What You Need to Know About Your Health Insurance Plan When You’re Pregnant
Reading the fine print in your health insurance policy isn’t how most people would like to spend an afternoon. But when you’re expecting, it should be added to the top of your to-do list. The thing is, your coverage can vary widely, depending on the type of health insurance policy you have and where you live. Unfortunately, new moms can end up with a major bill when they don’t know the rules. Here’s what to keep an eye out for as you’re reviewing your plan.
If you have insurance through your employer, you’ll probably be given plenty of paperwork concerning insurance coverage. While that’s a good place to start, it’s also important to explore beyond that and go directly to your insurance carrier. “Health-care companies have a customer service area and they put a lot of enhancements in their website, so using an app or going online can get you a lot of that information,” says Richard Gundling, Healthcare Financial Management Association’s senior vice president of financial practices. Take notes on the following:
Be aware of your plan’s network of providers
And try to stay within it. “Regardless of what type of plan you have—such as a PPO or an HMO—you will always have the lowest costs when you get care in your plan’s network,” says Jennifer Fitzgerald, CEO and cofounder of Policygenius, an insurance marketplace that allows you to compare and buy insurance online. “That’s because your health insurance company has pre-negotiated preferred rates with network providers.”
But it’s not as simple as choosing an in-network ob-gyn and hospital. You need to make sure that all the medical professionals—including the anesthesiologist and nurses—fall under the network umbrella, as well as all the labs involved with your care. Even if your plan provides some out-of-network benefits—as some PPO plans do—out-of-network care will always cost more than in-network care. The difference could mean tens of thousands of dollars of out-of-pocket expenses. So make sure the hospital has on-staff options in network. “When people get to the hospital, they forget about all that stuff, so it’s important to do it in advance. Keep a list and give it to your spouse or a family member so they know what to do once you go into labor,” Gundling says.
Understand who is considered a provider and in what settings
Not all providers are considered equal in the eyes of health insurance. “Consider what type of care you’re looking for,” says Jessica Daggett, a doula and childbirth educator who has worked in insurance for eight years. “Are you hoping to see an ob-gyn or a midwife? Do you want to give birth in a hospital setting, freestanding birth center or at home? From there, you’ll need to find out what is covered for your choice of birth setting. Not all insurance plans will cover out-of-hospital births.”
Know what services are covered under your insurance plan
“Under the Affordable Care Act, all major medical health insurance plans are required to cover pregnancy and maternity care,” Fitzgerald says. Besides delivery and inpatient hospital services, your insurance typically should (though it may not always) cover:
• Prenatal services, health screenings, lab work, ultrasounds and birthing classes across all three trimesters.
• Treatment for medical conditions that could complicate the pregnancy (e.g., diabetes).
• Procedures or treatments resulting from pregnancy complications, unplanned obstetrical surgery, epidurals, premature births, incubation or extended stays in the neonatal unit, NICU or maternity ward.
• Pediatric and/or routine and emergency care after baby is born, plus necessary immunizations, vaccinations and checkups in the early months and years of baby’s life.
Find out exactly how much is covered.
Some plans cover only a percentage of costs. Find out what percentage by looking specifically under the maternity section of your policy. Be aware, though, sometimes coverage isn’t as straightforward as you’d expect. “Find out what your plan’s definition of maternity and childbirth is,” says Michelle Katz, LPN, MSN, health-care consumer advocate and author of Healthcare Made Easy. For example, one of Katz’s clients went through IVF treatments and her policy’s definition of pregnancy did not cover multiples. She didn’t see that fine print until after she gave birth to triplets and was billed hundreds of thousands of dollars in out-of-pocket costs.
To avoid these surprises, do your research. Sit with your ob-gyn and ask her to list the tests she’d like you to have, write them down, then go to your insurance plan and highlight the sections and double check whether they’re covered, Katz says. “A lot of times policies online are not updated, so be sure you’re working with accurate information.”
“Go in with eyes wide open,” Gundling adds. “Have an open dialogue to make sure that your obstetrician and hospital are aware that you want to be in network so that you can get the highest care at the lowest price.”
Be aware of elective services
Though they may not seem elective to you, everything from certain pain medication to your newborn’s circumcision could be considered elective services by your health-care provider. Read your policy’s fine print and then make the decision if these costs are worth covering on your own. “If you need an emergency c-section, ask if that is covered, since some insurance plans consider that an elective and will not cover it,” Katz says. However, if you do need a procedure, an appointment with a specialist or something else that isn’t covered, there are steps you can take to ease the financial burden. “In some states, a mother may be able to apply for financial assistance or even Medicaid in these situations,” says Daggett. “It’s best to reach out to your clinic. Most clinics have patient advocates who help patients find ways to handle the financial issues that might arise.”
Understand your deductible
If your plan’s deductible is, say, $5,000, then you’re responsible for the first $5,000 of health-care expenses before your plan’s coverage kicks in. “The full cost of pregnancy and delivery will likely be higher than your deductible,” Fitzgerald explains. So be ready to pay that $5,000, but rest assured that your plan’s policy kicks in after that (so, for instance, if your carrier takes care of 80 percent of the bill, then you’ll need to pay only 20 percent of the cost out of pocket). Always check how far along you are in meeting your deductible when you find out you’re expecting. “If you are pregnant but had knee surgery earlier in the year, you might have already met your deductible,” Gundling says. In addition, the Affordable Care Act also caps out-of-pocket expenses you’re responsible for in a year. For an individual plan, that cap is $7,350, and for a family plan it’s $14,700. After you’ve reached that out-of-pocket cap, your plan will cover 100 percent of in-network health-care expenses.
Take note of pre-authorization rules
Call your insurer or log into your account online to see if you need pre-authorization for any service. Gundling also suggests talking to your OB to pin down the logistics. You’d be surprised at what your insurance might require pre-authorization for. For instance: “Find out if you have to call your carrier on your way to the hospital for delivery, because some insurances won’t cover you otherwise,” Katz says, “particularly if you’re going in earlier or later than your due date.” An emergency c-section is another common situation that requires pre-authorization. It also helps to place a reminder—attach it to your go bag—to remind your partner to make that call. Generally, the hospital will do that as well, but just make sure somebody is handling that.
Be aware of the billing process
Chances are, you’ll receive multiple bills, and some of the items on those bills may be vague. So check what each item refers to. For example, Daggett says, you might be charged for your doctor’s delivery fee and the hospital delivery fee separately. These aren’t the same fee: “One covers your provider and one covers the costs for birth associated with your nursing care and use of supplies at the hospital.” Don’t be shy about checking with the hospital billing office if you’re uncertain what each item refers to.
Watch out for hidden fees
“You can be charged for anything from tissue boxes to stirrups,” Katz says. “Anything that comes near you or touches you, and any doctor that comes in the door can be a hidden cost, along with the food they give you. If they offer you a ginger ale, ask if that’s included, along with the TV and phone.” Another surprise can be if you have a private room—some insurance policies won’t cover that and it’ll cost twice as much. “If you do end up with a private room by default, make sure they don’t put it in your chart if you didn’t ask for it,” Katz says. Your bill is drawn from the items in your chart.
Get an estimate on your delivery
Every hospital has a billing department, so call and ask for a cost estimate for having a baby. “Ask for a charge master—a list of prices for everything,” Katz says. It’s also helpful to know what the cash rate is (in the unlikely event that you lose your job and your insurance along with it). “Pregnancies can cost up to $30,000, depending on if you have complications and where you live,” Katz says—so you want to make sure your insurance has you covered. Check out your plan’s Summary of Benefits & Coverage document, which includes coverage examples, or you can call your insurer to get this information. Just keep in mind that the figure could potentially change due to extra fees that may arise from labor and birth.
Now that you have a ballpark figure for what your pregnancy and delivery will cost, you can create a budget. Set aside cash to cover the expenditures and, even better, include a little extra for unforeseen costs—because they often will come up.
Take advantage of an FSA or HSA
HSAs (health savings accounts) and FSAs (flexible spending accounts) let you put money into an account pre-tax so you can use it for qualified medical expenditures. If your insurance plan or employer offers an FSA or HSA, use them to help pay for any pregnancy-related expenses. “That way, you save a little on your tax bill for things you’ll likely be spending money on anyway,” Fitzgerald says. “HSAs are only available with high-deductible health insurance plans and FSAs are only available through employer health insurance, so make sure you qualify before you include either in your pregnancy plans. Check with your insurer, or the IRS website, to see what counts as a qualified expense.”
Ask for a discount
If you end up seeing a specialist who you really like but is out of network, don’t hesitate to explore lower payment options. “Many hospitals have programs for that,” Katz says.
Upgrade your policy
If you’re trying to conceive or in the early stage of pregnancy and realize your insurance policy isn’t exactly top-notch, you might want to consider switching if it’s an option. “If you have the opportunity to switch health insurance plans before delivery, do some comparison shopping to find the right health insurance policy,” Fitzgerald says. If it’s within your budget, you may want to consider a higher premium plan with a lower deductible. “Although your monthly insurance premiums may be higher, you’ll hit your deductible more quickly—because delivery is a major health-care event—saving you more money in the long run once your insurer takes over paying for services and health-care expenses,” Fitzgerald explains.
Do a price check on specific tests and procedures
Sometimes your doctor will recommend a test that isn’t covered. If that happens, get a cost estimate—if the hospital staff doesn’t know, try its billing department or check out services like Amino, which provides average costs of procedures in your area with your insurance. “Keep in mind that how much you’ll pay depends on how much you have left on your deductible, your coinsurance and copay, and how close you are to your out-of-pocket maximum limit,” says Fitzgerald. And before you shell out for the test, make sure it’s absolutely necessary. “If a pregnancy becomes high risk and your provider submits proper documentation, insurance companies usually make exceptions for coverage of extra testing or screening when needed and within reason,” Daggett says. “With the advancement of testing abilities, genetic screenings are being offered to even low-risk mothers. These tests, while informative, aren’t always required for care and can be quite costly. Some insurance carriers will deny claims for these types of tests.”
Add your new baby to your insurance plan
To make sure your newborn’s health care is covered, add him to your plan as soon as possible. “Once your baby is born, contact your insurance company to inform them of the birth,” Daggett says. You’ll need to give them baby’s name and date of birth and possibly other types of personal information. If you have employer-provided insurance, you can contact your company’s HR department and they may be able to process that change for you. Also, find out your state’s policies in regard to coverage. Typically, your baby will be covered under your plan for the first 24 hours after birth, and in most cases you have 30 days to add your baby to your plan. However, keep in mind that health insurance companies want to bill well-baby visits as soon as your baby has a Social Security number.
Ask for thorough records before you leave the hospital
Have your spouse or a family member write down detailed notes on the services and tests you’ve received at the hospital, as well as the professionals you worked with. Then, before you check out, request an itemized bill and a copy of your medical chart. Keep them handy in a file, so that you can refer to your documentation if you need to talk with your insurance provider about your bill.
Challenge surprise bills
Nothing kills that new mom buzz like getting slammed with a huge medical bill out of nowhere. This is where keeping all those records becomes crucial. Make sure the bill isn’t an error. “You’ll receive an Explanation of Benefits (EOB) with your bill that itemizes the treatment you got,” Fitzgerald says. Does it match your notes and the itemized bill from the hospital? You should also check that the bill was processed through your insurance first. “Every so often it can get processed incorrectly and they don’t get pushed through to insurance before coming your way,” Daggett says. Whatever the case may be, don’t be shy about calling the hospital’s billing department to dispute it.
If the item is a legitimate surprise bill, you may be able to work out a payment plan or request financial assistance. For instance, you may be offered an interest-free payment plan; if you can pay off the plan in six months or less, they may be willing to work with you. Some states, like New York, limit health-care providers’ ability to charge “surprise” bills if you inadvertently go out of network, so check your state’s laws too. If your hospital doesn’t have your Social Security number (and they shouldn’t; if a staff person asks for yours for record-keeping purposes, ask her to provide a medical records number instead), then the billing department won’t be able to send a collections agency after you, and therefore, they would be more likely to negotiate.
Published Decemeber 2017