How will I be billed for prenatal care and labor & delivery?
November 26, 2017 7:36 AM   Subscribe

I'm expecting first baby in a few weeks (yikes) and have a proper health insurance plan for, like, the first time in my life. It's a California off-exchange (meaning I receive no subsidies) platinum plan that is $0 deductible, 10% co-insurance, and $4,000 out of pocket max. According to my plan summary all prenatal office visits are covered with no co-pay. I've just been paying $20 co-pays for lab tests. I'm not totally sure the plan is technically an "ACA plan" since it's off-exchange.

But I'm confused by something called "global billing" by OB offices. Is it legal for OB offices to send me some big bill after the birth even though my prenatal visits should have been covered? I just want to be prepared in case they do. And if both the OB and the hospital bill me, and my out-of-pocket max is $4,000, how do I figure out which bill to pay first? If you had a baby on an ACA plan (on or off-exchange), how were you billed after the birth?
posted by KatNips to Health & Fitness (8 answers total) 1 user marked this as a favorite
Global billing means that the entire pregnancy and delivery are bundled into one charge, a "global" charge. If you need to see the doctor weekly or three times a week there is no difference in the bill, or the payment to the doctor. This probably doesn't include the hospital bill, but your deductible is for your costs per year, not costs per doctor or hospital. In no case will you need to pay more than $4000 per year under your policy.

Please call your insurer (number usually on the back of your insurance card) for further explanation on this. If your pregnancy crosses over into 2018 the bill is only presented once, at the termination of the pregnancy. All the prenatal visits are "free" (no copay) because of the ACA and it's requirement that all insurance policies cover pregnancy. Before the ACA many policies excluded pregnancy and delivery. Cheaper for seniors, but policies that covered pregnancy and delivery were way more expensive for potential mothers. Some employers refused to offer policies that covered pregnancy.

Global billing for pregnancy is extremely common, and has been both before and after ACA insurance policies to encourage pregnant women to keep all their appointments, and to discourage unnecessary testing by OBs.
posted by citygirl at 8:43 AM on November 26, 2017 [3 favorites]

Your insurance plan will tell you your responsibility on each bill you receive- you may receive an EOB in the mail, or you can login to your online account to review. They will coordinate how much each bill counts toward your deductibles and out of pocket maxes.
posted by ThePinkSuperhero at 8:50 AM on November 26, 2017

Also keep in mind that baby will have their own separate bills from the hospital, so check into what your family out of pocket max is. They can be covered on your plan for 30 days.
posted by wsquared at 9:00 AM on November 26, 2017 [3 favorites]

I’ve just been through this and have just one tip. Check with the hospital you plan to deliver at and see if they offer a discount if their fee is paid in full. For example, my OOP max is $6000 so a day before my csection I went in and paid $4800 as they offer a 20% discount if you pay ‘in full’. Just something to consider.
posted by PorcineWithMe at 9:29 AM on November 26, 2017 [1 favorite]

The OP has not indicated their plan is ACA-compliant.

ACA-compliant insurance can be bought on exchanges, off exchanges, or provided by an employer. A "platinum plan" is not necessarily ACA-compliant. If a plan is ACA-compliant, then yes, the responses here about ACA covering prenatal visits is correct. However, it is possible to buy non-ACA-compliant insurance in which case that'd be false. Insurance companies are not required to cover prenatal visits - for that matter, they are not even required to cover pregnancy. ACA-compliant insurance policies (which is not all insurance policies) are required to cover prenatal visits.

The more relevant question to the OP is - have you purchased an ACA-compliant insurance policy? In other words, do you pay the mandate "tax" because of not having an ACA-compliant policy?
posted by saeculorum at 10:59 AM on November 26, 2017

In my experience (can't guarantee it is 100% true) the doctor and hospital submit their bill to the insurance company, the insurance company pays their share and then you get a bill for your share. When the insurance pays, they should send you an EOB (Explanation of Benefits) which explains their calculations and shows what you owe. This will tell you which bill has co-insurance and which one got covered by your out of pocket maximum.
posted by metahawk at 11:18 AM on November 26, 2017 [1 favorite]

I think the plan I have is ACA-compliant because it's a new individual plan purchased in 2017, not a grandfathered plan from past years.
posted by KatNips at 12:46 PM on November 26, 2017

You may get three bills - hospital, doctor, and anesthesiologist, if you get an epidural. Also bills for baby. Save all your Explanation of Benefits statements, and pay whatever bills come first. If any come after you've hit your max OOP, call and ask them to resubmit to the insurance company.

I was SHOCKED at how easy pregnancy and delivery medical fees were, compared to literally every other medical/dental/vision procedure I've ever had. And I had two very complicated pregnancies, one with hospital bedrest and a long NICU stay. And both times, I paid a handful of lab co-pays, one lump sum at the end, and had zero hassles.
posted by peanut_mcgillicuty at 8:45 PM on November 26, 2017 [1 favorite]

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