insurance question — The Bump
Military Families

insurance question

So I just posted this on a different board, then scrolled down and saw this one, and figured this would be the right one to ask it in. This is our 1st and I have Tricare Prime, and it says that it doesn't cover any ultrasounds unless they are medically necessary or I am a high-risk pregnancy, which I'm not. But basically it's saying that I'll never get to see my baby or find out what I'm having, which I'm not ok with at all since my husband and I both want to know the sex. Does anyone here have Prime and know if anything will be covered? I'm going to try to call them on Tuesday but I read it today and am anxious to know what I should expect. Thanks in advance for any tips, answers or advice.
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Re: insurance question

  • Don't call Tricare, they are just going to tell you that they don't cover any non-medically necessary sonograms, you will just be frustrated and wasting your time and theirs. 

    Call your doctor and ask them what medically necessary sonograms they do routinely. 

    Most doctors (even at military treatment facilities) do two routine and "medically necessary" sonograms.  They do an early sonogram (usually about 10-12 weeks to date the pregnancy.  Then they do an anatomy scan between 18-22 weeks.  If your child cooperates at the anatomy sonogram you will be able to find out the sex of your baby then.  If your baby does not show the goods at your anatomy sonogram and you have a normal healthy pregnancy there will not be another covered sonogram for you (finding out the sex of your child is NOT medically necessary).  However, if that is the case you can always find a 3D place out in town to help you determine the sex of your baby.  Most of them give you a guarantee they will find the sex of your baby (or they will give you subsequent free sonograms until they do) and they are usually pretty inexpensive ($125-$200).

  • If you are seen on base, you will have a first trimester u/s for dating purposes, and around 20 weeks, you will have a diagnostic u/s. They are NOT intended, EVER, to determine the gender.  That is a perk, not a requirement.

    If you are seen in town, it is really up to the OB.  Some will do an early u/s, some will not, and it doesn't matter what your insurance is.  No matter who you go to, you WILL have a 20 week u/s.  It is determined to be medically necessary because it is to look for any abnormalities with organs, growth, the umbilical cord, etc. 

    A little word to the wise, babies don't always cooperate.  When you have your "big" u/s, it is entirely possible that the baby will be in an odd position or have his/her legs crossed making it impossible to tell the gender.  In that case, they WILL NOT have you back for another just to tell you the sex.  Like I said, it is a perk, not a requirement.  In any case, you can pay to have a 3D u/s done around 30 weeks or so.

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  • Yes, Tricare officially says that they don't cover ultrasounds unless it's medically necessary but most doctors will say that the ultrasounds, especially the growth scan ultrasound is medically necessary.  It's pretty common for doctors to do at least 2-3 ultrasounds per pregnancy, one in the 1st trimester, the growth scan (around 20 weeks), and possibly one near your due date.  Most ultrasound techs (or doctors if they do the ultrasound) will tell you your baby's gender at the 20 week ultrasound, they aren't usually so mean not too!  

     

    I do agree with PP who said that the baby may not cooperate with your plans!  My DD would not spread her legs during my 20 week ultrasound.  We had to wait over a week before getting another one to find out.  

     

    Good luck! 

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  • IlumineIlumine
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    You are correct, TRICARE will not pay for non-medically necessary U/S.  However, a 20 week U/S is standard practice for dianostic purposes....you do have to see the baby to make sure that everything is working properly.

    And Lissa is correct, finding out your baby's sex is not a right, just a perk of the U/S.  So if your baby is being porky and you REALLY need to know its sex, you are just going to have to pay out of pocket.

    If you DO want to get more U/S pictures, check for a U/S school in your area.  I know that there is one in Pensacola that charges a minimal fee for you to be their student's training tool.

     

     

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  • image kdodge423:

    That rule is not unique to Tricare. It's pretty standard for any insurance company.

     

    Yep.  I had my first 2 kids before my husband joined and only had the 20ish week u/s done.  Like others said, that one is medically necessary since it is NOT an u/s to find out the sex, it is when they do many checks to be sure everything is on track etc.  You can always go to a place and have a 3d one done and a video too if you wanted.

  • Does anyone know if it's better to have tricare prime or standaar? There is no real hospital or obgyn on our base, so i get referred to an obgyn off base and a local hospital to deliver.  My friend said with prime you might have to pay more, but it didnt make sense to me, anyone know?
  • If you are on Prime and are referred off base for care you pay exactly the same amount you would pay if you were being seen at an MTF = $0 (the only exception being if you have prescriptions filled at a non-MTF pharmacy, there is a charge for those $3-generics, $9-brand basically). 

    There are some co-pays associated with Tricare Standard and you pay a nominal fee per day you are in the hospital (like $12 a day), but ultimately your out of pocket for a Tricare Standard pregnancy/labor/delivery is less than $100.  You pay for prescriptions filled at non-MTF pharmacies as well when you are on Tricare Standard.

  • thank you for your help!! I'll stick on prime then!
  • I was on standard until I got pregnant, then I switched to Prime. We're a tiny base in New Orleans with no OB on base & my PCM referred me off base. I asked her if it would cost more since I'm going off base & she said bc they don't have the facilities, I'm not just electing to find an OB elsewhere, everything is still completely covered.

     

    And thank you to everyone for your help!! I appreciate all of your responses!!

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  • Are you seen on-base or referred off-base?  At my first appointment they told me I would only get one u/s at 20 weeks.  I got one at my first appointmnet (11 weeks) for dating purposes, and then a 20 week u/s.  They saw something minor on that u/s and are ending me for a follow up in 2 weeks (i'll be 28 weeks).  I used to work in Tricare - ignore what they said.  The dr. will do your u/s.
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  • my PCM is on base, but it's so tiny that I was referred off-base for my OB since we don't have one. I used to sell insurance so you'd think I'd know these things, but I guess your mind just races when it's about you. Thanks!
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