Dealing with Unexpected Charges for Prenatal Care and Labor and Delivery
You have built your registry, dreamed up a beautiful nursery, and maybe even set up a college fund for your little bundle of joy, but chances are you haven’t been thinking about what to do if you receive an astronomical bill for labor and delivery that you didn’t expect. In an ideal world you shouldn’t have to even think about this – being a new parent is hard enough! Here are some tips as you navigate billing and coverage issues.
If you have insurance, you are protected from surprise out-of-network costs. You do not have to pay more than your plan’s in-network fees for care at an in-network facility in the state of Virginia or for care you receive in an emergency or while in active labor. Regardless of your type of health plan (including private, marketplace, employer based, Medicaid, and FAMIS coverage), you are protected from “balance billing” in each of these situations.
Balance billing happens when you receive a medical service that is covered by your insurance, but you are billed for the out-of-network rate instead of the in-network rate for that care. Virginia has balance billing laws that protect patients from these out-of-network costs in certain situations. For example, if you are in active labor and one of the doctors who treats you is not in-network with your insurance, you are not responsible for more than what you would pay if that care was provided by an in-network doctor.
You may still be protected from balance billing even if you must receive care out-of- state. If you experience a medical emergency or go into labor while traveling, you may need care from an out-of-network facility or doctor. In those situations, you should only be charged what you would pay for in-network care.
Medicaid does not typically cover out-of- state care because it is a state-run program. However, Virginia Medicaid members should know that the program will cover out-of- state care in cases of emergency and also in cases where the person’s health would be endangered if they were forced to return to their home state.
By law, healthcare providers like hospitals and doctors’ offices are required to let you know if they are in-network with your insurance. They must post this information online or share it with you upon request. Accordingly, you can ease any anxiety you may have about your coverage by checking with your hospital prior to the birth of your baby to make sure they are in-network with your insurance.
If you are uninsured, hospitals must treat you in an emergency or if you are in active labor regardless of your ability to pay. There are also resources available to help with payment. Depending on your income level, you may be eligible for “Emergency Medicaid.” Emergency Medicaid is limited health coverage that covers emergency care, including the cost of labor and delivery. Individuals with income at or below 148% of the Federal Poverty Level, or $2,521 per month for a family of two (including your baby), meet the income requirements for the program. Emergency Medicaid is available regardless of citizenship status, and you can apply anytime.
Many Virginia hospitals also offer “Hospital Presumptive Eligibility” (HPE) for pregnant women. If you meet the income and residency requirements for Medicaid, staff at participating hospitals can screen you for “presumptive eligibility.” If found eligible by hospital staff, you can begin using your Medicaid coverage immediately for prenatal care. You do not have to wait until you formally submit a Medicaid application to be covered. If you have already submitted an application, you do not have to wait until the application is processed to use your coverage.
If you do not file a formal application for Medicaid, your coverage will end on the last day of the month after hospital staff found you presumptively eligible. For example, if hospital staff screens you and finds that you are presumptively eligible as of February 15, 2025, your coverage will end on March 31, 2025, if you do not file a Medicaid application.
If you do file an application for Medicaid after the HPE determination, your coverage will continue while your application is being processed.
You may have other options for help with your medical bills. You have the right to request a “good faith estimate” of the charges expected for your care, and hospitals are legally required to post a list of standard charges for most common procedures on their websites. Hospitals are also required to screen patients for eligibility for charity care and provide information about their financial assistance policies.
The Virginia Hospital and Health Association (VHHA) has created a website, controlyourcare.com, that has all this information available in one place. You can compare prices and access financial assistance policies for most health systems in the state using this site.
You may also find it beneficial to seek care at a Federally Qualified Health Center (FQHC). There are 26 Community Health Centers in Virginia that can take reduced payments for services based on your income level. You can search for a health center near you at vcha.org/locations.
If you receive a bill that surprises you, remember medical bills are not foolproof and often contain errors. Billing errors and inconsistencies are very common, so you may not actually owe what the provider says you owe. You have the right to question the charges on your bill and verify that the billing department is using your correct information.
Healthcare is expensive and dealing with insurance is confusing, but your health and the health of your baby comes first. No matter your situation, breathe deep and know that you have options for dealing with unexpected medical bills. You have the right to advocate for yourself, and there are various tools available to help you navigate the health care system as an expecting parent.
