Insurance - Gap Coverage Help/Advice Needed - Mothering Forums

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#1 of 1 Old 10-16-2008, 03:38 PM - Thread Starter
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I'm hoping there's some people with experience who could help me with my questions. I have GHI health insurance in NYC. My mw charges $7,500 under a global maternity code. She says they have always paid out $5,000 when she bills them. When we call the ins co we are given different information including:
-they will cover under catastrophic at 100% minus a $1,500 deductible but that they only pay $1,500 for global maternity - so that would leave us $4,500 out of pocket

-they will cover under regular maternity and catastrophic for a max of $6,500; this would make sense if they were being unclear and meant that the $1,500 catastrophic was in addition to maternity benefits

All of this is out of network as they don't have homebirth providers in-network.

My questions are:
-has anyone had experience with them and can they speak to this?
-can I apply for an in-network exemption or gap coverage; or does covering out of network exempt them from this requirement?
-if my provider was to itemize charges for coverage under catastrophic at 100%, what could she bill at as usual & customary?

I'm basically trying to figure out how to get my insurance to cover as much as possible. They're supposed to pay something like 80% for out-of-network, which would be $6,00 of $7,500. My provider's billing person is pretty convinced that they will def pay $5,000. I know that sounds good, but having to pay $2,500 out of pocket would really wipe us out. We're committed to this and almost done so we'll do what we need to do but we are willing to spend time fighting with the insurance company if we have to. Any advice is greatly appreciated.
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