Delivering at hospital that’s out-of-network?

[morebu]

My health insurance is so hard to understand I just need help interpreting it. So for out of network hospitals it would be $750 copay/admission and 20% coinsurance to deliver a baby. While in-network would be a $250 copay. I really want to give birth at a particular hospital, where my OB works, but it’s not in network. Can someone tell me how much you think a delivery would cost with the $750 copay/admission and 20% coinsurance? I unfortunately live 8 hours away from the nearest covered hospital (don’t ask) so I don’t think in network would even be possible.

(23, F near D.C area)

 

[savemeplz777]

@morebu I think I read all the comments and didn't see it mentioned anywhere:

I saw you mentioned it was your father's plan. Have you specifically verified with your insurance that the plan has maternity coverage for dependents that are not the policy holder/spouse? Just want to make sure you don't get a big surprise later on.

 

[basketball4him]

@morebu Delivering out of network, there is no upper limit on what you can be charged here. Your insurance will pay 80% (+$750) of what they think your delivery SHOULD cost but they can ignore everything else and you'll be on the hook for it.

I unfortunately live 8 hours away from the nearest covered hospital (don’t ask)

Could you file a network adequacy request to get the desired hospital covered? It would save you a lot of money.

 

[morebu]

@basketball4him Okay, and I never knew about the network adequacy thing I’ll look into it! Thanks

 

[ngocvncom]

@morebu WHY do you live 8 hours from the nearest network hospital? Did you buy a local plan that is supposed to have a local network? A network adequacy appeal is only going to work if you're supposed to have in-network providers in your area...

It's going to be extraordinarily expensive to deliver at an OON hospital. You'll probably end up owing $20k+ easy. There is literally no limit on what you could have to pay if there are complications.

 

[morebu]

@ngocvncom Because I’m still a dependent on my fathers insurance, if I deliver outside of Massachusetts, it’s considered out of network. But I recently moved to Maryland, and want to stay on his plan as long as possible, because health insurance is damn expensive

 

[ngocvncom]

@morebu Well, living outside your father's service area isn't a reason for a network adequacy appeal and you're going to be denied that. If you moved to MD within the last 60 days, you should use https://www.marylandhealthconnection.gov/ to purchase yourself an individual plan. The vast majority of people qualify for premium tax credits and have very affordable premiums. Even if you don't qualify because you make too much or turned down work insurance; it's going to be a lot cheaper than delivering out-of-network.

 

[giamfreeg]

@ngocvncom Couldn't OP run into an issue with pregnancy on her father's insurance plan? I thought plans are obligated to cover pregnancy/birth/related costs but only for the named insured and spouse, not for dependents. I may be wrong though.

 

[savemeplz777]

@giamfreeg Missed your comment. I just commented the same thing. I would be very surprised if the plan has maternity benefits for dependents.

 

[livelovelaugh99]

@giamfreeg This 1000xs. My friend was on her moms when she delivered since her work didn’t have any coverage then. I was finally able to help her appeal for payment since she had been told 40xs over that she was covered by reps.

 

[resjudicata]

@giamfreeg OP will have coverage for her stay, and baby will be covered applicable to state laws regarding automatic coverage, but after that automatic coverage period ends, the baby cannot be enrolled.

 

[morebu]

@ngocvncom Ok, but when baby comes will he be added to my individual plan or my boyfriends plan? We’re not married so it’s not like we can get a family plan right now.

 

[ngocvncom]

@morebu Your baby is very likely going to be eligible for CHIP unless you have a high income for your age. Which is free state insurance. If you are above that threshold; then it's your choice whether you add the baby to your plan or the father's plan. But yes, assuming you and the father aren't married; you won't be able to be on a plan together and will have to pick.

YOU might be eligible for MD Medicaid instead of a marketplace plan because of your pregnancy. That link will direct you to the appropriate program depending on the income you enter.

 

[morebu]

@ngocvncom Okay thank you

 

[marysnare]

@morebu You can call you insurance company and ask if they will do an LOA. Letter of agreement with the hospital to cover you. It is basically a one time contract for service. would greatly help if you had the support of you physician and a medical reason to support the request.

 

[yaaqov]

@morebu Check with your insurance and you may be able to get a preauthorization to deliver at the OON hospital and they would partially or fully cover it. I'm just not sure how it all works exactly, but worth a shot to maybe ask your doctor and your insurance!

 

[rozenliefde]

@morebu Appeal Supervisor here --Congratulations!!! Don't stress. Since your plan has out of network benefits, that's what you have to go with in this situation. The good news is childbirth falls under NO Surpises Act, so a non par facility will be limited to the Qualifying Payment Amount (QPA). They will not be able to balance bill YOU for the difference between the billed and allowed amount. You should just owe your $750 copay plus 20% coinsurance based off the QPA amount.

How will you be covering the baby's claim though? Usually, insurance does not cover grandchildren unless the grandparent legally adopts the baby. Check with your Dad's plan. If the baby's Dad has insurance, he needs to add the baby to the plan within 30 days of birth typically. Make sure the hospital has the insurance info on file for the baby.

 

[cyclone_105]

@rozenliefde Are you sure this is accurate? The OP states that they're on a family group plan and generally on most policies I've seen, M&B services do not apply to dependents but only the primary and secondary on the account.

To my reading, this likely would not qualify for the NSA as it would be a non-covered service.

Totally spot on about the kid needing coverage. Generally they'll have an automatic enrollment as long as they notify the parent's MCO.

 

[rozenliefde]

@cyclone_105 Most group plans will cover the delivery charges for the dependent child. There are some plans that exclude dependent maternity-- but that is rare. Most Plans will not cover the dependent of a dependent. Her Dad's insurance has been providing coverage throughout her pregnancy (ultrasounds/labs, etc). If the Plan did not cover dependent maternity, those claims would have already been denied as not covered.

This would qualify for NSA coverage. Childbirth is one of the primary causes of surpise billings.

 

[cyclone_105]

@rozenliefde Thanks for the clarification. I mainly deal with Medicaid and Medicare plans so commercial policies and benefits aren't my strong suit.