Are Insurance Companies Required to Cover Maternal Care

How can I tell whether my insurance plan will cover my pregnancy?

The Affordable Care Act ("Obamacare") requires all qualified health plans to cover maternity care and childbirth as well as many free services mentioned below.

However, some older plans, known as grandfathered health plans, are not required to cover pregnancy, childbirth, or preventive care.

To find out whether your plan is grandfathered, call your plan provider. If you do have a grandfathered plan, carefully review your pregnancy and childbirth coverage. You may want to switch to a new health plan.

What pregnancy and newborn services are covered for free?

The Affordable Care Act requires all qualified plans to provide many pregnancy, children's health, and well-woman benefits for no extra cost. For pregnant and postpartum women and newborns, these benefits include:

• All preconception and prenatal care visits
• Folic acid supplements: Experts recommend that all women of child-bearing age take 400 micrograms of folic acid a day to reduce the risk of having a baby with a neural tube defect.
• Alcohol misuse screening and counseling: All public health officials in the United States recommend that pregnant women avoid alcohol entirely.
• Tobacco use screening, intervention, and counseling: Special expanded counseling for pregnant women.
• Rh incompatibility screening: Your blood will be tested to determine your Rh status at your first prenatal care appointment. (If there's a chance this blood protein is incompatible with your baby's, you'll need to take certain precautions.)
• Iron-deficiency anemia screening: Your blood will be tested for anemia at your first prenatal care appointment and again later in pregnancy.
• Gestational diabetes screening: You'll most likely get screened for gestational diabetes between 24 and 28 weeks of pregnancy, or at your first prenatal visit if you're at high risk.
• Infection screening: Screenings for infections that can affect your baby during pregnancy, including hepatitis B, chlamydia, gonorrhea, syphilis, and urinary tract infections (UTIs).
• Breastfeeding support and supplies: Comprehensive lactation support and counseling from trained providers during pregnancy and postpartum. Includes breast pump purchase or rental (more on this below).
• Contraception and birth control counseling: All contraceptive methods approved by the Food and Drug Administration, including sterilization procedures, and patient education and counseling. (Some religiously affiliated employers may be exempt.)
• For newborns: Gonorrhea preventive medication for the eyes and newborn screening for congenital hypothyroidism, hearing problems, phenylketonuria (PKU), and sickle cell anemia.

Healthy pregnancy programs

Many insurers have free programs that are designed to help women have a healthy pregnancy. These programs offer services such as help finding a healthcare practitioner in your network and phone access to support and advice from nurses. Call your plan to see whether they have a program like this for you and how you can enroll.

How can I tell how much I'll end up paying for everything else?

For other services, you can look at a plan's Summary of Benefits to see what's covered and at what levels. You can also review the plan's Evidence of Coverage for more details. (See our article on how health insurance plans work for more information.)

If these documents are hard to find or interpret, you'll need to call your insurance company. Keep careful records of the answers you get and make sure to note the name of the person you spoke to and the date you called.

Start by making sure that all of your healthcare providers are in your plan's network. That includes the practitioner who cares for you during your pregnancy, your anesthesiologist during labor, your baby's doctor, and any specialists you know you'll need. For example, you'll need to see a maternal-fetal medicine specialist if you have any chronic conditions that would make your pregnancy high-risk.

Find out what the coverage is for out-of-network versus in-network care, in case you need to see a provider who is outside the network. Be aware that insurance companies will pay less for out-of-network care or it may not be covered at all. Before you head to any healthcare provider, check to make sure that the provider accepts your health insurance.

How can I tell how much I'll end up paying for a specific test or procedure?

Costs will depend on your provider's contract with your insurance company. Usually, the best way to determine your costs is to talk to the staff at your healthcare provider's office. They should be able to help you figure out approximately what you'll pay for everything from prenatal tests to delivery. Then call your insurance plan and see if they can confirm those approximate costs.

Unfortunately, sometimes an in-network medical facility will use out-of-network staff. They may not warn you when you are about to be treated by a practitioner who is out-of-network. That's when you may end up with a surprise bill. (See below on what to do about surprise bills.)

So it's always a good idea to ask before each procedure if all the staff who will be billing you are in-network. You may not be able to get a straight answer because in most states, hospitals are not required to tell patients if their staff is in-network, and the practitioners themselves may not even know. In some cases, there may be no in-network practitioner available. But it's worth asking.

How can I tell how much I'll end up paying for delivery?

Ask your insurer which local hospitals are in your plan's network, how long a hospital stay is covered after delivery, and whether you'll have to share a room.

There are a host of charges typically associated with delivery, including a hospital or facility fee, a provider fee for prenatal care and birth, an anesthesia fee, costs for the pediatric examination, and incidental charges for supplies or equipment. Your practitioner's office can help you gather this information ahead of time.

Find out how much a vaginal delivery and a c-section will cost. (Even if you're planning a vaginal delivery, you may end up with a c-section.) If you're interested in alternative delivery options, like a birth center or home birth, ask about coverage for those.

Keep in mind that neither the insurance company nor your healthcare providers will be able to guarantee a specific cost for you. They cannot predict any special tests or procedures you may need, from something small (an extra hospital gown) to something not so minor (an emergency procedure for you or your baby). A ballpark figure is often the best you can do.

What's the most I could end up paying in a worst case scenario?

Find out if you have an annual out-of-pocket maximum and how that works. This is defined as the highest amount your insurer will ask you to pay for medical costs for the year. Once you've paid this amount, your insurer generally covers 100 percent of other medical costs you have for the remainder of the year.

However, read the fine print to find out what's included in this amount. It almost always includes your yearly deductible. But it doesn't necessarily include premiums or out-of-network costs. (Some plans have a separate, higher out-of-pocket maximum for out-of-network care.) And you will still be responsible for amounts that are considered more than "reasonable or customary" for any service.

And remember that your pregnancy may start in one year and end in another, but your plan will only count the costs you paid in each calendar year toward your annual maximum for that year.

On the other hand, your doctor's office may bill for everything at once, including prenatal care and delivery. You'll want to work this out with your healthcare provider's office.

Thanks to the Affordable Care Act, qualified plans are no longer permitted to have limits on the total amount an insurance company will pay for your care each year. Grandfathered plans (that started before 2014) may still have limits.

How can I tell if I need pre-authorization for something or if I need to call my health plan when I'm admitted to the hospital?

Many plans require pre-authorization for certain services and procedures, such as ultrasound and amniocentesis. Most of the time, your practitioner's office will call your insurance company for pre-authorization when making plans for your prenatal care and delivery. But it's a good idea to confirm this.

Check your plan to find out whether you need to get pre-authorization for hospital admission or whether you need to call them when you get admitted. (In most cases, your healthcare provider will obtain pre-authorization when you begin your prenatal care.)

By the way, many hospitals will have you register online in advance of your delivery stay. This is not a pre-authorization.

How can I find out what kind of breastfeeding and breast pump benefits I have?

You'll have to call your plan to find out. All qualified plans are required to provide free breastfeeding support, counseling, and equipment for as long as you nurse your child. These services may start before the birth.

The pump provided may be either a rental unit or a new one you'll get to keep. Your plan may determine whether the covered pump is manual or electric, the length of the rental, and whether you get it before or after delivery.

Health plans will often follow a doctor's recommendations on what's medically appropriate and some require pre-authorization from your doctor.

By the way, don't be disappointed if you end up with a hospital-grade rental pump. These pumps are the highest quality and work as well or better than any retail pump.

Take advantage of counseling and support services. Most hospitals provide a free consultation with a staff lactation consultant (or a nurse with training in this area) during your stay, but breastfeeding problems may arise after you leave the hospital.

Find out ahead of time what kind of counseling services are covered. Ask about breastfeeding classes before birth and find out which lactation consultants you can see after you leave the hospital and how many visits are covered.

How do I add my baby to my plan?

Ask your insurance provider what the procedure is for adding your new baby to your plan. In most cases, your child will be automatically covered under your plan for the first month after birth (two months if you have a marketplace plan). So you usually have 30 to 60 days to contact your insurer and have the child officially added to your plan.

If you have a marketplace plan, you qualify for a special enrollment period when your baby is born, which means you do not have to wait until the annual enrollment period to sign her up for coverage.

If your child is eligible for free or low-cost health services through CHIP, the Children's Health Insurance Plan, there is no special enrollment period – you can apply year round.

Also ask about coverage in the event that your child has complications and needs to spend some time in the neonatal intensive care unit (NICU).

What can I do if I get a "surprise" bill?

What happens if you use an out-of-network provider without knowing it, for example, and end up with a big bill? Call your insurance provider and see what they can do. Some plans will cover the cost, especially if they originally told you the service was in-network.

Healthcare providers often have staff who are skilled at working with patients on these problems. Don't hesitate to ask for their help as well.

If you end up with bills you can't handle and can't get help from your insurer or provider, you may need a medical billing advocate. This is a person who will evaluate your bills for errors and duplicate or unreasonable charges and then negotiate with the hospital or insurer for relief on your behalf.

You can find medical billing advocates through the Alliance of Claims Assistance Professionals. Some charge an hourly rate of $100 to $200. Others charge a percentage of your savings, typically 15 to 35 percent of the reduction in your bills they achieve.

Are Insurance Companies Required to Cover Maternal Care

Source: https://www.babycenter.com/family/money/health-insurance-during-pregnancy-how-to-find-out-whats-cove_10413696

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