Prenatal Care Preventive and Global Billing ACA

[phausof]

My wife and I have a complicated situation. I'm hoping someone here maybe can help.

During 2017 my wife was on a HD plan/$3000 deductible with Anthem Blue Cross Blue Shield. In May we found out we were expecting. I understood the costs and that we were planning to have children when my wife chose the HD plan. However it's my understanding that with maternity care, prenatal care should be 100% without cost share due to the ACA. Her doctor was also part of a practice that does global billing for all routine maternity patients. I thought this was perfect because our due date was going to be in January 2018, new plan year, and I was afraid we were going to have to pay two deductibles. This wasn't the case since with Global Billing they bill at the end. My wife went to her doctor visits and we didn't get billed or see any EOB for any of her routine prenatal care, only extra items, ultrasound, Immunizations, and blood tests, etc., with the 2 ultrasound being the only thing applied to our deductible, most other tests were covered 100% under preventive care.

In December my wife's employer informed her they were switching insurance companies to Medical Mutual of Ohio (we live in Ohio) starting January 1st. At first this alarmed us, but we were rest assured that her doctor practice was still in-network. It basically is the same plan, different insurance company.

We had our daughter on January 6. My wife's last prenatal appointment was 12/27. End of January we got our hospital bill and we paid $3000 deductible for hospital care, bill was not a surprise, we were expecting it. However in February we got a bill from doctor's office requesting $1300 for prenatal visits. Since we had two insurances, the doctor's office couldn't do global billing and had to bill for services separately. They billed for Delivery and Postpartum to Medical Mutual and Antepartum Care (7+ visits) to Anthem dated for 12/27. I found this ridiculous for two reasons. 1 - like I said earlier, prenatal care is supposed to be covered 100% because of ACA & 2 - If we would have stayed with Anthem, we never would have been charged separately for Antepartum care because of Global billing.

Currently I am fighting with Anthem over the $1300 charge. I understand I changed insurance, so that's two deductibles. That's not the issue. The issue is prenatal care is considered preventive and preventive care should not be applied to deductible. According to the ACA, which states(42 U.S.C. § 300gg-13):

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for—

(1) evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and 1

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.

Under the HRSA Guidelines, it clearly states that prenatal care is considered a preventive care visit.

There are multiple references on the HHS and DOL sites that state prenatal care should be considered preventive. See FAQ. However for some reason Anthem calls prenatal care a "Maternity Service" not "preventive" According to my wife's Certificate of Coverage, Maternity Services are subjected to deductible. But also in my wife's certificate under preventive care it says for women's health, this plan follows the HRSA Guidelines. I have attempted multiple times to try and get somewhere with with Anthem Reps, but they don't even acknowledge prenatal & preventive. They keep saying my wife went to the appointment already pregnant, it's a pre-existing condition, therefore it's diagnostic, which is why it's applied to the deductible. I'm no lawyer but I don't understand how the insurance company can refute and not cover something by calling it another name.

I realize my wife's situation is probably unique because she changed insurances. Typically the hospital bills first for delivery, and one wouldn't pay for prenatal, because delivery & hospital charge is surly going to meet a deductible. The fact that my wife's insurance changed doesn't change the text of the law and what it considers preventive care.

We appealed with Anthem. Basically quoting the law and HRSA guideline and arguing it should be covered 100%. Claim was upheld. Anthem didn't even mention our assertion of preventive care in the response. They just said we didn't meet our deductible and that is why we need to pay $1300. I'm getting ready to do our second appeal with an Independent Review Board. However I'm afraid it's going to be a waste of time based my first experience. I also feel strongly we shouldn't pay and it's ridiculous that I have to go through all this just to get an insurance company to do what it's contractually obligated to do.

I don't know if anyone can relate to this experience but that's what I'm seeking or any other advice people might have. I feel like the only way to get Anthem to pay would be to sue and that's surly more than $1300. The doctor office is threatening sending us to collections. I don't want to pay the doctor because I strongly feel due to the law and my wife's contract we are not obligated to pay, but Anthem is. Happy to hear any advice anyone has.

Thanks!

 

[brenda76]

@phausof Simple question - are you sure it's a fully insured, ACA plan? If it's partially self-funded it's a whole new ballgame.

 

[phausof]

@brenda76 It's a non-grandfathered small group plan that I'm pretty sure is not partially self-funded in anyway.

 

[april1491]

@phausof I applaud you on doing your homework. Unfortunately the ACA does not require all prenatal care to be covered 100%. HRSA recommends only 7 procedures/screenings and a couple of counseling measures. Everything outside of these can fall under the illness benefit.

Screenings for:

1. Bacteria in urine
2. Gestational diabetes
3. STDs
4. Hep B
5. Iron deficiency anemia
6. RH incompatibility
7. Folic acid

Counseling is limited to tobacco and alcohol use during pregnancy and breast feeding support.

All other services/charges may fall under illness under the ACA.

Also - self or fully funded makes no difference with respect to the ACA. If fully funded the plan would have to follow any state regs in addition to the ACA.

 

[phausof]

@april1491 Is there a section on the HRSA site that says these specifically? HRSA list prenatal under "well-woman visit" and the report the recommendations are based on states a Well-woman Visit

Well-woman preventive services may include, but are not limited to, assessment of physical and psychosocial
function, primary and secondary prevention and screening, risk factor assessments, immunizations, counseling,
education, and preconception, prenatal, and interconception care.

I want to make sure I understand because like I said, I have been fighting hard with my wife's insurance company on this. I don't want to have to put foot in mouth.

 

[april1491]

@phausof https://www.healthcare.gov/preventive-care-women/

 

[phausof]

@april1491 The link you provided states well-woman visits separately as required preventive care. The law says HRSA Guidelines determine what should be covered without cost-share for women. The guidelines specifically state a well-woman visit includes prenatal care. Therefore shouldn't a prenatal care office visit be considered a well-women visit? All the federal information I've come across states this.

Not to mention my insurance (my wife and I have separate insurances through our employers) states prenatal care visits as preventive (except the first one to confirm pregnancy). My wife's new medical mutual policy states the same as per federal law. This is why I am at a lost with my wife's anthem insurance company because I don't understand. All I'm trying to do is understand...and hopefully not pay for the $1300.

 

[uldello]

@phausof A well woman visit is only covered once annually. The prenatal visits are not considered a well woman visit.

 

[phausof]

@uldello The HHS FAQ stated multiple wellness visits could be acceptable more than once a year depending on the need for the individual women. Prenatal care is listed on the HRSA Guidelines which the law says are services that much be covered without cost share?