Figuring out what your health insurance plan covers

5 Jul

This is the part of health insurance that originally gave me a bit of a panic attack. Figuring out what is covered and what is not can be really tough, especially if you don’t understand insurance terminology. So, here is how to figure out what your health insurance covers.

Step 1: Figure out what kind of services you may be receiving during pregnancy. This is my list:

  • Doctor’s visits (duh)
  • Ultrasounds at the doctor’s office
  • Blood work
  • Prescription medications for infections, nausea, etc.
  • Hospitalization for labor and delivery
  • Care for the baby after labor and delivery
Step 2: Locate these services on your insurance plan. Usually your policy coverage is broken down by type of service.
Step 3: Decode insurance plan. This one is the most fun. 🙂 Some insurance plans are easier than others. The Blue Cross Blue Shield Maternity Rider option that I am selecting has the following coverage:
This coverage is not difficult to decode. All of my maternity expenses are covered 100%, except for $35 each time I go to the doctor and $150 for each day I am in the hospital.
Well . . . now that I have figured out what my maternity coverage will be, good luck to the rest of you decoding regular insurance policies.
Except for the fact that complications and newborn care are covered under my regular policy. I did not decode that bit information. I asked an insurance agent. That is an important lesson: decode as much as you can, so you have a basic understanding of your policy and then ask an insurance agent. They are the experts on your policy coverage. Take advantage.
So. If I have complications or when the baby needs to go to the doctor, I will have to look to my regular insurance plan for coverage. There are several types of coverage available.
First there is coverage where Blue Cross Blue Shield pays a set amount:
Under this coverage, Blue Cross will pay the first $50 (for a family physician) or first $75 (for a specialist) of the doctor’s visit. This amount is all they will cover, regardless of the services rendered at the visit. However, I only have to pay the “allowed amount” which is the rate that Blue Cross has negotiated with the doctor. Which is (hopefully) lower than what I could negotiate myself.
Example: I go to a family physician and he recommends an MRI. The visit is $200 and the MIR is $650. Blue Cross will pay $50. I would have to pay $800.
Alternatively, there is a coverage option that I would just have to pay a set co-pay:
Under this coverage, I would pay either $35 (for a family physician) or $75 (for a specialist). However, I have an additional co-pay for any imaging services that are done at the visit. If I opt to go to an out-of-network doctor, then the co-pay system doesn’t apply. In that case, I would have to reach my deductible first and then pay for 50% of cost of the visit.
Example: I go to a family physician and he recommends an MRI. The visit is $200 and the MIR is $650. Blue Cross will pay $165 for the doctor’s visit and $350 for the MRI. I would have to pay $335. If the family physician was out-of-network, then I would have to meet my deductible of $2,500 before insurance would begin to pay. This means that I would pay the entire $850.
If, however, my visit was a preventative care visit, then a different payment structure would apply:
Example: I take the baby to a well baby visit with the family doctor, but it is an out-of-network doctor and it is $200. I pay a set 50% of the cost of the visit – $100. If I had selected an in-network doctor, then the cost would have been $0.
These coverage examples illustrate several different payment structures:
  1. Insurance pays a set amount, you pay the rest.
  2. You pay a set amount and the insurance pays the rest.
  3. You meet a deductible and then pay a portion of costs after that deductible is met.
  4. You pay a set percentage of the cost.
  5. The insurance company pays everything. Yay!
Once you have figured out which of the five scenarios your coverage fits into (and the answer may be different for each service), it is easier to compare the costs of pregnancy and labor with and without insurance.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: