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How Can I Ever Afford Children?: Money Skills for New and Experienced Parents

Overview

Bringing up baby—without going broke

No one ever said raising children would be easy—or cheap. In fact, parenting is one of the most expensive ventures you'll undertake. This invaluable new resource shows you how to plan for—and meet—the financial challenges of parenting. Included are helpful tips and advice, as well as useful worksheets and practical strategies.

"How Can I Ever Afford Children? is a must read for every parent. This is the most comprehensive guide to financial ...

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Overview

Bringing up baby—without going broke

No one ever said raising children would be easy—or cheap. In fact, parenting is one of the most expensive ventures you'll undertake. This invaluable new resource shows you how to plan for—and meet—the financial challenges of parenting. Included are helpful tips and advice, as well as useful worksheets and practical strategies.

"How Can I Ever Afford Children? is a must read for every parent. This is the most comprehensive guide to financial planning for raising children I have seen. Barbara Hetzer has created an invaluable, practical guide to planning for children from conception through college graduation." —Ellen Rogin, CPA, CFP President, Strategic Financial Designs Inc.

"Barbara has put together an excellent summary of the financial costs a parent needs to know (and are probably too afraid to ask about). I hope to make it required reading for all of my clients with children." —Douglas Mollin, CFP President, ProPlan Financial Services.

"This book is a great guide for the perplexed parent who wants to know the bottom line on everything from pre-conception to graduate school. Here are the ABCs of what it actually costs to have a child. At last, the financial facts are spelled out in detail to help parents every step of the way." —Linda Barbanel, CSW author, Piggy Bank to Credit Card: Teach Your Child the Financial Facts of Life.

"A wonderful guidebook to help parents anticipate the strategies they need to make the child-rearing years more joyful and less stressful financially. Beyond the financial strategies, How Can I Ever Afford Children? provides sound recommendations for the issues which need to be addressed by parents to protect their family's security." — Lydia Sheckels Chief Investment Officer, Vice President Financial Planning Services, Wescott Financial Planning Group, Inc.

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Product Details

  • ISBN-13: 9780471239116
  • Publisher: Wiley
  • Publication date: 9/28/1998
  • Series: Personal Finance Solutions Series
  • Edition number: 1
  • Pages: 256
  • Product dimensions: 6.02 (w) x 8.95 (h) x 0.69 (d)

Meet the Author

BARBARA HETZER writes regularly on personal finance, small business, and other work issues for Business Week and Working Mother. She is the author of The 10 Minute Guide to Smart Borrowing and The 10 Minute Guide to Working with Financial Advisors.

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Table of Contents

The Business of Birth.

If You Have Difficulty Conceiving.

Baby Gear.

The Juggling Act.

Who's Minding the Children?

Living on One Salary.

The Grade School Years.

The Teen Years.

College-Bound.

Finding College Financial Aid.

Your Little Tax Deduction.

Insuring Your Family's Well-Being.

Will You—Or Won't You?

Some Special Situations.

Index.

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First Chapter

0471239119 CHAPTER ONE

The Business of Birth

Kids drain your cash flow, almost from the moment they're conceived. Long before you have to fret about funding college, summer camp, or even that trip to Disney World, you'll first have to bring your little bundle of joy into the world. And that's an expense in itself. The stork, unfortunately, doesn't just drop off your baby gratis anymore. With prenatal care stressed these days from as early as the sixth week of pregnancy, the first expenses you'll probably face as a parent will be the medical bills incurred in the conception, gestation, and birth of your child.

How much you'll pay, and how much you'll have to pay in advance of your child's birth, will depend on whom you choose to deliver your baby; whether the birth takes place in a hospital, a birthing center, or the back of a taxicab; and what kind of insurance plan, if any, both you and your spouse have and how much of these medical expenses will be covered. Ideally, you should shop for maternity care that best meets your needs, regardless of the price. Unfortunately, however, the high cost of health care will inevitably play into your decision. For a prenatal and delivery program that won't put you into debt, you'll probably have to tailor a childbirth program to your budget.

Doctor or Midwife?

The first expense you'll have to evaluate is the doctor's fee. Many doctors charge a flat fee that includes prenatal visits, delivery, and, frequently, a follow-up visit six weeks after delivery. That fee varies, depending on where you live and if you deliver vaginally or by cesarean section (C-section). (See Figure 1.1.) Generally, that fee does not include routine lab work, such as urinalysis and blood tests for protein and sugar levels, nor more elaborate tests, such as a sonogram or an amniocentesis. (See Figure 1.2.)

Figure 1.1 What Price Pregnancy? The cost of having a baby varies widely, depending on the area of the country you live in and whether your baby is born vaginally or by cesarean section. The physicians' charges cited below include prenatal and delivery charges. Vaginal Delivery Cesarean Delivery geographic region Hospital Physician total Hospital Physician total New England $3,760 $3,160 $6,920 $7,060 $4,480 $11,540 Middle Atlantic $4,370 $3,980 $8,350 $7,580 $5,460 $13,040 East North Central $3,600 $2,310 $5,910 $6,750 $3,480 $10,230 West North Central $3,490 $2,150 $5,640 $6,520 $3,150 $9,670 South Atlantic $3,550 $2,940 $6,490 $6,760 $4,430 $11,190 East South Central $3,310 $2,190 $5,500 $5,850 $2,920 $8,770 West South Central $3,380 $2,340 $5,720 $6,290 $3,590 $9,880 Mountain $3,240 $2,290 $5,530 $7,010 $3,910 $10,920 Pacific $3,980 $2,740 $6,720 $8,350 $4,540 $12,890 Source: Reprinted with permission from Health Insurance Association of America, Source Book of Health Insurance Data 1996. Data represents only Metropolitan Life claims.You don't need a doctor to deliver your baby, of course. Many women who have low-risk pregnancies opt for a certified nurse-midwife instead. Physicians' fees for a normal pregnancy average $2,740 nationwide; those of nurse-midwives run about the same. Still, a nurse-midwife will generally cost you less than a medical doctor because she uses less high-tech equipment (which is billed separately) and focuses more on the natural aspect of childbirth.

Figure 1.2 Testing, Testing, Testing Whether you use an obstetrician, family practitioner, or nurse-midwife, their prenatal and delivery fees generally don't include all of the testing that is required these days. Expect to pay extra for the following tests: TEST average COST Urinalysis E$40 Blood tests E$95 Sonogram $225 Glucose tolerance $100 Alpha-fetoprotein (AFP) screening $125 Amniocentesis $900

Which practitioner is right for you? That depends on the type of pregnancy you have, and the type of birth experience you want. If yours is a high-risk pregnancy, you're carrying triplets, let's say, or you're a diabetic, you'll probably want a medical doctor. But if you're healthy and you want a low-tech, less "medical" birth experience, pick a nurse-midwife. To make the best choice for you and your baby, consider the following:

Obstetrician

Obstetricians deliver four out of five babies born in the United States. All licensed obstetricians are medical doctors who have at least three years of specialty training in pregnancy, labor, and delivery. Most are board-certified, which means they have received postgraduate training in their field. (That's no guarantee that he or she is a good doctor, of course, but it's generally a good sign that a doctor is up-to-date on procedures, theories, and so forth.) Some are also fellows of their medical specialty societies. If your obstetrician puts FACOG after her name, for instance, it means that she's a fellow of the American College of Obstetricians and Gynecologists.

You can verify your doctor's credentials by calling the American Board of Medical Specialties at 800-776-2378. (You can also contact the American Board of Obstetrics and Gynecology, but you must put your request in writing and include a $25 processing fee: 2915 Vine Street, Dallas, TX 75204; 214-871-1619.) If your doctor is a doctor of osteopathy rather than an MD, you can contact the American Osteopathic Board of Obstetrics and Gynecology to find out if he or she is board-eligible: 1000 East 53d Street, Chicago, IL 60615; 773-947-4632. Put your request in writing and include a $25 processing fee. Or you can call the American Osteopathic Association at 800-621-1773 to verify that a doctor is board-certified. Osteopaths are fully licensed physicians and surgeons, too, but they take a more holistic approach to care. Why do so many women choose an obstetrician to deliver their babies? If you have already established a trusting relationship with your gynecologist, and your gynecologist is also an obstetrician, you'll probably want to stick with him or her now that you're going to have a baby. (Not all gynecologists maintain an obstetric practice, but many do.) Plus, many women simply like the security of using a specialist. Should any complication arise, the doctor can handle it.

Questions to Ask an Obstetrician: ¥ How many cesarean sections do you perform annually? (How many vaginal births?) ¥ What procedures do you routinely administer during delivery? IVs? Fetal monitoring? Episiotomy? ¥ Do you encourage natural childbirth? ¥ At what stage of labor do you administer drugs? ¥ When do you feel it's necessary to induce labor? ¥ How frequently have you used forceps or a vacuum extractor in the past year? When would you resort to such methods?

Family Practitioner

The family practitioner is a relative newcomer to the obstetrics scene. Basically, he or she is an updated version of the old-fashioned family doctor who took care of you and your kid brother as well as your mother and father. Like an obstetrician, this doctor has three years of training following medical school, but only about three months of that training has to be in obstetrics and gynecology. The focus is "primary care." Some pregnant women like the continuity of care with this type of physician. It's a doctor you already know and trust. He's your internist, your gynecologist, and now your obstetrician. Once he has delivered your baby, a family practitioner can then switch hats and become the baby's pediatrician. Most family practitioners charge roughly the same as an obstetrician to deliver a baby. To verify this doctor's credentials, contact the American Board of Family Practice: 2228 Young Drive, Lexington, KY 40505-4294; 606-269-5626. You must put your request in writing and include a $25 processing fee.

Questions to Ask a Family Practitioner: ¥ How much of your practice is currently devoted to obstetrics? ¥ How many babies have you delivered in the past year? ¥ Were any births complicated? ¥ Were any of the pregnancies considered high-risk? ¥ Why, and when, would you refer me to a specialist?

Midwife

Certified nurse-midwives specialize in the prenatal care of healthy women with low-risk pregnancies. They can deliver a baby (provided it's a normal, uncomplicated delivery) and offer postpartum care to both the mother and the newborn.

Only 5.2% of all births were attended by nurse-midwives in 1994 (the latest year for which the records are available). But the number has increased every year since 1975. The five thousand or so certified nurse-midwives in the United States today are registered nurses who have completed at least one year of obstetric training in an approved graduate midwifery program and have passed the national certification examination given by the American College of Nurse-Midwives.

Contrary to what you might think, nurse-midwives don't offer second-class care. The majority of them attend births in hospitals or birth centers, not at home. And most work with a physician, who will take over in case of an emergency or complications. Over the years, study after study has documented the safety and effectiveness of midwifery care. Most recently, researchers at the University of Washington studied 1,300 low-risk pregnant women and found that the patients of nurse-midwives had cesarean section rates of only 8.8%, compared to 13.6% for obstetricians and 15.1% for family physicians.

Lay midwives, on the other hand, aren't licensed or formally trained in obstetrics. Much of their experience is hands-on. A handful of states prohibit lay midwives from practicing. The rest are rather vague on this point: They have no specific laws pertaining to the subject of lay midwives. Why would you go this rather risky route? It's cheaper. Lay midwives charge as little as $1,000. Or, perhaps you simply feel that doctors and hospitals intervene too much in this natural phenomenon called birth, and you want to give birth at home. Most doctors and certified nurse-midwives won't deliver a baby at home anymore. But lay midwives will. In fact, those are the kinds of births that they attend predominantly.

Questions to Ask a Certified Nurse-Midwife: ¥ Are you certified by the American College of Nurse-Midwives? ¥ Are you employed by a hospital or a physician's practice? ¥ Where do most of the births that you attend take place? ¥ What happens if complications occur during the course of pregnancy or during labor? ¥ What procedures, such as an episiotomy, are you certified to perform? ¥ Are you permitted by law to write prescriptions?

Further Considerations

Once you've decided which type of health professional you want to deliver your child, you'll need to find some likely candidates. The following are good sources:

Personal recommendations. Ask your family doctor, your gynecologist (if he or she doesn't do deliveries), and friends and family members (especially those who've recently had babies). The county medical society. This group should be able to supply a list of names of doctors who deliver babies as well as some information on their training, specialities, board certification, and type of practice. The American College of Nurse-Midwives. The association's toll-free practice locator line (888-MIDWIFE) will help you find a certified nurse-midwife in your area. You can also check out its Web site, www.midwife, for more information.

Childbirth education programs. Often, these are a good source for parents-to-be, especially if you want a professional who espouses natural childbirth. If you're a breastfeeding advocate, you might try your local La Leche League, too.

Your local hospital. If a nearby hospital boasts a birthing room or an adjacent birthing center that you like, ask for the names of the attending physicians or midwives. Doctors and midwives generally want their fee up front, before the baby is born. They often expect that payment in full by the seventh or eighth month. Sometimes, the practitioner will let you pay just the part not covered by insurance, the 20% or so not covered under a typical indemnity plan, plus your deductible, but you generally must provide an estimate from the insurance company on what they're going to pay. Other doctors and midwives insist that you pay the entire bill now and then get reimbursed from the insurance company. That can be a costly proposition.

When I was pregnant with my second son, my obstetrician insisted that his $6,000 bill be paid by the end of my eighth month. My husband and I were a bit strapped for cash at the time so we kept putting it off. Ultimately, we never had to pay it. I gave birth six and a half weeks early, about two and a half weeks shy of the payment due date, so I just paid the deductible and copayment and filed my insurance claim for the rest. While I obviously wouldn't recommend going into early labor to avoid paying your doctor bill, I wouldn't rush to pay that bill when you're three months pregnant, either. You could go into early labor like me, or miscarry in your fourth month, or, well, you just never know. Hold onto your money until the absolute last moment. And, before you make any payment, make sure you understand what the fee includes, and doesn't include.

Ask the following questions of the doctor or midwife you've selected to deliver your child: ¥ What is your fee? ¥ What exactly is included in that fee? All prenatal visits? What about a postpartum checkup? ¥ Does your fee assume it will be a vaginal birth? If so, how much more does a cesarean birth cost? ¥ Are there any additional tests, such as amniocentesis, or lab work not included in that fee? How much will those tests cost? Do you expect to be paid up front for them? ¥ Does insurance generally cover your fees? ¥ When do you expect payment? ¥ Will you require me to pay the entire bill up front and wait for reimbursement from my insurance company? Or, can I pay just the portion of your bill that my insurance won't cover?

The Birth Setting

Paying the doctor or midwife to deliver your baby is only part of the cost. You have to give birth someplace and, unless you've decided to give birth at home, you have to pay for the use of that facility. Most births today take place in hospitals, which are equipped with the latest equipment to deal with almost any medical emergency. Hospitals generally charge a baseline fee for a birth (see Figure 1.1), which varies depending on the region of the country and whether it is a C-section or a vaginal delivery. (Hospital charges are steeper for a C-section because more time is needed to recuperate; the hospital stay is five days rather than the typical two days with a vaginal birth.) Also included in that hospital fee are nursery charges for the baby once he or she is born. If the baby needs more than routine care, such as a brief stay in the intensive care unit, you'll be charged extra.

Often, your hospital bill will be higher if you choose a doctor rather than a nurse-midwife. Doctors simply use more procedures and equipment, all of which cost more and are tacked onto your hospital bill. That epidural may ease your contractions, but it'll cost you about $900. Midwives, on the other hand, use 12.2% fewer resources than doctors, according to a recent study by the University of Washington. A hospital isn't the only place your baby can be delivered these days, however. Many parents opt for birth centers, which are staffed by midwives predominantly, and offer a more homey setting. The difference in cost can be significant. According to the National Association of Childbearing Centers, vaginal births in birthing centers cost $3,241, on average, in 1995; an average vaginal birth in a hospital, by contrast, cost $6,378.

The trouble is, the choice of hospital or birth center is restricted to where your doctor or midwife has privileges. (Obviously, you'll want to keep this in mind when shopping for your health practitioner.) And, if you want to give birth at home, it may be even more problematic. You'll have to find a doctor (almost impossible these days) or midwife who's willing to deliver the child at your home. Ultimately, most parents choose the health practitioner first, and the facility becomes a secondary consideration. But, if you have your heart set on a certain type of birth experience, you should familiarize yourself with these available options, and their advantages and disadvantages:

The hospital delivery room offers the most security. Should complications develop during delivery, the technology and a team of doctors and nurses are on hand to deal with it immediately. In recent years, the conventional maternity ward, complete with bright lights, cold metal furnishings, and loads of machinery, has slowly been replaced by warmer, homier hospital birthing rooms. With soft lighting, curtains at the window, a rocking chair, and a comfortable bed, these birthing rooms look and feel like a motel room. In most cases, you can labor, deliver, and recover in this same room. Afterward, you'll generally be moved, however, to another private or semiprivate room for the duration of your hospital stay. Visit the hospital well before your baby is due. If possible, ask a hospital representative the following questions: ¥ Will I be using a birthing room? (Some hospitals have a limited supply of these. It may depend on how many babies are being delivered that day.) ¥ Will I be hooked up to a fetal monitor once I'm admitted? Or can I move around freely during labor? ¥ Can my husband attend the birth? Any other family members? ¥ After the birth, will I be sharing a room with another mother? ¥ Do you offer childbirth classes? ¥ What percentage of women have episiotomies? ¥ Who administers anesthesia? How often is it used? ¥ What's the cesarean section rate for the hospital?

Birth or maternity centers are a cross between hospital births and home births. They provide a homelike setting, but there's some high-tech equipment on hand for emergencies. Certified nurse-midwives provide the bulk of the care, but obstetric and pediatric doctors are generally on 24-hour call, as needed. Some birth centers are actually based in hospitals; others are freestanding units. All are affilitated with a nearby hospital, however, should serious complications arise during a delivery that require hospital care.

A birth center will cost you about one-half the price of a hospital because you generally stay for only one day. In some cases, you can bring your baby home hours after giving birth. Finances aside, a birth center may give you the low-tech birth experience you want, without resorting to a home birth. In general, women who deliver in birth centers tend to have fewer C-sections and are subject to fewer medical procedures, such as electronic fetal monitoring, forceps, and episiotomies. (Of course, this type of experience works best for low-risk, uncomplicated pregnancies.)

To find a birth center staffed by a certified nurse-midwife and accredited by the Commission for the Accredition of Freestanding Birth Centers (not all are), write to the National Association of Childbearing Centers: 3123 Gottschall Road, Perkiomenville, PA 18074; 215-234-8068. (Include a $1 processing fee.) Not all birth centers are licensed. Twenty-eight states, including New York, Georgia, and Massachusetts, have strict licensing requirements; the remaining states do not. To find out about licensing requirements in your state, contact your state health department.

Visit a birth center in person, well before the big day, and find out the following: ¥ What type of prenatal, childbirth, and postpartum care do you provide? ¥ Does the birth center operate within a hospital? ¥ If not, which hospital is the center affiliated with? ¥ Is the bulk of the care provided by certified nurse-midwives? ¥ What kind of physician backup is available? ¥ What emergency and/or life-support equipment do you have on-site? ¥ What happens in case of an emergency? ¥ What types of situations would cause transfer to a hospital during labor and delivery? ¥ Can the father attend the birth? Other family members, too? ¥ After birth, how long do the baby and mother stay at the birth center? ¥ What type of care is provided for the baby?

A home birth is the cheapest birth alternative. Often you pay just the midwife's professional fee. Home births have enjoyed something of a revival in recent years. But, although many prospective parents want a homelike birth setting nowadays, very few opt to go with the real thing. How come? It can be risky. Should something go wrong, you need an emergency C-section or the baby needs to be resusciated, that equipment isn't close at hand. And with even five or ten minutes to get you to the hospital it may be too late. What's more, it's difficult to find a licensed or certified practitioner who will come to your home. Most doctors feel it is dangerous, backward, and old-fashioned. And many certified nurse-midwives are restricted by state law from attending a home birth. Lay midwives are often your best, and only, alternative.

Still, many women want to give birth surrounded by family and friends and all the comforts of home. Others who live in rural areas far from a hospital or clinic may have no other choice. For more information about safe home births, contact the National Association of Parents and Professionals for Safe Alternatives in Childbirth: Route 1, Box 646, Marble Hill, MO 63763; 314-238-2010.

What to Expect from Your Medical Insurance

Most couples depend on their health insurance to cover their doctor and hospital bills. In many cases, your medical coverage will pick up most but not all of the tab. Health insurance companies usually don't cover every medical treatment. They often set limits on how much they'll reimburse you for a certain procedure although your doctor may charge more. And they'll ask you to fork over an annual deductible before reimbursing you for any bills. After that, you'll probably be required to pay a small percentage of the bill, up to a predetermined amount.

All of these variables depend on the type of plan you have. There are three basic types: A traditional fee-for-service plan lets you pick your own doctor. A preferred provider plan allows you to see any of the doctors who participate in the plan's provider network (often, these plans will let you use a doctor outside the network, but you'll pay a bigger chunk of the bill). And a health maintenance organization (HMO) restricts coverage to doctors who are part of the group.

With each of these plans, you'll probably have a deductible that can range from $100 to $2,000 or more. If you have a policy with a $200 deductible, for example, you must pay $200 worth of your medical bills each year before your insurance kicks in.

Most policies have an individual deductible as well as a family deductible, meaning that once you reach the family deductible, your insurer will start reimbursing you for bills, even if each individual member hasn't met the deductible. Let's say your individual deductible is $200, but your family deductible is $500. You've just given birth to twin girls. Assuming you've incurred no other medical expenses this year, you'd have to pay the first $200 of your hospital bill, the first $200 of one daughter's hospital bill, but just the first $100 of your other daughter's hospital bill. Your insurance would then kick in because you'd met the family deductible of $500.

After you've met your deductible requirements, the insurer will start paying your bills. You're not off the hook yet, though. You'll probably still have to fork over some portion of each bill, called the copayment. With both a fee-for-service plan and a preferred provider plan, you'll pay a certain percentage, often 20% of the allowable bill. With an HMO, however, you'll pay a set amount instead, ranging from $5 to $15 per bill. Under all three plans, you'll be required to make copayments until you reach a certain "out-of-pocket maximum," at which point the insurer will pay 100% of your medical bills.

Unfortunately, you probably won't get one neat little bill that itemizes your maternity care. The hospital or birth center itself will send you a series of bills depending on the services rendered. If you had an epidural, for instance, you'll get a bill from the anesthesiologist. You'll get another bill for your hospital stay. Another for the baby's hospital stay. And probably still another for the pediatrician who checked him out. Want Junior to be circumsized? That's another bill.

Some hospitals and birth centers will bill the insurance company directly. That will save you some paperwork. (Otherwise, you'll have to file the claim yourself.) Once they receive payment, the hospital will then bill you for whatever the insurance company did not pay. That amount will vary, depending on your deductible and copayments.

Generally, your insurer will pay for "reasonable and customary" charges, an amount the insurance company deems fair payment for service. Often, it can fall far short of the actual bill. If an anesthesiologist charges $5,000 for a spinal but your insurance company thinks that $3,500 is the reasonable and customary charge for that particular medical service, you'll be expected to foot the difference ($1,500 in this case). In some cases, your insurer will deny a claim completely. That means they won't pay a dime because of noncoverage. Perhaps your insurance doesn't cover such procedures. You'll have to check your plan's handbook. Some private insurance companies don't cover a midwife's services, for instance. Or, perhaps your insurance covers such procedures only under certain conditions. Many insurers don't cover amniocentesis, for example, if you're under 35 years of age. Even if you meet the age limit, some insurers won't pay unless your doctor writes a note saying the test was a "medical necessity." (See Figure 1.3.) Figure 1.3 What's Covered?

As soon as you find out that you're pregnant--or before, if you're very organized--get the details about maternity benefits from your insurance company. Confirm your individual and family deductibles, your copayments, and your out-of-pocket maximums. Find out if you have to advise your insurer of the impending birth ahead of time. Nowadays, many insurers won't cover a hospital stay unless contacted within 48 hours of admission. Some good questions to ask include:

Prenatal Care How many doctor visits are covered? (Visits are usually more frequent as a pregnancy advances.) Are the services of a midwife covered? Does the midwife have to be certified? Which tests are covered? (Ask about amniocentesis. Many policies don't cover this.) Sonograms? How many? Prescriptions? What about vitamins?

Labor and Delivery Care Is use of an epidural or some other anesthesia covered? A cesarean section? How many days can I stay in the hospital? How many days in the event of a C-section? Is delivery in a birth center covered? (Some insurers will pay 100% of birth center delivery costs but just 80% of hospital delivery costs.) Is delivery at home covered? Care of the Baby For how long? Are visits from my pediatrician covered? Which tests? Procedures such as circumcision? Intensive care?You and your spouse may have separate insurers. You can submit your claims to both. One insurer may pay what another doesn't. Generally, you should submit the claim to the mother's insurer first. (That's your "primary" insurer, in this case.) After the mother's insurance company has paid its share, send it to the father's company (the "secondary" insurer) to pick up the balance. If neither insurance company covers such a fee (and you feel it's legitimate) or both insurance companies reimburse for reasonable and customary charges that you think are too low, you can fight it. Start by contacting the insurer. Explain your situation, and ask for an explanation. (Be sure to note the date, time, and person you spoke with.) Follow up with a letter. The insurer will probably write back in a few weeks saying that this is its policy and, sorry, there's nothing it can do about it. You can then pay the bill, or, if you feel you really have a case, complain to your State Insurance Department. That will involve another round of letters. (Be sure to include copies of your previous correspondence with the insurance company.) You still may not win your case, but the insurance department will make sure that you get a thorough answer from your insurance company. Still not satisfied? Take the matter to a lawyer who specializes in insurance matters. Or work out a deal with the doctor. Here's what I did: After my son was born prematurely, he had to stay in intensive care for two weeks. He was assigned a pediatric neonatal specialist who was on the hospital staff. A bill for $4,300 arrived, and my insurer would allow just $2,500 as a "reasonable fee" for such care. Being a frugal money manager, I wasn't about to pay the $1800 difference. So I wrote letter after letter to the insurance company and my State Insurance Department. Nothing worked. Finally, after several dunning notices from my doctor, I called his office to explain the situation. And lo and behold, he split the difference with me. The man actually lowered his bill! I wrote him a check for $900 that very afternoon.

If You Don't Have Insurance

An estimated 36 million Americans don't have health insurance. Some people simply can't afford to buy coverage. Others are denied coverage outright because of a history of illness, or their preexisting condition is excluded from coverage. If you can't afford health insurance, your state health department may be able to refer you to a free or low-cost clinic in your area. If you've been laid off from a job or your hours have been cut back so that you're no longer eligible for insurance, COBRA (Consolidated Omnibus Budget Reconciliation Act) gives you the right to keep your benefits in your employer's group health plan for up to 18 months. If you become disabled and can't work anymore, you have the same right for up to 29 months. And if you are divorced, legally separated, or your insured spouse dies, you have the right to continue participating in the company plan for up to 36 months. Of course, your employer won't give you this coverage for free. Expect to pay the full premium yourselfplus a 2% administration charge. A company's group rate is cheaper than buying an individual policy, but it may still be expensive.

If you can afford to buy insurance, but don't have it because you're between jobs or you're not eligible for health coverage at your job, you can frequently buy coverage through professional organizations. Members of the National Association of Female Executives, for example, can buy individual and family coverage. It's not cheap, but it's less costly than footing the maternity bill yourself.

When buying a new policy, keep in mind that pregnancy is considered a preexisting condition. Be sure to buy the policy before you get pregnant. If you buy a policy after you've already conceived, none of your maternity care will be covered. (The baby's hospital and doctor bills will be covered, however.)

Questions and Answers Q. Will my insurance company pay for a midwife? A. Most private health insurers, as well as Medicaid and Medicare, will reimburse you for a nurse-midwife's services. It generally doesn't matter whether the birth occurs at home, in a birth center, or at a hospital. A sticky point that should be addressed ahead of time: What happens if complications arise and an obstetrician is called in at the last minute to perform a cesarean section? Some insurance companies won't pay for both a doctor and a certified nurse-midwife. Q. I requested a private room during my hospital stay, but was given a semiprivate room instead. Now I'm being billed for a private room. What recourse do I have? A. It's not surprising to find errors in your hospital bill. Hospitals bill patients for services and supplies when they're ordered, not when they're actually delivered. Perhaps the hospital intended to give you a private room but there wasn't one available when you needed it. You can correct the error by calling the hospital. If the problem isn't immediately resolved (it should be), follow up with a written letter to the hospital administrator. Q. My husband and I have separate medical insurance policies through our jobs. Can we both claim my maternity expenses? A. Yes, but you can't make money on the deal. Although you may be able to get all of your medical costs covered by your insurance, you won't be reimbursed for more than 100% of the bill. Here's how it works: You should first submit your claim to your primary insurer. (When you both have plans, the wife's plan is usually primary for her, the husband's plan is primary for him.) After you have collected from your primary insurer, you can then file the remaining expenses, including documentation of what the primary insurer has already paid, with your secondary insurer. Often, that policy will pick up whatever expenses the first policy did not. Q. When can I add my newborn to my health insurance policy? A. As soon as the baby is born, or legally adopted. He or she should be covered automatically if you have a family policy. But check with your insurer beforehand to make sure. Q. Is midwifery legal in all states? A. Yes. Certified nurse-midwives (but not lay midwives) are legally able to assist in low-risk, uncomplicated births in all 50 states and the District of Columbia. What else can a nurse-midwife do? That depends on the state. In Alabama, for instance, nurse-midwives can't deliver a breech baby or multiple pregnancies, or use forceps. In Idaho, nurse-midwives can administer pitocin (a drug frequently given to hasten labor). And, in all but a few states, certified nurse-midwives can write prescriptions. For more information on your state's laws, contact your state licensing board.

For More Info Check out the National Association of Childbearing Centers' Web site (www.birthcenters.org) for some general information on childbearing centers. Contact Informed Homebirth/Informed Birth & Parenting if you're thinking about a home birth: Box 3675, Ann Arbor, MI; 313-662-6857.

The People's Medical Society, a consumer health care group, publishes a newsletter and a variety of consumer health books such as So You're Going to Be a Mother and The Savvy Medical Consumer. Contact them at: 462 Walnut Street, Lower Level, Allentown, PA 18102; 800-624-8773. The American Board of Medical Specialties will send you its booklet, "Which Medical Specialist for You?" when you write to them (and include a $1.50 fee): 1007 Church Street, Suite 404, Evanston, IL 60201-5913.

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