Insurance advice: Put Baby Boy 2.0 on hubby's PPO, or my HMO?

Chatting with one of hubby’s friend’s last night got me thinking about this, so here I am asking for input.

Baby Boy 2.0 isn’t due until January 2, and because I cook 'em big and fast, the C-section is scheduled for December 21. Baby Boy is not patient, though, and I have twice been to the hospital in the last week to stop (or at least, turn down the volume on) contractions. He could quite easily show up this week at 36 weeks…darn close to full term, so not too scary.

I assumed we’d be adding Boy to hubby’s PPO insurance as we did with our first. We opted for that as it gave us the freedom to go wherever we want without worrying about referrals. It is more expensive, though, in that we pay something like 20% (I’m not entirely sure) for various medical tests and procedures. Adding another dependent on this plan apparently will cost us another $70 or so a month, so there’s that added expense as well.

My HMO is, of course, an HMO–so we must Go Where They Say When They Say. But, there is no added expense. I already pay the family rate, so having another dependent won’t cost us anything in monthly fees, and as long as we play the referral game (and they’ve always been good about that; it just goes slower than we’d prefer), there is nothing out of pocket shy of $15 copays. I have had two back surgeries in two years and paid not a cent for either of them.

I thought about having the boys on both insurance so they’re completely covered, but when I asked about that here a few months ago I was warned we’d run the risk of the two insurance companies arguing about who should pay what.

FTR, the two plans are with two different major medical insurance companies. They do, however, service the same providers–our docs take both of them. I don’t know if that has any impact or not.

So…PPO and more $, or HMO and more freedom?

PPO, because if something goes on, you can quickly act, and not wait for your PCP to give you a referral.

I am deaf in my left ear because my PCP was out of town and I couldn’t find another doctor to take my insurance to switch PCPs temporarily, so I couldn’t get to the ENT to find out that I blew my ear drum out and all that crap. I just sat in horrible pain with stuff draining from my ear while my PCP was in India doing Doctors Without Borders.

I personally find the “freedom to go to any doctor” highly overrated. I would choose the HMO.

If you’re already paying the family rate for your HMO, is there a reason for your husband to stay on a separate plan? Could you all migrate to one plan more cheaply?

Tom, hubby has a rare genetic condition (Marfans syndrome) that, while it hasn’t caused him any problems symptomatically, makes us want to have the freedom to be able and go see the specialists at a clinic an hour away without HMO protest. Marfans can lead to fatal complications if not monitored properly, so hubby goes to specialists every few years to get his heart and aorta checked. Again–he doesn’t have to do the referral song and dance this way.

Hmm. There’s another reason to maybe put Boy 2.0 on the PPO. Marfans is a dominant condition; if either of our sons inherit it (not really determinable prior to age 3 or 4, unless genetic testing is done), we’d want to be able to go see someone familiar with the condition. As it is, Son 1.0’s pediatrition seems to base a lot of his understanding on what was believed about the condition 10-15 years ago. We hate talking to doctors and realizing we know more about the condition than they do.

Should I call my insurance and ask? Or is that naive of me? I did add hubby and Son 1.0 to my plan two years ago, but they always use hubby’s PPO when they see the doc. I actually had planned on dropping them, but since I could add them at no extra cost, I did. Would I be risking “Oh reeeeally, they have other insurance?” by calling and asking about one insurance backing up another as a secondary?

You can have your PCP be a group, though, so you can see another doctor in the same group if yours isn’t there.

Is your son’s pediatrician covered under your HMO?

If not, you will want both boys on the PPO so they can go to the same doctor.

Zipper, yes, the pediatrician is under my HMO as well as hubby’s PPO.

ETA - also, if yours is like mine urgent care is covered, the copay is just a bit higher. That’s why I spent three hours in an urgent care waiting room on the Friday after Thanksgiving. Cost me 35 bucks for the copay, but that’s all I paid except for this ridiculous little bill I got a couple days ago - 5 bucks for the bandage. Evidently crutches and x-rays are free, but an Ace bandage costs a fin.

I work in finance at a major hospital in the Boston area. I routinely deal with COB (coordination of benefit) issues and the like. Since I had a lot of training on insurance rules and the industry, I’d like to let you know that if a patient has two health insurances it is industry standard to follow the calendar rule - ie. whoever has a birthday closer to January is primary. For instance, if your birthday is April and your husbands, is September and baby 2.0 is on both insurances, your HMO would be primary.

Also as a consumer who happens to work in the healthcare industry, I tried out a PPO at first but if you like your doctors and stick with them, you don’t really to use that whole flexibility aspect. Ooh, I can go to out of network doctors without a referral but when am I going to do that? Meanwhile I’m paying $60/week.

I think it would be a good idea and have baby 2.0 on both plans, to hedge your bets. And over time, when nothing drastic happens healthwise, switching to HMO would make sense. Also, a sign of a good hospital/healthcare provider is that you never have to hear/deal with coordination of benefits problems. Heck, that is my job!

Having had dual insurance a couple of times, I’m not 100% sure I’d agree with this.

In earlier years (the 1990s), we found that insurance B would pick up whatever insurance A didn’t pay. More recently however, we’ve found that insurance B says “Ah, A paid 80% and we’d have paid that same amount, so no more money for you!”. So our premiums for the secondary insurance were being flushed down the toilet.

Now, Ruffian has said that with the HMO, there’s zero extra cost. If that’s secondary to the husband’s insurance (per birthdate as you noted) then there’s no problem. If Ruffian’s is primary, then the secondary stands a very high chance of being wasted money.

We have always had problems with coordination, even when the care was delivered at supposedly the premier hospital in our (large, well-funded near-urban) county. The insurance companies also do their level best to screw things up.

If all the regular doctors, and most of the likeliest specialists are in-network on the HMO, I’d consider going that route. Especially if there’s some provision - even if a crappy one - for some out-of-network care. That was something I weighed when making a recent insurance decision; we could have paid about 30 bucks a month extra and had far lower copays etc., AND all our doctors happen to be in-network… but there was ZERO provision for out of network and I wanted the safety net of being able to go out of network if it was absolutely essential.

Also - when are yours and your spouse’s “open season” times? You can always switch from one to the other at that point if you think it’ll be worthwhile. Plus, heck, the birth of baby #2 would count as a qualifying even and you could switch the whole family one way or the other within 30 days, if you like.

Not my insurance, the doctor on the card is the only one that can render service.