potentially stupid question about insurance

DuckDuckGoose123 · October 2010

I was looking at my insurance manual today out of curiosity - since so many people have mentioned insurance only covering one ultrasound, I thought I'd take a look and see exactly what's covered during this process for me.

The language re: maternity care is really vague. It just says that, if you use a preferred provider (my doc is), then "Prenatal care (including ultrasound, laboratory, and diagnostic tests)" is covered. No specifics about numbers of ultrasounds, which tests, etc.

Does that generally mean that whatever my doctor orders is covered? Or do I need to call the insurance company to get more specifics? I'm trying to avoid calling them because I'll have to call from work and I don't want folks overhearing.

jengon · October 2010

I am not sure on it. But I would call anyway just to make sure for myself. Maybe wait until Saturday to call when you are at home.

rachie34741 · October 2010

I do believe that it means whatever is ordered is covered. With my previous pregnancy, I had united. After my first appt. and confirmation everything was covered and I never had to pay a copay. My dr also did numerous u/s do to me being somewhat of a high risk.

tarmar81 · October 2010

Definitely give them a call. It's really the only way to know for sure. Policy handbooks never give every single detail, unfortunately.

dandi799 · October 2010

Give them a call. It varies greatly from provider to provider. My friend and I looked at our insurance plans together and the language was almost identical, but they were different companies. I wound up paying exactly $0 for my entire pregnancy and she had to pay $2000.

Birdies08 · October 2010

That's almost the exact same wording as my insurance company, but I plan to call them to make sure.

Just a PSA about insurance companies- they will make things difficult for you. Don't be afraid to be pushy and fight with them, if need be. I deal with them daily, but on a specific pregnancy related note, I do have a friend who recently had to go above and beyond to get more than one ultrasound covered. They did pay, eventually, though!

tarmar81 · October 2010

You guys are lucky. I work for an insurance company and even I'm confused by the language. I actually just now called my insurance to ask about maternity benefits. Very, very little is fully covered. With my plan, you basically pay $1000 out of pocket (deductible) and then they pay 80% of everything until you hit $3000, at which point they pay 100%. So next year, I will very likely pay $3000 for appointments and delivery and the rest will be covered.

Sucks, but not much I can do about it.

dandi799 · October 2010

Birdies08:

That's almost the exact same wording as my insurance company, but I plan to call them to make sure.

Just a PSA about insurance companies- they will make things difficult for you. Don't be afraid to be pushy and fight with them, if need be. I deal with them daily, but on a specific pregnancy related note, I do have a friend who recently had to go above and beyond to get more than one ultrasound covered. They did pay, eventually, though!

This. I have had a bunch of tests that should have been completely covered. I was charged for all of them. It was fairly painless to resolve, but I wondered how many people just pay charges that they really shouldn't be responsible for.

J9melissa · October 2010

When I called into our insurance rep with the city, he stated that I would have one copay at the very beginning and everything else was covered except for the hospital stay/delivery (which would come out of my Deduct and OOP)

Birdies08 · October 2010

dandi799:
Birdies08:

That's almost the exact same wording as my insurance company, but I plan to call them to make sure.

Just a PSA about insurance companies- they will make things difficult for you. Don't be afraid to be pushy and fight with them, if need be. I deal with them daily, but on a specific pregnancy related note, I do have a friend who recently had to go above and beyond to get more than one ultrasound covered. They did pay, eventually, though!

This. I have had a bunch of tests that should have been completely covered. I was charged for all of them. It was fairly painless to resolve, but I wondered how many people just pay charges that they really shouldn't be responsible for.

And that is exactly why they do it. It's awful, but I'll try not to go on a rant here...

DuckDuckGoose123 · October 2010

Thanks! I'll give them a call and see.

MrsJuicy2B · October 2010

Generally, they'll cover anything that's medically necessary. They usually leave it up to the doc to decide medical necessity. If your doc is outside of the range of normal (orders a ton of ultrasounds without justification, etc) they might decline to pay for that procedure, but I would argue that if it isn't medically necessary, you shouldn't have received the test and therefore shouldn't owe for it. But that's just me. Maternity coverage is pretty standard between insurance companies. Your deductible, copay and coinsurance vary enormously between plans, so find out what that is, but from the wording you mentioned it sounds like you're covered.

Cat-in-Boston · October 2010

Hi

I'm a case manager for an insurance company and I really have to recommend that you call the insurance company to clarify the benefits. Most insurance plans have a standard limit, but they aren't going to put the limit in the master policies as they do change with current regulations and advice from major medical boards (such as the college of obstetrics).

You also need to find out about network coverage - i.e. do you have an HMO, PPO, POS??? What is the network and who will the prenatal care be covered under and at what level of coverage.

Seriously get to know your insurance coverage inside and out... know it like you would know the back of your hand. The knowledge will only protect you.

MelanieAdam0707 · October 2010

I hate insurance talk - I am en educated individual and it all sounds like jibberish to me...thanks ladies for helping clarify some of this - I may also continue to pick brains myself.

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potentially stupid question about insurance

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