Sorry, but can someone translate this insurance stuff for me?

[stelly]

I really don't get it. Being from a country where everything is just paid for, and having a family who had the bonus of extra, private, health care, I have never really managed to get my head around the insurance system over here.

I am insistent on having a homebirth.

We currently have Aetna HMO. There is no out-of-network coverage.

My H's boss is open to us changing policies (to BCBS) or upgrading (to an Aetna PPO or something). H is going to check out tomorrow if we would be covered for anything if we changed companies since I am now already pregnant and it is "pre-exsisting".

Am I right in thinking that:
1. You are never going to get HB coverage under a HMO plan?
2. Aetna are notoriously difficult on HB?
3. BCBS can also be difficult?
4. If H's company "self-fund" we may not get anything from anyone?

What does self-fund mean? How can I tell if H's company self-fund? How can I find out if NJ has that law which requires insurance companies to pay for homebirth (I've googled and got nothing, which is quite normal for me - I never seem to know how to phrase things for the result I want ).

I hope these questions aren't daft, I've read through the archives and things on this site, but am still not understanding completely. I already have my midwife picked out and will call her tomorrow and see if she has any tips regarding coverage, but I thought MDCers seem so knowledgeable I'd ask here also.

Thank you in advance!

[jengacnm]

[QUOTE=stelly;8553282]I really don't get it. Being from a country where everything is just paid for, and having a family who had the bonus of extra, private, health care, I have never really managed to get my head around the insurance system over here.

Most of us here don't get it either...



My H's boss is open to us changing policies (to BCBS) or upgrading (to an Aetna PPO or something). H is going to check out tomorrow if we would be covered for anything if we changed companies since I am now already pregnant and it is "pre-exsisting".

It's my understanding that "preexisting condition" problems arise only when you have a lapse in coverage.

Am I right in thinking that:
1. You are never going to get HB coverage under a HMO plan?

Not without a long, hard, painful struggle.

2. Aetna are notoriously difficult on HB?

Yep. They will pay for a home birth only if required by state law.

3. BCBS can also be difficult?

Can be, but I haven't had a problem in Illinois. At least, my problems have not been because they don't pay for home birth, because they do. Some individual policies don't cover home birth, however. That's not blue cross, it's the company contracting with them.

4. If H's company "self-fund" we may not get anything from anyone?

That's another problem of your H's company, not the insurance company. What they choose to include in their policy is up to them, and self funded companies are not bound by state laws.

What does self-fund mean? How can I tell if H's company self-fund? How can I find out if NJ has that law which requires insurance companies to pay for homebirth (I've googled and got nothing, which is quite normal for me - I never seem to know how to phrase things for the result I want ).

I can't speak to these with any clue at all-hopefully another MDC mama knows more about this than me...

The biggest thing to understand is this: insurance companies are for profit. They don't care about anything as trivial as people getting health care; their objective is to collect as much in premiums as possible and to pay out as little as possible in claims. Once you understand this, all of their behaviors, antics, and policies will make sense. This understanding will not lead to joy and good cheer, just understanding.

Regarding businesses and self funding, companies are just trying the best they can to contain costs, and do so by limiting choices. Never mind, of course, that home birth is a fraction of the cost of hospital birth.

I don't like how cynical I sound, but I am a HCP that deals with insurance companies regularly. I am also uninsured. After accepting my above premise (ins cos. being for profit, etc), I still get angry, but I'm not surprised anymore.

HTH!

Jennifer

[dinah]

.

Originally Posted by stelly

Am I right in thinking that:
1. You are never going to get HB coverage under a HMO plan?

I think you're correct in thinking this. I recently switched from an HMO to Aetna PPO because of this. I was already pregnant and it was not a problem because it was a group plan through my work. It would have been a problem if it was an individual plan.

2. Aetna are notoriously difficult on HB?

I called both Aetna and BCBS before switching - my company offered both. I chose Aetna because I think I'll get more money from them. My midwife provided a form of what questions to ask and to document their response. It was INVALUABLE. There's no way I could have figured it all out without her help - so definitely call your midwife.

3. BCBS can also be difficult?

See above

4. If H's company "self-fund" we may not get anything from anyone?

I have no knowledge about companies who self-fund.

[stelly]

Thanks for the replies. Does anyone know anything about this "self funding" stuff?? Any anyone got a link to show which states have laws requiring Ins.Cos to pay for homebirth?

Thanks!

[Jessmomto2]

Originally Posted by stelly

I really don't get it. Being from a country where everything is just paid for, and having a family who had the bonus of extra, private, health care, I have never really managed to get my head around the insurance system over here.

I am insistent on having a homebirth.

We currently have Aetna HMO. There is no out-of-network coverage.

My H's boss is open to us changing policies (to BCBS) or upgrading (to an Aetna PPO or something). H is going to check out tomorrow if we would be covered for anything if we changed companies since I am now already pregnant and it is "pre-exsisting".

Am I right in thinking that:
1. You are never going to get HB coverage under a HMO plan?
2. Aetna are notoriously difficult on HB?
3. BCBS can also be difficult?
4. If H's company "self-fund" we may not get anything from anyone?

What does self-fund mean? How can I tell if H's company self-fund? How can I find out if NJ has that law which requires insurance companies to pay for homebirth (I've googled and got nothing, which is quite normal for me - I never seem to know how to phrase things for the result I want ).

I hope these questions aren't daft, I've read through the archives and things on this site, but am still not understanding completely. I already have my midwife picked out and will call her tomorrow and see if she has any tips regarding coverage, but I thought MDCers seem so knowledgeable I'd ask here also.

Thank you in advance!

subbing to this thread since we are in almost the exact situation with Aetna HMO and I am about 4 weeks pregnant. We also have the option to switch to BCBS or Aetna PPO but not until Jan 1 and by then, would it be too late? Only difference is we are in Texas.

[bobandjess99]

Well, I'm not an expert, but in a PPO, there is "out of metwork" coverage. That is the whole point of a ppo. You can go to a Preferred PRovider, and get in-network coverage, or choose whoever you want, and get out of network coverage at a reduced rate.
So, I would think that "upgrading" to a PPO would be your best bet, as long as the midwife you are using takes that PPO's out of network coverage. However, in that instance, you are going to be hit with your deductible, and then oon coverage is usually onlt about 50%, so you will be paying your entire deductible, and then 50% after that, which, frankly locally, would be more than just paying the midwife out of pocket, because my deductible is $2000, and the midwife's total fee is $2000.

[CEG]

Originally Posted by stelly

Am I right in thinking that:
1. You are never going to get HB coverage under a HMO plan?
2. Aetna are notoriously difficult on HB?
3. BCBS can also be difficult?
4. If H's company "self-fund" we may not get anything from anyone?

1. It is possible. Our HMO option just happens to include a doctor who does homebirths. It just depends on who your primary care provider options are under the HMO.

2. I have heard this but not sure.

3. Actually, we have BCBS and their customer service has been wonderful. I am not sure about getting a homebirth paid for as I haven't tried, but in other issues I have had they have been helpful and knowledgable. For instance our plan does not cover lactation consultants, breast pumps, or donor milk, but the rep on the phone had never even heard of an LC, didn't know what it was, and took the time to research and call me back.

4. Self-fund kind of sucks. It basically means that your husband's company has hired the insurance company to administer their health plan while in fact the company is paying all of the expenses. The result of that is that your husband's company will have it's own individual rules for what is covered. this can be good because you can actually contact his company directly to ask for changes (I think it's usually the HR department). I could see them being interested in homebirth as a cost-saving measure. It also means that they follow the state rules for where their company is headquarted, not where they are located. For instance we live in Illinois but my husband's company is HQ in Delaware so they follow Delaware's laws regarding coverage even though 90% of their employees are in Illinois.

But anyway, being self-funded shouldn't result in not being paid, it just means that you have to make sure you follow your individual company's rules.

As for preexisting conditions, as long as there is continuous coverage there are no preexisting conditions. If you have a lapse in coverage they can refuse to cover you for two times the length of your lapse for certain preexisting conditions (like if you have asthma and you lapse on insurance for one month then get insurance they can refuse to pay for your treatment for two months).

I think though that there are laws saying that pregnancy is never considered a preexisting condition and is always covered.

This is all stuff that I have uncovered during my own insurance struggles so don't bet the farm on it but good luck with your birth. I hope you can work it out.

[stelly]

Thanks for the info. From what you've said I doubt H's company are self-insured. There are only 3 employees so I don't think his boss can afford or would need to self-insure.

H spoke to his boss and we'll either upgrade to Aetna PPO, or we'll pay for the midwife out of pocket and his boss will pay either all or some of the cost (if it works out less than upgrading our coverage). I feel very happy about it now.

Although H's boss is not really understanding our need to use a midwife and have a HB, he at least is respectful of our choice.

Thanks again.

[Momma2DoubleCuties]

We have BCBS but its in Oregon and we are having a homebirth. They will cover the same as they cover an OB as long as the midwives are CNM and licensed as Nurse Practioners. We lucked out and found some great Naturopaths who are also CNM and licensed as NP. So its really worked out wonderfully!! Maybe look into something similiar. Good luck!