IQ expert Jason Beans: Health insurance for pregnancy delivers plenty of variables
Q: My husband and I are trying to have our first child. I’m on his health insurance, which he gets through his job. When I get pregnant, what can I expect his health insurance to cover or not cover?
A: Every employer, every plan and every state differs. There’s no uniform coverage when it comes to pregnancy and spousal coverage. Typically, you will be treated as if you are a pregnant employee of the company. But, again, it depends on a few variables:
▪ Is your spouse’s company fully insured or self-insured (the employer is bearing the risk)?
▪ What does your spouse’s plan specifically say? Your spouse can get all the details from HR or call his health insurance plan directly. Again, there’s no standard policy when it comes to pregnancy. Companies can even opt out of pregnancy coverage because it’s seen as an optional benefit.
▪ What does your state mandate? For example, Illinois requires health insurance policies to provide coverage for the treatment of pregnancy complications.
Most major health insurance plans draw a simple line: if pregnancy is not approved on the plan, then it’s not approved for anyone. If it’s approved for every employee, then it should be approved for every spouse who’s on the policy.
Study the plan
Figure out what’s covered and what’s not covered. Check your spouse’s in-network versus out-of-network benefits for office visits, ultrasounds, lab work and delivery. While the particulars of every plan are different, you can expect most major health insurance plans to operate on a similar basis.
Regardless of the medical situation — be it pregnancy, diabetes or simple routine physicals — your first step toward understanding costs during pregnancy is to know how your plan works. In general, your health plan is likely to be a PPO, an HMO or a high-deductible plan.
If you have a PPO, you can expect to pay co-pays for routine care, and you have a small deductible you must pay if you receive certain medical or surgical services. After you meet that deductible, your insurance will pay 70 percent to 100 percent of your remaining costs, depending on how the plan is designed.
HMOs operate almost exclusively on a co-pay basis. You pay a fee for services, but your network of physicians and facilities is very limited, and severe penalties (and sometimes no coverage) are imposed if you go outside that network.
Under a high-deductible plan, you usually don’t have co-pays; instead, you have a higher deductible that you must satisfy before the insurance company picks up a portion of the remaining costs, usually at a rate of 70 percent to 100 percent.
In-network and out-of-network
Most plans offer different coverage for in- and out-of-network services. For example, your plan may charge a co-pay to see a doctor who’s in your network, but if you go out of your network, you’re responsible for your deductible plus 20 percent to 40 percent of the entire bill for the doctor and facility. There’s a big financial incentive to stay in your network, so check your insurer’s list of participating providers.
|If you’re covered by your spouse’s health insurance and are planning to have a baby, make sure you understand what’s covered and not covered before the new bundle of joy arrives.|
Most insurance plans that are based on co-pays (like a PPO or HMO) will charge a co-pay only for your first prenatal visit for a pregnancy. This applies to regular prenatal checkups required by your physician.
All other maternity services, such as special ultrasounds and minor procedures, would be covered in the same way that a non-maternity medical or surgical service would be covered. With other maternity services, you’ll have to pay a deductible; after that deductible is met, you’ll pay a small portion of the remaining bill.
Most health insurers have adopted policies requiring you to pre-certify hospital stays and surgical services. Be sure to call your health insurance company and find out its rules concerning pre-certification before delivery, as insurers may deny coverage without pre-certification.
Your health plan may assess a hospital admission co-pay, especially if you go out of your network; so again, it is a good idea to check the hospitals in your area for in-network status before having your baby. Deliveries (both natural and Caesarean) usually are covered like other surgical services, meaning you’ll have a deductible to satisfy, and you’re responsible for a small portion of the bill.
Check your health insurance plan for coverage of well-baby checkups and immunizations, and be sure you know ahead of time your plan’s rules for adding dependents to your health coverage. Most health insurance plans give you only 30 days after the date of birth to add the child to coverage; otherwise, you’ll have to wait until the insurer’s next open enrollment period. You should request the necessary forms from your spouse’s HR department before the due date.
In the event your spouse’s company has declined maternity coverage (or you don’t have a partner), there are ways to get care throughout your pregnancy (Medicaid, discounted care, negotiated care or maternity insurance). Don’t feel limited or stressed — you have plenty of options to make well-informed financial and health care decisions.
Jason Beans is CEO of Chicago-based Rising Medical Solutions, a medical cost containment/care management company serving the workers’ compensation, group health, auto and liability markets. Beans founded Rising in 1999. Since then, Beans has received a number of honors, including Business Council Advisory Man of the Year and Midwest finalist for Ernst & Young Entrepreneur of the Year. Rising has appeared several times on the Private Company Index’s Top 10 Growth list and Inc. magazine’s Inc. 5000 list.
Beans earned a master’s degree from MIT’s Entrepreneurial Masters Program and a bachelor’s degree in finance from Boston College.
For more information, visit www.risingms.com.
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