Can someone help me understand how my coverage works for Employee + Child only, when it is just two of us on a plan? Pregnant and trying to navigate options before baby comes (FL)
Hi there! I thought I had a good understanding of health insurance but as it turns out, I am in the dark. I am getting conflicting information from my benefits rep at my office versus the BCBS rep I spoke to and am hoping someone can help me navigate this.
Currently I am 31 weeks pregnant, due on 01/05. Not ideal as I am unsure which calendar year I will be delivering in. If I was certain it was a 2024 baby, I would no question choose my HDHP plan. However, if I deliver in 2023 it is unlikely I will reach my OOP max (lower on the HDHP), and coverage is otherwise not great (my weekly therapy appointments would have to paid in full until deductible is hit and I am hoping to do things post-partum like pelvic floor therapy which would also not be covered).
I am currently on an individual PPO1000 plan, and intend to sign up for this again. Once baby arrives, I will add him to the plan. I do not believe I have the option of switching to the HDHP plan if I do in fact deliver in 2024, and even if I did, I am under the assumption my labor and delivery would still be billed on the existing PPO plan at that time/making it counter-productive to try to switch to the HDHP plan with a lower deductible. If I am misunderstanding, someone please let me know!
*** My larger question is how embedded deductibles and OOP max work on an Employee Only + Child plan, where there are only two people on the account (me and baby). The individual deductibles and OOP max do not total the family amounts when only taking two people into consideration.
My question is this: Under the BCBS PPO1000 Plan for Employee Only + Child, do we each have our own individual embedded deductibles of $1K to meet before co-insurance kicks in, as well as an embedded $4K OOP max for the 2024 calendar year? Or, as far as the max amount in out of pocket spending, will I still be responsible to meet the $12K OOP max for 2024 before in network care is covered at 100%? I have been told both things are true – which does not make sense. $4K + $4K means an $8K OOP spend, not $12K. How can it be both?
I know labor and delivery will put me at my OOP max if it happens in 2024, so I am really wanting to be sure I understand the information provided. I have broken down the plan info below.
I have included the HDHP details in case the hivemind thinks I am absolutely making the wrong decision regardless of calendar year for my delivery. Again, keep in mind that I do see a therapist weekly and intend on post-partum care. I’m not sure I would be hitting $3K+ in 2024 if I deliver in 2023, so it seems like it is not worth the risk to elect in an HDHP.
THANK YOU SO MUCH! My brain is smol.
Details for Employee Only + Child(ren) Coverage:
BCBS PPO1000
HDHP with HSA
Semi-Monthly Contributions
$279.58
$103.01
In-Network 2024 Deductible *EMBEDDED
Individual $1,000; Family $3,000
Individual $3,500; Family $7,000
OOP Max (includes deductible) *EMBEDDED
Individual $4,000; Family $12,000
Individual $3,500; Family $7,000
Coinsurance
You pay 20% after deductible
You pay 0% after deductible
** Embedded plans are important to consider if you are going to cover family members on your plan.
With family coverage in embedded plans, the individual deductible and out-of-pocket maximum still applies to each individual on the plan. You can satisfy the individual limit and the plan begins covering your eligible expenses. Additionally, once a combination of family members satisfies the full family deductible and out-of-pocket maximum, the plan begins covering all family members eligible expenses.
