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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. ūüôā 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.

Find Available Plans

2 Jul

I thought that finding an insurance provider would be the easiest part of this entire process. I was surprised to find that most insurance providers don’t cover maternity (at least when you are purchasing insurance as an individual). There may be more insurance companies willing to cover maternity outside of Florida, but in my area, there is only Blue Cross and Blue Shield. Here is the process I went through to make sure I looked at all of the health insurance options available to me:

  1. Check with the major insurance providers. An aggregate site such as can be helpful for this step.
  2. Check with the federal government, if you are low income you may be eligible for medicaid.
  3. Check with your state government. They may offer health insurance plans to residents, especially if you are low income.
  4. Check with your local government.
  5. Check with any professional organizations you belong to (or could belong to). Some organizations offer health insurance plans for purchase as a part of membership.
However, even after all of this checking, I found that the only provider that was willing to sell me a plan to cover maternity was Blue Cross Blue Shield.
Blue Cross Blue Shield health insurance plans don’t¬†usually¬†cover maternity. You have to purchase an additional maternity rider. (For more information about what a rider is, see Learn the Lingo.) For an extra premium each month (about $190, but this varies a bit depending on the underlying plan), I can purchase maternity coverage. However, this rider cannot be added to all plans. There were 8 plans that allowed maternity riders.
So, instead of the plethora of insurance options from various companies that I expected, I found 8 insurance plans, all from the same company. I was very surprised, but I guess it makes choosing an insurance plan easier, huh?
This aggregate site searches for insurance quotes with 8 different insurance companies in Florida:
You can also get health insurance quotes from the companies directly:
(Just to name a few! A google search of health insurance + your state will find more companies that offer policies within your state)

Costs of Pregnancy

20 Jun

Estimating the costs of pregnancy is tricky business. The costs can vary widely depending on your health, your healthcare provider and how complicated your labor and delivery is. However, I wanted to estimate my costs to try to figure out how much insurance would save me over paying for everything out-of-pocket.

There are two components of maternity care. First, the cost of doctors visits and related testing. Second, the costs of labor and delivery.

Typically, a pregnant woman will visit a doctor once a month during weeks 4 through 28, twice a month during weeks 28 through 36 and once a week for weeks 36 through delivery. This adds up to about 15 doctors visits. However, it was hard to figure out how much each visit would cost. After reviewing some discussion boards, it seemed like $200 per visit was a good estimate. There may also be additional charges for ultrasounds (~$250 each), blood work (~$350 for all testing during the pregnancy) and other testing (this is pretty unpredictable and will vary greatly depending on the testing you want and the testing your provider feels is necessary). So, my broad estimate for the cost of doctors visits and related charges is $4,850 (15 doctors visits + 4 ultrasounds + blood work + $500 for other testing).

Next, I needed to estimate the costs of labor and delivery. After having scoured the internet for information on costs of doctor’s visits, I expected it to be very difficult to figure out how much labor and delivery would cost. However, it was actually very easy.¬†If you live in Florida, as I do, you can go onto this website:¬†¬†and find out how expensive it is to give birth at the hospitals in your area. In my area, one hospital averages $14,945 for labor and delivery plus $1,895 for infant care ($16,840 total). The other hospital averages $8,020 for labor and delivery and $1,313 for infant care ($9,333 total). Of course, the more expensive hospital is the one I would prefer to go to. It is much nicer and it isn’t a teaching hospital.

Including labor and delivery (at my preferred hospital) and doctors visits, my estimated total for maternity care is $21,690. I’ll be honest, this is¬†way¬†more than I expected it to be. And, this doesn’t even consider the possibility of complications! The average cost for a¬†Cesarean is $22,200 and after birth care for an infant with complications averages $4,455!¬† This means that for birth alone a complicated pregnancy can cost $26,555. When you add in the doctor’s visits and such, you are up to $31,405. And, if you consider that there might be 5 extra doctor’s visits and an extra ultrasound, then the cost is up to $32,755.

I am beginning to think that the phrase “babies are expensive” is the biggest understatement ever.


Find out about labor and delivery costs in your area (Florida only):

Information about the number of doctor’s visits during pregnancy and what to expect at these visits:¬†

Learn the Lingo

14 Jun

When I began looking for health insurance, I jumped right into looking at the available health insurance plans. That was a huge¬†mistake. I had no idea what I was looking at and I quickly became overwhelmed and disheartened. I began to think: How is it possible that I can’t understand a health insurance plan? How will I ever pass the bar exam if I can’t even figure out a health insurance plan? If I can’t pass the bar than none of this matters, I won’t be able to have a kid because I’ll have to work two jobs to pay off my law school debt and we’ll never be able to buy a bigger house and I’ll just work until I’m too old to have kids and then I will die alone and in poor health because I don’t have a health insurance plan because I could never figure it out . . .

You get the picture. And it wasn’t a pretty picture. But, once I stopped hyperventilating, I realized that understanding a health insurance plan is a lot like understanding the law: you have to learn the lingo. So, here are what I think are the most confusing insurance terms along with simple definitions.

Co-insurance¬†– this is an amount (usually a percentage) that you will be responsible for paying. For example, if your coverage description says: “20% co-insurance” that means you will have to pay 20% of the cost of the service.

Co-payment – this is very similar to co-insurance, but is usually a flat amount that you are¬†responsible¬†for paying. For example, if your coverage description for a visit to the family doctor says “$35 co-payment” then you will have to pay $35 each time you go to your family doctor.

Deductible¬†(or¬†calendar¬†year¬†deductible, often abbreviated CYD) – This is an amount that you have to pay each year before insurance begins paying. The deductible may not apply to all services. If the description of coverage says something like “CYD + 20% co-insurance” then you have to pay whatever your deductible is before your insurance will start to cover the service. There are other types of deductibles as well, such as a pharmacy deductible. These specific deductibles are the amount you have to pay for a specific service (here, prescription medications) before coverage for that service will begin. While the normal deductible counts all of the expenses you paid, no matter what the expenses were for, specific deductibles include only expenses you have paid in a specific area (such as prescriptions). Otherwise, they work the same way a normal deductible works.

Out-of-pocket maximum – this is the maximum amount you will have to pay, for covered services, each year towards health care. Some companies do not count prescription drug expenses towards reaching your out-of-pocket maximum. Once you have paid your out-of-pocket maximum, your health insurance will pay 100% of your bills.

Pre-existing condition – this is a condition that you knew or should have known existed before your policy went¬†into effect. How do you know if you should have known (but didn’t)? Well, the standard is whether a reasonably prudent person would have gotten it checked out. Who is the reasonably prudent person? (This, by the way, is a question that haunts first year law students as they progress through their Torts course.) The reasonably prudent person is a very boring guy. He doesn’t take risks and he always stops, looks both ways and listens for vehicle traffic before crossing the street. He doesn’t speed and always comes to a full and complete stop at stop signs. I could go on, but I think you get the picture. Basically, if there was any symptom at all (an odd mole, stomach pain, etc.) that you had before the policy that could have clued you in that there was something wrong, whatever is wrong is considered a pre-existing condition. Now, if you can show that you had insurance coverage during the time that the reasonably prudent person would have figured out there was something wrong, then there may be some coverage. Additionally, and here’s an important one for us pregnancy planners: Pregnancy is a pre-existing condition. If you conceived before your coverage began, you may not be covered. The tricky thing here is that pregnancies are dated by the first day of your last period – so your insurance company could claim that you were pregnant on that date, even though you actually weren’t, because that is how your pregnancy is dated. The lesson: buy insurance early. Like a few months early. Just to be safe.

Rider Рthis is essentially a policy that stacks on top of (or rides on top of, if you will) your basic policy. For example, Blue Cross and Blue Shield offers a maternity rider because their basic policies do not cover maternity care. This rider has completely different coverage than the basic policy and I would pay an additional premium every month for the rider.

Total Lifetime Maximum Benefit – this is the most the insurance company will pay out over your lifetime.

Vesting period – this is basically a delay in coverage. The vesting period is a time period during which your insurance company does not cover you. Now, usually vesting periods relate to a specific type of coverage. For example, coverage for maternity may not vest right away. You may have to have the coverage for a few months before it kicks in. And, here’s the kicker, you may not be covered if you conceive (or develop whatever condition the vesting period concerns) before the vesting period is over.