So, you’re pregnant and excited to be a mom! Aside from peeing on about 10 more sticks to make absolutely sure it’s real, your future will now be filled with tons of doctor’s appointments—and, possibly, rogue insurance bills for your prenatal care.
It’s easy to assume if your OB/GYN recommends a test or tells you to come in for an appointment that it’ll be covered by your insurance. But as many women have found out, that’s not necessarily the case.
Ask a group of moms for their insurance horror stories and you’ll get flooded with responses, like $1,000 bills for lab work, “routine” ultrasounds that had to be paid out of pocket, charges for an out-of-network anesthesiologist who administered their epidural, and the list goes on. The struggle is thanks to the labyrinth of insurance rules that differ depending on the multitude of plans out there.
However, despite all this, one thing is for certain: Things are better for women today than they were before the passage of the Affordable Care Act (ACA). “The ACA was a game-changer for coverage of maternity services. Before, plans routinely excluded maternity care or it was available for an additional fee. Now most coverage must cover it,” says Stephanie Glover, senior health policy analyst for the National Partnership for Women & Families (NPWF).
It was an unfortunate reality that women purchasing insurance on their own before the ACA struggled to find plans that covered maternity care, which is a critical service for women. (You know that, but some lawmakers still disagree that it should be guaranteed.)
If you consider that 45 percent of pregnancies every year are unintended, women who didn’t have the special coverage might have been caught without proper insurance for prenatal care, which plays a critical role in health outcomes for mom and baby. Today, ACA-compliant insurance plans must cover pre-existing conditions, which include pregnancy, so even if your coverage starts after you get pregnant, the plan still has to cover you. (Still, some “grandfathered” plans purchased before 2010 may defer to the old regulations, so always check with yours on the specifics.)
The ACA offers certain financial protections for women. “While it may be confusing to navigate plan options, there are some standards across the board,” Glover says. Many health plans, including those people purchase themselves on the marketplace, cover certain maternity services as “preventive” care without a copayment or coinsurance—aka for free, even if you haven’t met your deductible yet—but only when they’re given by an in-network provider.
But first: Do you have insurance?
The first hurdle, obviously, is making sure you have adequate health insurance. “The maternity care protections we all worked for in the ACA are being undermined these days. There are more and more plans being sold that don’t comply with the law,” says Cheryl Fish-Parcham, director of access initiatives for Families USA. These include short-term, indemnity, and association health plans. It’s likely if you have one of these, maternity care won’t be covered. “Be wary about buying one of these,” she says.
If you’re uninsured: In 2010, two-thirds of unintended births, and half of births overall, were paid for by public insurance programs like Medicaid, according to the Guttmacher Institute’s most recent analysis. If you don’t have insurance and have a lower income (based on the federal poverty level), check if you qualify for Medicaid, which is insurance paid for by states and the federal government.
“Medicaid income guidelines may be fairly generous depending on your state,” Fish-Parcham says. For instance, some states count the unborn child as a household member, which can increase what your need looks like and qualify you for the program, she says.
A final word on insurance—yes, you need it. If you don’t have it through an employer, a marketplace plan you purchased, or Medicaid and you get pregnant, you’re still on the hook for your medical bills. You’ll have to pay out of pocket for your appointments and will receive a hefty bill from the hospital after delivery.
According to one study from the University of California in San Francisco, women could be charged between $3,000 and $37,000 for a vaginal delivery, and $8,000 to $71,000 for a C-section in California. That is not a bill you want, and one that can only go up exponentially if you or your baby has complications and requires an ICU or NICU stay.
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Got it, I have insurance. What prenatal services will be covered in full?
Prenatal vitamins and folic acid supplements and are covered. You may need a prescription from your doctor or you can pay for them using your tax-free flexible spending account (FSA), health savings account, (HSA), or health reimbursement account (HRA). These vitamins have been shown to prevent birth defects, primarily neural tube defects, which compromise the growth of the brain, spine, or spinal cord (spina bifida is one example of this kind of defect). If you’re looking to become pregnant, it’s important to take either or 400 to 600 mcg of folic acid alone or a prenatal multivitamin that contains folic acid.
Covered tests include those for anemia, gestational diabetes, Rh incompatibility, gonorrhea, syphilis, hepatitis B, UTIs, and preeclampsia (for women with high blood pressure). These screenings either happen on a routine basis during prenatal visits or are a one-time occurrence depending on how far along you are in your pregnancy.
Tobacco intervention and counseling
Twenty percent of pregnant moms on Medicaid smoke, which can lead to preterm births and sudden infant deaths. Plans offer options for helping women quit.
But: It’s not a perfect system
A 2015 report by the National Women’s Law Center (NWLC) found numerous violations of the mandatory ACA maternity coverage, like limiting the number of ultrasounds or prenatal visits—which your plan may not cover in full, though Medicaid programs in most states do cover ultrasounds—or imposing restrictions on a woman receiving emergency maternity care outside of her area.
If you’re pregnant, the best way to protect yourself from surprise bills is to do your homework. So, take a deep breath and read on.
Good to know. What steps should I take before I give birth?
Call your insurer to talk costs
When you know you’re pregnant, call your insurance company. They can give you an estimate of what additional services are covered beyond the ACA requirements (like chromosomal screenings, ultrasounds, the copay for office visits, etc), as well as provide an estimate of how much the birth will cost, which can vary widely. For instance, when I had my first son in 2013, we paid about $2,000 in hospital bills. This year when I had my second son, we had the same insurance company but a different plan and we paid nothing.
Specifically, here are the questions you should ask your insurance company:
*What’s the estimated cost of a vaginal birth? C-section?
*What services are covered under my plan?
*How do these services fulfill my deductible? (That’s the amount you need to pay out of pocket before your insurance starts footing the bill.)
*Is my preferred doctor and hospital in-network? Again, those fully covered services listed above are only free when performed by a doctor in the insurance company’s networks.
*Are delivery services like anesthesiology or visits from additional staff going to automatically be billed in-network (even if they’re technically out-of-network)?
*When the baby is born, will the baby itself be charged separate fees? That can easily double your burden for hospital services.
*Do I need to call the insurer for pre-approval/prior authorization before I go to the hospital to give birth? Yes, sadly, this is sometimes a thing.
*How late in my pregnancy can I order my free breast pump?
*Is the 6-week postpartum checkup covered?
*If you’re interested in a home birth, ask if it’s covered. But you may be out of luck. For example, Aetna says they consider planned deliveries at home “not medically appropriate,” deferring to the American College of Obstetricians and Gynecologists’ recommendations. In some states, however, Medicaid will cover a home birth.
*If you’re interested in hiring a doula or a midwife, ask if they’re covered. Medicaid reimbursement for doulas differs by state but has been difficult to implement, notes a 2016 report from the NPWF. Minnesota is one such state that offers this benefit through the Minnesota Health Care Programs. Midwife services, on the other hand, are more likely to be covered under insurance, and are allowed through Medicaid.
Do some reading
Also, it’s worth noting that the insurance rep you talk to may not have all the information, depending on how well they’re informed, and it’s smart to double check their word against your plan. (“So-and-so agent told me that ultrasounds were covered” will not fly when disputing a charge.)
Health plans are required to have a Summary of Benefits and Coverage. Page 7 of most summaries (there’s an example here) will explain coverage for childbirth and how much you will likely owe for the birth, and your plan may also have a separate document spelling out maternity coverage. They may even provide an online cost estimate calculator that can give you a picture of what you might owe.
Prepare for money questions
From there, many doctor’s offices encourage you to appropriately save for the cost of prenatal bills and delivery. My doctor for my first child had us pay a deposit at 28 weeks to defray costs not covered by insurance. My doctor for my second baby, at a different practice, simply sent home a flyer encouraging us to call the insurance company to plan for the possible financial burden. Another option is maxing out a health savings account, or HSA, (if you have a high-deductible plan) or socking money away in a flexible spending account, or FSA, to help cover some costs.
What benefits are covered after delivery?
Here’s what should be covered without a copay or coinsurance:
Before you’re allowed to leave the hospital, your newborn will receive a bilirubin test (to check for jaundice), a blood screening, hearing screening, and more. These tests are all covered by plans thanks to the ACA. It’s important to know this, should you incorrectly receive a charge for them. (Had I known that these were covered, I could have fought back against the hearing test that was denied by my insurance, which I ended up paying for out-of-pocket.) Note that the 6-week postpartum checkup isn’t required to be covered under the ACA, but most Medicaid programs cover postpartum visits.
Breastfeeding support and counseling (such as a lactation consultant), as well as breastfeeding equipment and supplies are all covered. The biggest perk from ACA-compliant plans is a free breast pump, which can normally run in the hundreds of dollars. Each plan has its own rules about exactly when you can order one, so If you want to breastfeed, ask your insurance about your benefits. Alternatively, the company Aeroflow Breastpumps will also contact your insurance for you to verify coverage, give you qualifying options, and allow you to order one. (In my experience, Aeroflow has saved a lot of time and confusion.)
What else do I need to do once the baby arrives?
Get your baby on your health insurance
In most cases, you have a 30-day window to add your baby to your insurance. (If you have an HMO-type plan, you’ll also have to formally declare a doctor for the little one.) You can do this by calling them or going online. However, some insurers will ask for a social security number for the baby, something they won’t receive until they’re five or six weeks old. Helpful! Ask your insurer what you should do to get around this.
If you bought a plan on the Marketplace, you don’t have to wait until the next “open enrollment” to add your baby: Pregnancy qualifies you for a special enrollment period when you can enroll your baby in your plan or change your coverage.
Talk to your doc about contraception
After you give birth, you’ll likely want to talk to your doctor about birth control. With the exception of employers who have a religious exemption, the ACA requires that insurance plans cover all FDA-approved methods of contraception and sterilization for women without a copay.
Review your bill
Anyone who’s looked at a hospital bill—especially for a delivery—knows how batshit crazy they can be. If you’re in doubt about a bill, one option is to check with your state’s insurance department, which regulates insurance companies, Fish-Parcham advises. If you were denied coverage you feel you were entitled to, you’re also able to appeal to your insurance company, says Glover, though she acknowledges that competing demands on time and resources with a newborn can make this, uh, challenging. It’s easier said than done, but doing what you can up front to make sure you’re covered and know what your plan entails can save you a lot of grief in the end.
What else can I do if I think I’m being incorrectly charged?
The National Women’s Law Center also notes that many insurers fail women by not complying with the ACA coverage requirements. If yours is giving you trouble, you can contact their hotline, CoverHer, for help.
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