fall in these three categories. They differ when it comes to things like costs and provider networks (the doctors, hospitals, labs, and so on that your plan covers).

HMOs (health maintenance organizations) are typically cheaper than PPOs, but they tend to have smaller networks. You need to see your primary care physician before getting a referral to a specialist.

PPOs (preferred provider organizations) are usually more expensive. In exchange, you will likely get a larger network and the ability to see a provider outside that network. You can also see specialists without a referral.

EPOS (exclusive provider organizations) combine features of HMOs and PPOs. They have exclusive networks like HMOs do, which means they are usually less expensive than PPOs. But as with PPOs, you’ll be able to make your own appointments with specialists.

amother

↑ Seablue

Tue, Aug 27 2024, 2:15 pm

I just had my baby a few months ago and got insurance through the marketplace as my Medicaid wasn’t accepted by my OB

I got the BCBS Omnia Gold. It was the most expensive plan but after calculating the costs it came out the cheapest because of copays

On each plan you can click on the summary of coverage and it shows what it covers and costs, on the bottom of the packet should be a “Peggy has a baby” that gives a breakdown of the standard pregnancy costs

My costs were as follows:

Dr- $15 copay, first visit only (unless I go in for an issue that’s not a part of a regular checkup)
Ultrasounds- $20 copay
Bloodwork- $0
Hospital- $500 per day up to $2500

Total pregnancy cost (c-section) was around 1900- I needed a lot of ultrasounds because it was a high risk

The other plans had more expensive copays, like 30-50% copay on ultrasounds or hospital stay

amother

↑ OP

Tue, Aug 27 2024, 2:17 pm

amother Seablue wrote:

Thank you. This is very clearly broken down. Did ultrasounds cost you more? What about additional tests or procedures in the hospital?