Financing Your Maternity Care
Posted on December 18, 2007
Filed Under Pregnancy Care |
Health care financing has been undergoing rapid change in the past decade. For this reason, it is impossible to write with any certainty what services will be covered by insurance companies and to what extent. Coverage changes at a phenomenal rate and varies by state, by plan, and even within plans, depending on the employer. We can only provide some general guidelines regarding the questions to ask and the pitfalls to watch out for.With the increasing reliance on what is called managed care-or should be called managed payment-families need to be very careful in choosing health care plans, where they have a choice, to make sure that what they want for birth will be covered. Some states, for example, mandate that health insurance cover midwifery care for pregnancy, birth, and the postpartum period. In states that do not mandate this, women must check to make certain their policy covers the services of midwives, should they want this option. In more than fifteen states, there are laws prohibiting the denial of access to any licensed provider, with two provisos their education and scope of practice includes services covered by the plan and they are willing to meet the plan’s conditions.
If appropriate, you should check to determine whether birth at a birthing center will be covered (it usually is since these births are less expensive, relying on fewer technological interventions and with shorter stays). A home birth is less likely to be covered again, if this is the option you want, you must check in advance with your insurance company.
We discussed previously that you might have a preference for a particular physician or midwife or place for birth. Remember, some plans only provide coverage if you use a provider within the plan’s network. If you can only use in-network providers, get the list of your plan’s obstetricians, midwives, or family practitioners who provide maternity services and see what information you can find out about them, including where they attend births. You might want to make an appointment to have a gynecological visit with a potential obstetrical provider or group and find out something about the philosophy of the provider or members of the group. You might want to ask women (or men who’ve participated in a birth) whose opinions you value and whose philosophy is similar to yours.
If your health plan allows you to use out-of-network physicians or midwives, but pays only a percentage of their fees, then find out what these fees are. Determine whether or not you can afford the percentage of the fees for which you will be responsible-often 20 percent, up to a maximum outof-pocket expense, beyond which you will be reimbursed for the whole fee, if the insurance company determines that it is reasonable and customary. If the insurance company deems the fee beyond its usual and customary reimbursable fee, which varies by state, city, or even county, then you will be responsible for any amount above the usual and customary. The provider’s office can provide you with its standard maternity service fee. Maternity services are generally covered in a package-one fee for the entire prenatal care, the birth, and the 6-week postpartum visit. You can call your insurance company to see if your provider’s fee is usual and customary. You may need to send in a form. Remember, of course, that tests such as ultrasound, blood work, and amniocentesis, for example (see Chapters 8 and 17), will have additional fees. The services of additional team members, such as genetic counselors, radiologists, anesthetists or anesthesiologists, will be billed separately. It is up to the insurance company to set each usual and customary fee and decide how much it will pay.
Another concern is whether you need to pay any of the provider’s fee up-front. Insurance companies will often pay for only the prenatal care at the start of the pregnancy, not paying for the birth until it has occurred. In-network providers cannot bill you for anything except your standard co-pay, but those out-of-network may ask you to pay before your insurance company is willing to reimburse. Generally, hospital fees are billed directly to the insurance company as are fees for services rendered at the hospital, such as anesthesia.
With the change in laws to assure that “pre-existing conditions” are covered, it is not as imperative as it was previously to get the coverage you want before you are pregnant. However, in many places of employment you can only change plans at certain times of the year. If you marry, or have a baby, you can update your plan to reflect this changed status-a baby need not wait until the usual change of plan time to be put on your insurance. But in ordinary circumstances, where there is no major life change, you must change during the weeks set aside for this. In smaller places of employment, you may not have a choice. In this case, you may choose to have your partner’s plan cover you. Again, these are things that should be investigated as soon as you are thinking about a pregnancy. Even before it seems like a reality, check the maternity coverage of your plan so you are not taken by surprise in the event of an unplanned pregnancy, or even a planned one.
Tags:choosing health care, families need, family practitioners, health care plans, health insurance, home birth, maternity services, midwifery care, midwives, obstetricians, pregnancy birth pregnancy care
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