Premie parents are startled by the health insurance gap

[Guest guest]

Health insurance plans sometimes don't cover care needed by newborn babies By

s Monday, January 3, 2011; 11:10 PM

Many expectant parents are pretty savvy these days about making sure that their

obstetrician and the hospital where they plan to have their baby are in their

health insurance network. Using an out-of-network provider would almost

certainly mean higher out-of-pocket costs: The plan might pay just 60 percent of

charges, for example, instead of 80 percent or more.

However, fewer parents-to-be realize that they may be in for a nasty surprise if

their baby is premature or for some other reason needs special care immediately

after birth: The neonatal intensive care unit (NICU) personnel at their

in-network hospital may be out of network.

" Some hospitals do contract with other clinical provider groups to run their

NICUs, " says Marie Watteau, director of media relations at the American Hospital

Association. The companies that staff the NICUs may accept the same insurance

carriers as the hospital, or they may not.

" When selecting a hospital, pregnant women should â & #128;¦ verify that all

hospital care, including NICU care and physician services, are in network, " says

Watteau.

and Sonji Wilkes thought they had covered all the insurance bases before

the birth of their son, , seven years ago. Their obstetrician and the

hospital near their Englewood, Colo., home were all in network. They checked

with the health insurer that provided their coverage to estimate their

out-of-pocket costs. The expected total: $400.

's birth was uneventful. But when hospital personnel circumcised him, he

wouldn't stop bleeding. He was given a diagnosis of hemophilia, treated and

placed in the hospital's NICU, where he received treatment to stop the bleeding

and remained under observation for a day.

A few weeks later, the Wilkeses got a $50,000 bill for 's NICU stay. They

learned that the unit, located on the same floor as the regular nursery and

delivery rooms, was staffed by a company under contract to the hospital, and the

company didn't accept the family's insurance plan. " We just thought it was part

of the hospital, " says Wilkes. " We had no idea that it was even an option

that the NICU could be in a different network. "

About 75 percent of the infants who wind up in neonatal intensive care come in

because they're premature; the remaining 25 percent have other medical problems.

In 2009, one U.S. baby in eight was born prematurely, defined as birth before 37

weeks' gestation, according to data from the Centers for Disease Control and

Prevention's National Center for Health Statistics. Although the rate of

premature birth has declined slightly in recent years, it's still more than 30

percent higher than in 1981.

There are many factors associated with preterm birth, including chronic health

conditions such as diabetes and high blood pressure and fertility treatments

that result in multiple births.

An Institute of Medicine report found that medical bills and other costs related

to prematurity totaled at least $26.2 billion in 2005, or $51,600 per premature

infant.

Ablondi's water broke at 25 weeks, and she delivered her daughter,

Abigail, about 21/2 weeks later. The doctors at Inova Fairfax Hospital, near the

family's home in Sterling, told her that it was unlikely her daughter would

survive. Abigail weighed just 2 pounds, 9 ounces, her lungs were immature and

she had sepsis.

Abigail pulled through and is now 4 years old. But she spent the first three

months of her life in the NICU and accumulated $750,000 in bills. Shortly after

her birth, the hospital billing department gave Ablondi the bad news that their

insurance plan might not cover all the NICU expenses because the staff was out

of network. " All of this stuff you're trying to juggle while you have a sick

child, " she says.

Gibbs, a spokeswoman for the Inova Health System, declined to comment

on the Ablondi case, saying she couldn't discuss specific patients because of

privacy laws. In general, she said, most health plans in the Washington area

that contract with Inova also cover the neonatology staffs. But she advised

patients to consult with their health plans ahead of time to confirm if the

charges would be covered.

(This was the Ablondis' first experience with insurance problems related to

childbirth, but not their last: A previous Insuring Your Health column examined

coverage difficulties during Ablondi's pregnancy with her second

daughter, Bethany.)

An astute social worker alerted the family to one possible way to address the

billing problem: Abigail might qualify for Medicaid, the federal-state program

for low-income or disabled patients. Under federal rules, if Abigail met certain

weight and other medical criteria, she could be deemed disabled under the

Supplemental Security Insurance program and thus be eligible for Medicaid.

Babies weighing less than 1,200 grams (about 2 pounds, 10 ounces) are considered

disabled; Abigail weighed 1,162 grams.

People generally must meet income guidelines to qualify for Medicaid. But " while

the child is in the institution, the child's income alone is what's looked at

for Medicaid purposes, " says Kahn, a spokeswoman for the federal Centers

for Medicare and Medicaid Services. Once she went home, Abigail was no longer

eligible for Medicaid because her parents' income was taken into consideration.

The family's insurance policy covered the baby's NICU stay at the out-of-network

rate of 60 percent, and Medicaid took care of nearly all the rest. Including

their deductible and other out-of-pocket charges, Ablondi estimates the family

paid $24,000 for Abigail's birth.

Her advice: Don't take no for an answer. Initially, the insurer refused to pay

any of the NICU bills. Eventually they paid their share. Things weren't much

different at the local Medicaid office, says Ablondi. The first person said

Abigail couldn't qualify because of the family's income. Eventually, Ablondi

talked to a supervisor who, she says, was also clueless. " But she did her

research and called me back. " Abigail got the coverage she needed.

This column is produced through a collaboration between The Post and Kaiser

Health News. KHN, an editorially independent news service, is a program of the

Kaiser Family Foundation, a nonpartisan health-care-policy organization that is

not affiliated with Kaiser Permanente.

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