Planning a Family? Get to Know Your Health Insurance Policy

Congratulations! You’ve decided to start a family. Up until now, your health insurance has probably been adequate, paying for routine doctor visits and prescription drugs. But now that you’re facing a lifestyle change, you must make sure that your health insurance policy will keep up with those changing needs.

Check your coverage

Some policies insure only spouses and dependent children. So, if you and your partner aren’t married, you’ll want to check your policy carefully. If coverage is an issue, and you don’t plan on getting married, consider whether purchasing an individual health insurance policy is an option.

Don’t wait until you become pregnant to look for that policy, though. The insurance company will know that you have a condition that’s going to require treatment and care. In a worst-case scenario, something happens (e.g., a difficult birth, or a premature baby), and the baby ends up in the neonatal unit. So, whenever you try to buy insurance for a condition that already exists, expect the cost to be high.

When will the baby’s coverage start?

Usually, your baby will be covered from the time of birth. Even if you and your partner are not married, either one of you should be able to add the baby to an existing plan.

Find out what you have to do to add your baby to your health insurance policy. Some plans require you to add your baby within the first 30 days following birth. Other plans will waive the additional premium for the first 31 days if you enroll within 31 days following birth.

If you’re adopting an infant, and the birth mother has no insurance, you may have to pay for prenatal care and the costs of childbirth. If you’re adopting an older child, make sure that you know when your insurance policy will begin coverage.

What is covered before your baby is born?

Will the plan pay for the first prenatal visit during the first trimester of pregnancy? Does the plan offer a prenatal program to assist you in having a full-term baby and avoiding a problem pregnancy? Some plans provide prenatal education, health screening to determine risk, and case management services to encourage a healthy delivery. Are services for any medical condition that may complicate a pregnancy covered? If your physician leaves the insurance plan while you’re pregnant, does the plan’s continuity of care policies cover the remainder of the pregnancy with the noncontracted physician if you’re already in the second or third trimester?

What is covered during and immediately after birth?

• Is precertification required prior to hospital admission? If so, make sure you take care of it, otherwise you might have a problem with claim payments.

• What length of hospital stay is covered? Do vaginal and cesarean deliveries have different time limits?

• Is the baby’s stay in the nursery covered?

• Does the plan pay for administering anesthesia, obstetrical procedures, and any assisting required?

• If it is necessary for your baby to be hospitalized past the normal time period, will a separate deductible and coinsurance apply?

• Will the policy cover any complications from a premature birth?

• What if there’s a difficult birth that lands your baby in an expensive neonatal unit?

• Does your plan provide care before the baby leaves the hospital, including routine tests, nursery service, doctor exams, and circumcision?

After you bring your baby home

How easy will it be to get emergency care under your plan’s rules? Babies are susceptible to illnesses and injuries. You don’t want to have to wait for prior approval or drive past two hospitals while rushing your sick newborn to an approved medical facility.

Will the plan pay for transportation costs to the nearest facility to treat any special conditions? If so, is there a maximum amount?

Does the policy have a maximum amount it will pay for well-child care? Well-child care usually includes physical examinations, laboratory tests, developmental assessment, immunizations, and guidance necessary to monitor the normal growth and development of your child. How many years will it pay?

What if your adopted baby is born with medical problems you didn’t expect? Will the policy cover pre-existing conditions if you’re adopting an older child? Does the plan offer home visits for new mothers?

Understand your out-of-pocket expenses

Many policies have a family deductible, which is the maximum amount that the family as a group must pay before the coverage begins. Instead of multiplying the individual deductible by the number of family members, the family deductible is often two or three times the individual deductible, regardless of how many family members are covered. The same is true of your coinsurance cap.

Review your co-payments. With a new baby, you will be making more trips to the doctor and buying more prescription medicines. It might be worthwhile to lower your deductible and co-payment. Your insurance premiums will be higher, but your benefits will be greater. Do a comparison to see what will work best for you.

Maximum lifetime benefits

The  Affordable Care Act prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage, rescinding coverage except in cases of fraud, and from denying  coverage based on pre-existing medical conditions. Also,  plans may not place annual limits on coverage, except in the case of grandfathered plans.

Read your policy carefully and make sure you have the coverage you need. If you have questions, meet with an insurance professional. Understand how your policy works–what’s covered and what isn’t.