A prominent media figure recently asked me what advice I would give to a patient who did not have maternity health insurance coverage through her husband's employer. This woman could not access her own employer's health plan because her company required that she use her spouse's health plan if one was available.
This was a very unique situation because she could not get maternity benefits through her existing health plan and could not enroll in Medicaid or SCHIP to cover labor and delivery because she already had health insurance. When she called providers to determine what labor and delivery would cost, she was quoted total out-of-pocket cost of "$14,000" for all pre-natal and delivery services.
The reporter had to paraphrase my response for The Today Show and the Utah Daily Herald but here is what I said in entirety:
1) If she and her husband both have insurance but labor and delivery is not a covered service, they will be considered "self-pay" patients for this service. This seems overly simple, but it is important to note because it precludes them from enrolling in Medicaid or SCHIP. This rules out public health insurance for them.
2) I believe that the "gross charges" or as I like to call them "sticker price" of the pre-natal care and delivery are probably $8,000-$14,000. This is the "gross" amount that providers charge to insurance companies before the "insurance discount" or "contractual allowance" is applied. The "net fees" that an insurance company would pay would be smaller than this. You could think of this as a volume-discount arrangement. Insurance companies get "contractual discounts" because they negotiate on behalf of hundreds of thousands of patients.
Some states, like Minnesota, preclude hospitals from billing self-pay patients more than the "most favored" insurance contract rate they have for a non-covered service. South Carolina is not such a state, but it is reasonable to expect to pay the same as an insurance company.
3) I would expect the "net charges" or "net fee" amounts to total $5,750-$7,000 for the delivery:
� $3,500-$4,000 for hospital
� $1,500-$2,000 for the OBGYN physician
� $750-$1,000 for the anesthesiologist
I found these figures on HealthcareBlueBook.com. I ran a search for "delivery" in Charleston, South Carolina and their database calculates the average insurance payment for a delivery in that area. It is also important to note that if she ends up having a cesarian section ("c-section"), the hospital component of the payment could be up to $2,000 higher.
4) I would recommend she and her husband apply for financial aid at all the hospitals at which their OBGYN physician has privileges and make sure at least 2-3 of them are "charitable" not-for-profits. They need to make the hospital representatives aware that they will be self-pay and ask for "self-pay" and charity care discounts.
To answer your question, yes I think a 4-9 month payment plan would be reasonable for all providers involved, but I would not expect to get one "after the fact". I advise setting it up before hand. I cautiously warn people when they are offered Care Credit by physicians. They can get hit with very high interest if they do not realize there is a balloon payment. The attorney general of New York is investigating this company now.
5) She will have to ask each hospital which anesthesia group provides service there and contact the anesthesia groups about their fees for deliveries.
6) If the OBGYN physician and the hospitals he/she has privileges at do not come in this range and money is an issue, the patient should shop other physicians.
7) Assuming they are not already pregnant, they could start saving up money now. This isn't a very exciting option, but it is probably the best one.
8) I personally am not a proponent for birthing centers or home births to save money. These sites are not equipped to handle complications and I do not believe it is not worth the risk to save money when having a baby.
9) Most medical bill advocate services will charge the patient a percentage of their savings. I think this can be misleading because these services may the lead patients to believe they are saving the difference between the "sticker price" and the "net fee". This is a big spread and no one really pays the sticker price anyways. I would advise her to get the best price she can on her own first. If the advocate can't get anymore, she is not out anything.
This couple had a unique insurance situation that precluded them from accessing Medicaid or SCHIP maternity coverage like most people would. Another good resource for pregnant and recent mothers is the Women-Infant-Children (WIC) program, which is available in many states.
The Affordable Care Act of 2010 has also made maternity care coverage a "minimum essential health benefit" effective in 2014 for Medicaid and all individual health plans that are subsidized by the federal government. So starting in 2014, if you purchase an individual health plan that is partially funded by government money, it will have to include maternity coverage.
Contributed by Nicholas Newsad, M.H.S.A., author of Medical Bill Help and The Medical Bill Survival Guide.
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