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The Hidden Holes in Our Health Coverage


On February 9, the Administration announced a final rule under the health care law that requires all health insurance companies to describe the benefits, limitations, and costs of their plans in plain, consistent language. Beginning later this year, the new “Summary of Benefits and Coverage” must be provided for every plan, which will allow consumers shopping for insurance to do an apples-to-apples comparison of plans.

Before this regulation, consumers found themselves confused and deceived by the process of shopping for insurance. Here is the story of one such consumer.

By, Jenifer Wilson

As freelance live event producers, my husband and I have always had to rely on the open market to get our health insurance. Freelancing can be a little unstable at times, so when I got pregnant with our first child, it was a little scary. I thought that we were prepared for the medical costs though. We already had that insurance policy, and we had shuffled through so many to find the one that was right for us. It wasn’t until this time, when I got unexpectedly pregnant, that we realized that we didn’t have maternity coverage – something that we had taken for granted as being a basic part of any plan. Instead, we learned that we would have had to buy a rider at an additional $320 a month for at least a year prior to conception. This was our first child, totally unplanned, and already arriving at a very financially uncertain time for us.

I don’t think people genuinely appreciate how expensive it is to have a baby. It would have cost $35,000 to bring Flynn into the world if we hadn’t haggled it down to $7,000 by helping the hospital institutionalize a cash payment program. Even though I had had an emergency c-section (which we had agreed ahead of time would be $12,000 if I needed one), the hospital was kind enough to bill us the negotiated rate for a normal, vaginal birth. But that $7,000 didn’t include the $2,500 for the doctor and the $6,000 for the anesthesiologist. That’s $15,500 to give birth!

By the time we had our second child, we were prepared. We looked into getting maternity coverage first. That’s when we learned that my c-section was a pre-existing condition. We couldn’t get maternity coverage anymore. I started working at Lowe’s just for the health insurance, but the child care costs were higher than my pay, so I left soon after qualifying for the health coverage. We continued the coverage through COBRA at a whopping $750 a month, but we knew that we would pay at least as much to pay for a child birth out of pocket.

The process of shopping for health insurance on the individual market is too confusing, even for consumers who look carefully at all of their options. There is no uniformity, no transparency, and no clarity in the information you get while you’re comparing plans. If there had been, we would have seen quite clearly that we didn’t have maternity coverage and been better informed about our options. Instead, the insurance company buried that in the fine print and the unsaid.

I understand that the Affordable Care Act will fix that by requiring a uniform summary of benefits and coverage that every insurance company will have to use. It will state the things it covers and doesn’t cover and give us an example of our out of pocket costs. That would have helped put it into perspective. I’m glad that future moms won’t have to go through what I did.

Jenifer is a Families USA Story Bank Participant. Like all of the consumers in our story bank, Jenifer has volunteered to lend a voice to those the Affordable Care Act will help. She did an interview on NPR where she spoke about the importance of access to maternity coverage. Join with Jenifer in sharing your own story here.