Insurance is something my husband and I were anxious about when we first learned about my pregnancy. What will they cover? What won’t they cover? Will we be left with enormous debt if something unforeseen happens?
We were very nervous, but everything worked out. We had a few things come up, but with good communication with our insurance company we were able to survive financially the childbirth.
With that in mind, we went out and contacted an insurance company to answer some common questions woman have related to insurance while pregnant.
In today’s post, we took the time to interview Nisha Rk of navixmarketplace.com.
1. Are Midwife and/or Dula covered by insurance?
It depends. Midwives that practice in hospitals, if they are legally licensed to practice in your area, are probably covered by insurance. It is much more difficult to find an insurance company that will cover home birth midwives, and if you can, it’s very likely that the midwife will be “out of network,” which usually means that your deductible and out of pocket expenses will be higher. However, since many home birth midwives have been practicing in this environment for many years, many of them have very reasonable cash prices they can quote you, which may be less than the out of pocket expenses for a hospital birth. To find out what would be covered under your plan, call your insurance company, but also read your plan documents. When I wanted to get a home birth covered, my plan documents said it could be, but the insurance company initially stated that it would not be. I had to speak to several people to get the misunderstanding clarified, and I did eventually get about half of the costs covered by my insurance company.
Doulas are much less likely to be covered by your insurance, but again, it’s worth asking your insurance company.
2. Are birthing centers covered?
Very possibly. Many people view birthing centers as the middle ground between home birth and hospital birth, and many insurance companies do cover the cost of delivering at one of the centers. Start by asking your insurance company if they will cover the cost, and then ask which centers are in-network for your plan.
3. I am Trying To Conceive, how do I know if I’m covered for maternity with my current policy? If not, what do I have to do?
If you have an insurance policy through a group (like your employer) or through one of the new ACA Marketplaces, your policy almost certainly includes maternity benefits. To be sure, review your plan documents, or call your insurance company to ask.
If your plan does not cover maternity care, you still have options. Many states offer expanded Medicaid income limits to pregnant women, so contact your state’s health insurance line to find out if you might qualify. If you are over income for the program, talk to your provider to see if you can arrange a cash price up front, which you can budget for over your pregnancy, so that you’re not trying to pay for it all at once. Also, consider looking for care through a birthing center or a midwife; since these providers often work with patients who do not have insurance coverage for their services, they often have a lower cash price than an OB in a hospital.
4. If I get insurance after conception is my pregnancy considered a pre-existing condition? What does that mean?
As of January 1st, 2014, the answer is no. Before the Affordable Care Act, this was a possibility; pre-existing conditions meant that a person could be denied coverage for any illness or condition that they knew of before they applied for health insurance. After the ACA was passed, insurance companies were no longer allowed to deny children benefits due to pre-existing conditions; in 2014, this will be true for all plans, other than certain individual plans that you purchase on your own. If you are going through a Marketplace or insurance through an employer, pregnancy will not be considered a pre-existing condition.
5. Am I allowed a limited number of ultrasounds & blood tests?
It depends. In general, maternity care is considered an Essential Health Benefit under the ACA, so if your plan is not grandfathered, all medically necessary care during pregnancy should be covered under your plan. Where this can get sticky is the definition of medically necessary. During my first pregnancy, for example, my OB preferred to check the baby’s heartbeat with an ultrasound instead of a doppler. All of the visits were covered, but my copays were higher when the ultrasound was used.
6. Is Anesthesia and/or epidurals included?
Almost certainly, but call your plan to be sure. That said, so many women request epidurals that they are almost always covered, though they will increase the cost of your bill for the birth (more providers = more fees = more coinsurance to pay).
7. What is a deductible?
A deductible is an amount of money that you have to pay out of pocket before your insurance pays anything. You might have a $500 deductible for maternity care, for example; the first $500 your OB bills would still be sent to the insurance company, so they can keep track of it, but you’ll be expected to pay for it out of pocket.
8. If I give birth in a new year do I have to start paying the deductible all over again?
Probably, but call your plan to see if they make an exception for situations like this.
9. How long a hospital stay will be covered for vaginal vs. cesarean birth and how is the time determined? Hours or days?
It depends on your plan, but most will cover two days after a vaginal birth, and four after a c-section. Depending on how you recover, and how you feel, you may be able to leave earlier, though hospitals usually want you to say at least over night, to make sure that no sudden complications (like a postpartum hemorrhage or pre-eclampsia) arise.
10. If I have to have a cesarean birth, what is and is not covered?
I know it’s frustrating to hear over and over again, but it depends on your insurance. What shocked me when I had my c-section was how very many bills I got; each department of the hospital (the general hospital care, the anesthesiologists, the NICU team that evaluated my daughter immediately after her birth) all billed separately, and then I also got separate bills from my OB’s office for her fees as the surgeon, as well as the remaining balance from my prenatal care. Some of those things applied to different deductibles as well, which shocked me, and we ended up owning more than we budgeted for. More insurance companies now have cost estimators on their websites; use them. I cannot recommend it enough.
11. How long after giving birth do I have to add the baby to my insurance?
Having a baby (adding a dependent to your household, so adoption counts too) is a qualifying life event, and you have 30 days from the date of the event (your child’s birth) to make changes. It sounds like this will be plenty of time, but remember that you’ll be trying to do paperwork with a newborn in the house. Get the paperwork from your employer before your baby is born, and do it as soon as possible, to make sure it won’t get forgotten. Most insurance plans cover babies for their first 30 days of life, as long as Mom was insured when the baby was born, but if you miss that QLE period, you’ll be waiting for open enrollment to get the baby covered, and that’s a real problem with a newborn.
12. Do all your plans cover well-child care visits?
Well-child visits are Essential Health Benefits, so all non-grandfathered health care plans must cover them, usually at no cost (since they’re preventative medicine).
13. I like my current OB/GYN, can I keep him/her?
It’s definitely possible. Call your OB/GYN and see if they’ll accept your current insurance plan.
14. Will I need a referral to an OB from my primary care physician?
Some plans are called HMOs, and require referrals; some plans are PPOs, and do not. To find out which you have, contact your plan.
I can not thank Nisha Rk enough for all the great information. I hope you found it as useful as I did.
Remember that it is important to read over your insurance paper work and to take the time to call your insurance provider to make sure they are up-to-date, and you have all your questions answered.