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Wondering what specific questions to ask your insurance company once you get pregnant!? You’re in the right place!
Our first pregnancy was the first major health event we’d ever dealt with, thankfully. But, I had NO CLUE how pregnancy & insurance worked.
Since then (that was 2012), we’ve had a few job changes, lived in a couple states, and had 3 more babies! We even had a baby during a time when we didn’t have a viable insurance option. Instead, we used a Christian medical sharing network which is a legal alternative to health insurance.
Needless to say, I’ve learned a lot about insurance & pregnancy, and I’ve compiled 10 specific questions you need to ask your insurance provider once you find out you’re pregnant.
Just call the number on the back of your card and say you’re newly pregnant and have a few questions. They’ll get you to the right person.
Side Note – I’m in the USA, so this advice is geared towards our insurance system. If you live in a country that has more of a universal healthcare type thing, I don’t think this post will be super helpful. Also, this post isn’t intended to be any sort of legal advice. There’s my official disclaimer. 🙂
Quick Overview of How Pregnancy Billing Works
There are a lot of different costs associated with having a baby. Here’s how the billing typically works!
- Usually, your OBGYN or midwife has what’s called a “global charge” for pregnancy related care. It includes standard prenatal appointments, delivering the baby, and checking up on you after birth during your hospital stay. They probably have one price that includes a vaginal delivery & a higher price for a c-section.
- It may or may not include ultrasounds – that usually depends on whether or not they outsource them. You can ask the office person at your OB’s office if the global charge includes ultrasounds.
- You will be billed separately by the hospital for the costs of delivering in the hospital. This will include your hospital stay AND baby’s hospital stay and newborn care.
- If you get an epidural, the anesthesiologist will bill you separately. (A check I happily wrote with each baby.) 🙂
- The pediatrician who visits your baby in the hospital will also bill you separately.
- If you circumcise a boy, that’s also an extra charge… typically either from your OB or the pediatrician, depending on who does it.
So yeah. That’s why it’s complicated! You’re not alone in wondering what the heck do I even ask my insurance provider when it comes to the costs for a baby!?
Here are the top 10 questions!
1. What is my copay for the standard appointments during prenatal care?
Clarify – is there a specific number of appointments that are considered standard?
You will typically have a basic prenatal checkup once every 4 weeks, beginning around week 8-10 and continuing through week 26. Your prenatal care provider may or may not do an early ultrasound at the first appointment to help date the pregnancy.
Once you hit 26 weeks, you’ll go in every 2 weeks until week 36. From 36 weeks on, you’ll go in for a quick appointment every week.
You will also have a 20 week ultrasound!
If you are considered high risk or “geriatric” (35+ lol) then you will likely have more appointments and/ or more ultrasounds.
2. Is there a copay for any extra visits to my doctor during prenatal care?
For example, say you have your first appointment at week 8, and have a second one scheduled for week 12. But then at week 10, you feel some cramping and you want to go in to check on baby…
3. What is my annual deductible?
Your deductible is the amount you have to pay each year before insurance kicks in and starts covering costs.
You may already know your annual deductible. You can likely log in to your insurance provider’s members dashboard and see details about your deductible & how much you’ve used. But you can also call and ask for further explanation if needed.
If you have a $500 deductible, and you’ve already paid $100 out of pocket for other medical costs this year, you will pay the remaining $400 for your pregnancy-related medical costs before insurance starts helping out.
Remember, the deductible resets each year, so if you get pregnant in a given year later than March, you’ll likely pay out the reminder of your deductible for the current year AND you’ll have to pay it again the year your baby is actually born.
4. Once I reach my deductible, what percentage do we pay?
After you reach your deductible, there is usually a percentage breakdown for how much your insurance company pays versus how much you pay out of pocket.
A common split is 80% insurance and 20% you. I’m going to totally make up numbers for an example, so don’t use these in your planning at all.
For simplicity, let’s pretend all your prenatal care and the baby delivery is happening in one calendar year, and that you haven’t used any of your deductible yet.
Let’s also pretend your insurance plan includes a $500 deductible and that your insurance pays 80% after that. All your care costs $8,000.
You will pay $500, so there is $7,500 remaining. Your insurance company will pay 80% of that, which is $6,000 and you’ll be on the hook for 20%, which is $1,500.
(The costs are typically higher than that and vary greatly across states and caregivers. Plus the cost depends on whether you give birth vaginally or c-section and how long you and your baby stay in the hospital!)
5. What are my individual and family out of pocket maximum costs and how does this work with a pregnancy?
Your out of pocket max is the maximum amount your insurance company has you pay before just covering 100% of the costs. Remember, in our pretend scenario, you pay 20% of the costs out of pocket after the deductible is used up.
Let’s pretend your individual out of pocket max is $3,500 and your family’s out of pocket max is $7,000 annually. Let’s also pretend your baby needs to stay a few days in the NICU, and that the total cost of all your maternity care plus delivery plus baby care is $30,000. Subtract your $500 deductible to get $29,500. 20% of that is $5,900. So you would be required to pay all of that out of pocket since it’s under your family’s annual out of pocket max. BUT, if someone else in your family has an expensive medical issue the same year, you’re only $1,100 away from hitting that out of pocket max.
Honestly, it’s not that hard to hit your out of pocket max with a pregnancy. All it takes is one complication to run the bill WAY up!
I highly recommend always having at least the amount of your family’s annual out of pocket max set aside in cash in a savings account. A better rule of thumb is 3-6 months living expenses saved up!! Here’s how we budget & track spending using YNAB. And, here’s how to plan ahead and save up for having a baby!
6. Do costs for the baby in the hospital count towards my individual out of pocket max or family out of pocket max?
The unique thing about a pregnancy is the mom is treated medically as an individual until the baby is born, including prenatal care & labor/delivery charges by the OBGYN. But, once the baby is born, the baby becomes part of the family in terms of medical costs.
This matters because the individual out of pocket max is typically lower than the family out of pocket max.
Ask your insurance provider which parts of the baby’s care will be separate from the mother’s and to clarify what counts towards the individual out of pocket max vs. the family’s out of pocket maximum.
7. When do I need to call in to officially add the baby the policy?
The person you talk to will likely make a note that you are due with a baby in whatever month you estimate. Then you’ll have a certain number of days to call update your health care plan.
This typically doesn’t have anything to do with the open enrollment periods, a special enrollment period, or the insurance marketplace.
Most insurance companies allow you to add a new family member to your insurance coverage any time.
8. If I need or want testing during the pregnancy, what is covered by insurance and what isn’t?
There are a handful of optional tests you can get during pregnancy. If you’re high risk or over 35 years old, your OBGYN may highly recommend certain tests. You’ll want to ask your provider which tests and maternity care services are covered and which are not. (Depending on the helpfulness and knowledge of the person you talk to at the insurance company, you may have to call the doctor’s office to get the names of the tests you’re curious about and then call the insurance company back.)
Always read up about the pros/ cons and ask some trusted friends and medical experts about any potentially invasive procedures or tests.
Since I had 4 typical pregnancies, and was not a high risk, I always opted out of the optional genetic tests/ blood tests, etc.
9. Do you reimburse for a breast pump? Which pumps/ supplies are included and what is the process for getting it?
Almost all insurance coverage includes a breast pump under the Affordable Care Act. But the specifics vary. Typically, they’re only giving you the baseline model. You may or may not be able to choose from more than one option.
Your provider will be able to tell you exactly what’s included or how to view your options. They’ll also tell you the process for getting your pump. Often, it involves calling back in the last 4-8 weeks of pregnancy and placing an order from a specific selection of stores.
If you have plans to breastfeed and/or pump a lot, you might want to research the pumps available through your provider. I used both a Medela pump and a Spectra occasionally. Both worked well. If you plan to pump while working, you’ll likely want some extras that aren’t included…
- A portable bag to carry everything in.
- Some sort of lunch box or cold storage option to save what you pump at work.
- Breastmilk bags or an attachment for pumping directly into bags.
- A second set of the attachments for frequent use.
10. Is Doctor _______ in Network?
Make sure you clarify that you’re going to use a provider and hospital that is in your insurance network!
Hopefully these will get you started with the discussion, and hopefully the person you’re talking to is helpful. I’ve generally found that when I’m asking someone these questions, they’re pretty helpful.
Some other things you’ll probably want to think about during your pregnancy are…
What to register for (this one is fun!)
And seemingly far away but highly recommended – creating a healthy, happy routine for newborns!