How having a C-section affected my health insurance

[cabinqueen]

When I had DS (via CS), I was covered by my group health insurance at work. Since then I have switched to individual family coverage with another company (because I'm a SAHM now-no group insurance). I just learned that if I ever have another CS, insurance will not cover it. That's just lovely. Unless I try VBAC, I'm up against an $18,000 hospital bill. Just great. I'm considering dropping coverage altogether.

Are there any others out there up against a similar situation? The premium on this family policy is just freakin ridiculous! We're all pretty healthy people; I just want to make sure that if some freak accident happens, we won't land in the poor house. It's either drop health insurance altogether or get into one of the HSA plans with a high deductible.

Sometimes I feel damned if I do and damned if I don't. DH and I are small business owners so we fall above the income cap for our state health care program for children (Georgia Peachcare-really a pretty good program if you're below the cap). But we are still not in a position to fork out ridiculous amounts of money for insurance we don't fully utilize. DH hasn't been to the doctor in years; the only health concern I have is what if I get pregnant. Add to that if I do and have another CS, it's all out of pocket anyway. I'm further wondering if we should just pay ALL health expenses out of pocket and if a freak accident does happen, we can always pay the hospital $50 a month til we die, right?

I don't wish this situation on anyone, but I can't help but wonder if anyone else is in this boat and what are you doing about it?

[Momof3Labs]

Huh??? How do they justify not covering a second c-section? What if it is medically indicated? Try contacting your state insurance department - I just don't understand the grounds for this. Particularly if you go back and read the thread about VBACs from a week or less ago (where doctors are refusing to do VBACs unless you sign a waiver)!!

[egoldber]

See its the competing insurance companies here. Private health insurance companies do not typically like to pay for elective repeat C-sections since they are far more expensive than vaginal births. But doctors malpractice insurance companies WANT repeat C's, since their liability exposure is less. But I would certainly think that in the case of an emergency C, the private health insurer would pay.

Gotta love our health care delivery system in this country.

[stella]

We have shopped and shopped for insurance in Texas and I understand that no individual plans (not group) will cover MATERNITY/DELIVERY at all. You can't even buy a policy that does.

My friends who have had babies in these circumstances say that they negotiate with the doctor and hospital and get a better rate - especially if they pay up front. No vaginal birth is covered. C-sections only in an emergency. Those who had vaginal births the first time paid for that and the second baby out of pocket. For the second baby, my c-section friends had to try a vbac. Only for the fact that it is thousands of dollars less expensive. But after the labor had begun, when the doctor could say that the labor wasn't progressing or the mother's health was in danger, the insurance (that does not cover maternity) would pay for the c-section.

It makes NO sense at all. Whether or not you are a proponent of vbac vs. repeat c-section. Because there is no incentive to try a vbac. The incentive is to have a 2nd c-section and have it declared an "emergency." If you are successful with the vbac, your insurance won't pay.

I believe that the doctors know that if they do a voluntary c-section or a vbac, they won't be paid by insurance, but in an emergency, sugical delivery is covered. But not vaginal delivery. It's a stupid system and costs the insurance company much more than just covering vaginal births in the first place.

I hate insurance and have gone back to work for the district attorney SOLELY to get health insurance for my family as my husband is self-employed and has a pre-existing condition. We could not get coverage for him on our own.

I sympathize with you!!

[pritchettzoo]

We just went through the same thing with DH's last job switch--going from a firm to taking over a private practice. Individual health care plans, unlike group health plans, are not subject to HIPAA so they can exclude whatever and whomever they wish. DH has a medical condition that would have been excluded for 12 months, and they would have excluded prenatal and maternity care for me for 12 months--meaning we would have to wait at least 12 months to even try again. And then the maternity deductibles were insane!

Based on our insurance agent and CPA's suggestions, we incorporated. DH & I are both attorneys and we formed an S-corp as partners. As a professional corporation, we qualify for group health coverage. If your small business incorporates, DH would have to pay you as an employee (unless you incorporate as a partnership as we did but there are limitations on the types of professions who can use S-corps as I understand it) at least minimum wage for at least 35 hrs/week in order for you to qualify. You might want to call your CPA and check out whether the end result would be beneficial to you or not.

HTH!

Anna

[jubilee]

Maybe my understanding of HIPPA is limited (and I certainly don't want to defend the rotten policy) but HIPPA stands for Health Insurance Privacy and Portability Act, and involves legislation protecting patient privacy and records security. I don't believe it covers who can be covered by insurance or what insurance will cover. I work in medical billing and insurance for a surgeon, not in a healthcare insurance company anymore, so I could be wrong.

As for the original poster's insurance- do you have a catastrophic plan, which doesn't cover regular doctor's visits, well-child checks, etc? Those plans only pay for injury claims. As for you comment about going without insurance- I certainly don't encourage that. In the office I work for, we won't even see cash patients. And that is standard for docs here, or the patient has to pay upfront. Cash patients tend to not pay their bills, and since I work for a surgeon the bills are $3000+ just for the surgeon portion. So, the office will only take insured patients. Now, I'm sure you would pay your bills, but my point is that your choice of doctors might be limited by not having insurance. Maybe you could call your state insurance commission and find out what alternatives there are for you. The cheapest comprehensive coverage will be with an HMO... in my area that is Kaiser. Depends on your area. Hopefully you find a good plan at a good rate.

[heidi_timms]

I don't have any answers for you regarding the C-section thing. Maybe you should try and incorporate like Anna suggested?

I feel for you though on the huge premiums! I am a realtor and get to sign up for group coverage through my Realtor's association, BUT we have to pay for the entire premium monthly! It's outrageous how much we pay (more than our 2004 truck payment!)

I would continue to keep coverage though. If you are in a serious accident you will pay through the nose if you aren't covered. I did hear a commercial about some sort of small business association here in CA. They might have something similar in other states. You might have to pay dues yearly, but you might be able to qualify to sign up for group coverage, which might have better plans available.

~Heidi
Mom to Kailey
4/03

[chlobo]

I totally feel for you.

Our healthcare industry is a shameful disgrace as we allow more and more Americans to live dangerously without insurance despite having there being plenty of resources to go around.

Policy makers in this country aught to be ashamed of themselves.

[pritchettzoo]

Actually, it's the Health Insurance Portability and Accountability Act. It applies differently to group and individual insurance plans. HIPAA guarantees that if you have at least 12 months of continuous creditable coverage, or 18 months if you are a late enrollee, then your group health plan cannot apply a preexisting condition exclusion to your coverage, regardless of your health condition. Some provisions in it are supposed to cover privacy, but they're pretty much a joke--like the doctor's office isn't supposed to call out your name when they call you to the back.

If you're covered by an individual health plan, there are 7 eligibility requirements that must be met in order to avoid the pre-existing condition/exclusion under HIPAA. We didn't meet one of them and thus HIPAA didn't protect us.

Check out this website to see if your insurance company is not complying with HIPAA: http://cms.hhs.gov/hipaa/online/Individual/HIPAARights/HIPAARights_default.asp

As far as Kaiser goes, they are very particular about whom they cover. We were advised not to even try because of my DH's minor health condition--once you've been turned down for coverage, you have to mark that on every insurance (health, life, everything) that you apply for in the future and it raises a huge red flag. We were about to apply for Kaiser, and I'm so glad we consulted our old insurance agent before going forward. In GA, there's a commission built in to every insurance premium, so going through an agent doesn't cost you any more. If there's no agent, the insurance company just keeps the money.

Anna

[DebbieJ]

If you live in CA, please write the Governator and urge him to sign SB 1555.

Here's an email I got about it:
August 31, 2004

Dear Friend:

It's happening once again. Women are being discriminated against in reproductive health. Please help women and their families by urging Governor Arnold Schwarzenegger to sign one of the most important women's health bills of the 2004 legislative session - a measure to halt a dangerous insurance practice which could have a devastating impact on the future of affordable maternity coverage for women and their families.

Last week, the Legislature approved Senate Bill 1555; a measure to prohibit insurance companies from offering individual health insurance policies without maternity benefits. The legislation is sponsored by the American College of Obstetricians and Gynecologists, District IX, March of Dimes, Planned Parenthood Affiliates and Kaiser Permanente and is supported by a wide variety of women's, healthcare and consumer groups.

SB 1555 responds to one of the latest cost-cutting practices in the individual insurance market - a disturbing trend in which private insurers are dropping maternity coverage from basic health plan benefits, in order to sell lucrative low-cost products to target populations. It smacks of gender discrimination of the worst kind.

The exclusion of maternity care has been considered discriminatory in all other insurance regulatory schemes for the past 30 years. In 1975, the California Legislature determined that maternity care was part of basic health care and required all HMOs to include maternity coverage. Since 1978, the Federal Pregnancy Discrimination Act has dictated that if an employer offers health insurance that excludes maternity, it's considered gender discrimination.

Unfortunately, in the individual insurance market, basic plan benefits have never been defined, and private insurers have now discovered they can exclude women in their childbearing years and offer bare bone policies to their economic advantage. The result: pregnant women, their families and taxpayers are paying.

This health care restructuring has a devastating impact on women working in small businesses or who otherwise must pay for their own health insurance. By isolating maternity coverage, women and their families are forced to pay disproportionate health care costs because they now must bear these costs alone.

Opponents of this bill argue that people who do not need maternity should not have to pay for it. But health insurance is about sharing the financial risk of needed medical care. We all pay for care we don't need. Women will never need treatment for prostate cancer, men will never need treatment for cervical cancer and adults without children will never need pediatric care. Yet, all of these services are covered by health insurance.

We all care about controlling health care costs, but the solution is not to cherrypick patient populations at the expense of women in their childbearing years. Paying for all of men's basic health care needs or providing only low-cost coverage to more desirable populations, but making women pay extra for their health care, is purely discriminatory.

Help send a clear message to the Governor.

Reproductive health care is not a luxury and women should not be priced out of the insurance market. This unacceptable practice runs counter to the decades of research and public policy reform that has increasingly supported programs to help women get proper medical care throughout their pregnancy.

Lack of insurance translates into inadequate prenatal care. Consider the following:

* A woman with late or no prenatal care is three times more likely to have a premature baby.

* Estimates for the cost of each premature birth are $75,000 to $130,000 more per baby. Ultimately, these children will need additional state resources.

* An average baby born with Cerebral Palsy requires an additional $500,000 of lifetime services.

* A March of Dimes study concluded that having a premature baby could cost up to 60 times more for an uncomplicated birth.

The health and cost implications of not providing for this population are serious. We need state policies that encourage, not discourage women from getting insurance.

When Governor Schwarzenegger ran for office, he pledged that he would be a "champion for women". The Governor's signature on SB 1555 would offer an excellent opportunity to showcase his support for the women's community.

Please take the time today to call the Governor's office at (916) 445-2841 or write to

Governor Schwarzenegger,
State Capitol, Sacramento, CA., 95814

or send an email at www.govmail.ca.gov

And urge him to sign SB 1555 to ensure access to affordable maternity coverage for women and their families in California.

Let the Governor know that California has a compelling public policy interest to ensure that every pregnant woman has a safe labor and delivery and positive birth outcome. Urge him to close this loophole that results in a cost-shift to women in their childbearing years.

Please take action ASAP. The Governor has until September 30 to sign or veto measures, but will likely make decisions earlier. A clip-off message to the Governor is attached for those who do not wish to send a specialized
communication.

Thank you for your support of this important effort.

~ deb
Mommy to my sweet boy
B born 12/03
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