HDHP during pregnancy?

[endo4jc]

Hello. My wife is expecting our second child with a due date in June 2021. We are currently on a HDHP. I am an independent contractor and fortunately the organization that I'm contracted with pays my monthly health insurance premiums. I'd like input on staying on the HDHP for the pregnancy or switching to the PPO Premium plan for the first half of 2021 and then switching back to the HDHP after the birth (in order to contribute the $7,200 to the HSA), since it is a qualifying event. We are currently very light users of medical services as my wife, myself and 15 month old are healthy.

PPO Premium Plan (In-Network) PPO HDHP (In-Network)

Coinsurance (Member pays) 20% Coinsurance (Member pays) 0%

Calendar Year Deductible Calendar Year Deductible
- Individual (In-network): $750 - Individual (In-network): $3,000
- Family (In-network): $1,500 - Family (In-network): $6,000

Out-of-Pocket Maximum Out-of-Pocket Maximum
(Deductible included) (Deductible included)
- Individual: $4,000 - Individual: $4,000
- Family: $8,000 - Family: $8,000

Office Visit Office Visit
- Primary: $25 Copay - Primary: Deductible
- Specialist: $50 Copay - Specialist: Deductible
- Preventive: 100% Covered - Preventive: 100% Covered

Inpatient Services:20% after Deductible Inpatient Services:Deductible

Outpatient Services:20% after Deductible Outpatient Services:Deductible

Emergency Room Services: $150 Copay Emergency Room Services: Deductible
(Waived if admitted) (Waived if admitted)

Urgent Care: $60 Copay Urgent Care: Deductible

From my interpretation, I don't think it would be difficult to get to $8,000 OOP maximum on the PPO Premium plan with a two day inpatient stay. Opinions welcome.

[ENT Doc]

Keep in mind the new child will become a new individual on your plan subject to a new deductible under the HDHP. Regarding the $7200 contribution, you would technically be eligible to contribute only for months in which you held the HDHP. So $7200/12 per eligible month. Or, you could contribute $7200 if you held the HDHP in the last month of next year, but this would require you to have the HDHP through the end of 2022.

[endo4jc]

Keep in mind the new child will become a new individual on your plan subject to a new deductible under the HDHP. Regarding the $7200 contribution, you would technically be eligible to contribute only for months in which you held the HDHP. So $7200/12 per eligible month. Or, you could contribute $7200 if you held the HDHP in the last month of next year, but this would require you to have the HDHP through the end of 2022.

Good point above the new child being a new individual. Even though they have their own individual deductible, the amount paid for each individual deductible counts toward the family deductible. So for a family of four, each could have $1,500 paid towards their respective individual deductibles (and thus not having maxed the individual deductible), but the sum total is $6,000 which maxes the family deductible. Is that correct?


Forget everything I just wrote about the HSA. I didn't understand you were referencing the "last month rule", which I just read about here. https://healthsavings.com/contribute...erage-changes/

So the reason I was able to contribute the full $7,000 in 2019 is because I stayed on the HDHP all of 2021. Got it.

[ENT Doc]

Good point above the new child being a new individual. Even though they have their own individual deductible, the amount paid for each individual deductible counts toward the family deductible. So for a family of four, each could have $1,500 paid towards their respective individual deductibles (and thus not having maxed the individual deductible), but the sum total is $6,000 which maxes the family deductible. Is that correct?


Forget everything I just wrote about the HSA. I didn't understand you were referencing the "last month rule", which I just read about here. https://healthsavings.com/contribute...erage-changes/

So the reason I was able to contribute the full $7,000 in 2019 is because I stayed on the HDHP all of 2021. Got it.

So it's a close call on which one you should do. Keep in mind that if you start with a PPO and switch to a HDHP mid-way through the year (assuming you're able to) I believe you'd hit the reset button on all the deductibles.

I think what I would do is create an Excel model of what your OOP would look like given different cost scenarios of your wife's birth, newborn charges, follow up visits, etc. There will be meds. There will be random trips to the OB or Pediatrician. Don't forget to include the HSA benefit in your calculations. Play around with the numbers and see where your cutoffs are where it starts looking bad for the PPO vs HDHP. If based on reasonable research and assumptions one looks clearly better then obviously choose that one.

We stuck with a HDHP for several reasons. It limited our OOP max to less than the PPO plan, the premiums were lower (which I pay fully), and the HSA benefit was there. You *might* hit that individual OOP max for the PPO plan with your wife, but you'd be capped at $3k. You'll pay more for your newborn under the HDHP plan, but you'll have the benefits of the HSA. Run some numbers. Curious what you find.

Also - and this is perhaps the most important thing - is make sure you check with the hospital whether or not ALL providers who would ever potentially interact with your wife and newborn are in-network with your plan. Last thing you want to deal with is thousands of dollars of balanced billing nonsense.

[tylerjw12]

Your OB office should be able to give you estimated cost for the delivery. Family deductible applies collectively to all of you. The expenses for the FAMILY add up to 1500 (individual protection of 750). The OOPM for the family are no more than $8000 (individual protection of $4000). I would expect mom to get close to or probably hit 4k OOPM.
Keep in mind: if your employer allows you to switch plans after delivery (def check this) you will be accruing towards higher QHDHP deductibles and OOPM.

[billy]

If you switch mid year, the deductibles reset. Find out how much the delivery is an how much the childs likely health care cost will be, then it turns into a math problem. Even if you keep on the PPO in 2020, you can go back to an HSA in 2021, and you can still keep the HSA you have invested in 2020, you just dont contribute any more to it. Follow the math and you'll get your answer