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The fetal ultrasound is a milestone procedure in many pregnancies. The images produced from an ultrasound are called sonograms, and prospective parents love to post them on their refrigerator, share them on Facebook, or give them to the soon-to-be grandparents.
You might think that ultrasounds are part of ordinary pregnancy care, leading to no out-of-pocket costs for an expectant mother. After all, the Patient Protection and Affordable Care Act, a.k.a. Obamacare, says that routine prenatal care should be completely paid for by the pregnant woman’s health insurance plan.Instead, many women pay a lot for their sonograms. Expectant mothers without insurance are responsible for all of the costs. But even those with insurance may have to first pay their deductible, or a copay or coinsurance for each one. Also, ultrasounds performed in some settings, like many hospitals, can result in both a procedure charge and a physician fee, with the patient responsible for a copay or coinsurance for each. So, how much can a pregnancy ultrasound cost?
Ultrasounds use high-frequency sound waves to produce images of the body’s internal structures. Pregnancy ultrasounds are often done transvaginally or over the abdomen to visualize the fetus, the placenta and the amniotic fluid. They can estimate the age of fetus and thus, the mother’s due date. They can also detect some problems like ectopic pregnancies or birth defects, as well as monitor fetal size and position as the due date approaches.
A recent update on prenatal care from the American Academy of Family Physicians says, “It is the standard of care in most U.S. communities to offer a single ultrasound examination at 18 to 20 weeks' gestation, even if dating confirmation is not needed.” It mentions, however, that there is little scientific support for routine ultrasonography in uncomplicated pregnancies.
Still, most pregnant women in the U.S. will get at least one or two sonograms before they give birth and some, who have suspected problems or high-risk pregnancies, will get many more.
How Much Does a Pregnancy Ultrasound Cost?
The “sticker price” of an ultrasound can vary dramatically, depending on where you live, and who’s providing the service.
Healthcare Bluebook, which estimates fair prices of medical procedures in various parts of the country, suggests that a reasonable cost for a fetal ultrasound is $280. On Manhattan’s tony Upper East Side, Healthcare Bluebook’s suggested fair price for a sonogram is $325. But even in down-and-out Detroit, it’s $281. In small-town Lititz, PA, it’s $265. In rural Louisiana, back up to $321.
The amount you’re charged can also vary dramatically by provider. Healthcare Blubook says the cost can be four times as high from one to the next. Usually, big hospitals with higher administrative costs charge more for a sonogram than a doctor’s office or stand-alone clinic would. In Philadelphia, for example, we found one pregnancy ultrasound option for $143 at Aria Health, while one performed at the Lower Bucks hospital would run $300, counting the procedure and the radiologist’s reading.
The only way to figure out what your sonogram will cost, is to call up the provider you’ve chosen and ask for the cost. If you’re uninsured, or if you want an ultrasound without a referral from your doctor (though not all centers will perform these), you’ll pay the whole thing. If you’re insured, make sure you are finding out the rate they’ve negotiated with your insurer. Feel free to comparison shop within your network for a better price, although it’s probably wise to get suggestions from knowledgeable sources like your doctor’s office. Be sure to stay within your network, if you’re insured, to minimize costs.
Avoid “keepsake” sonograms —those not prescribed by your doctor which may be offered by companies under no regulation or medical oversight, for as little as $45. The FDA and several medical groups like the American Medical Association and The American College of Obstetricians and Gynecologists warn women against this practice.
How Health Insurance Covers Sonograms
To comply with the Affordable Care Act, health insurers must cover preventive care including “many services necessary for prenatal care” with no cost-sharing, according to The U.S. Department of Health and Human Services. That means, no deductible, no copay, no-coinsurance, literally no out-of-pocket cost to the insured beyond the premium. Certain tests are mentioned in the legislation and subsequent guidance, including a screening for gestational diabetes, however, no specific mention is made of radiology, which is the category that includes ultrasounds.
Most insurance companies have interpreted the Affordable Care Act’s requirements on prenatal coverage with no cost-sharing to exclude ultrasounds. As United Healthcare explained in a 2013 document for those they insured: “Prenatal services not covered under the women’s preventive coverage include, but are not limited to, radiology services, delivery and high-risk prenatal services. While radiology services like obstetrical ultrasounds may be part of routine prenatal care, they are not included under the health reform law. A copayment, coinsurance or deductible may apply for these services.” As of June 2015, information on United Healthcare’s website on women’s preventive services reiterates this position.
Doctor-prescribed sonograms (but not keepsake ones) will still be covered by your insurance, meaning they’re considered medically necessary and part of acceptable care. However, depending on your plan’s specifics, you may have to pay for some portion - or all - of them yourself.
What to Expect, When You’re Expecting to Pay Some Part of Your Sonograms
Exactly how much you’ll have to chip in for your pregnancy ultrasounds depends on both the cost of the procedure at your provider, and the payment structure of your health insurance plan.
As mentioned above, if you don’t have health insurance, or are opting for a totally elective sonogram (perhaps to find out the gender of your baby), you’ll have to pay the entire cost out of pocket with no help from insurance. In these cases, it is possible to negotiate directly with ultrasound providers, so ask them for their best deal.
If your ultrasound was prescribed by your doctor, you may have to pay for it as part of your deductible before the insurance plan steps in. Otherwise, you will pay your plan’s predetermined copay or coinsurance percentage. You’re only home-free after you’ve reached your plan’s out-of-pocket limits for the year. After that, insurance should pay for all of your health care in its entirety. Ultrasounds conducted at a larger hospital can also incur a physician or radiologist fee.
Let’s take an example: A pregnant woman in Tampa, Florida has health insurance through one of the plans on the federal exchange. Depending on which of the 53 options she chooses (among those available for 2015, and assuming she earns enough to not qualify for Medicaid or cost-sharing assistance), she might pay for her sonograms using one of the following cost-structures, as long as she utilizes in-network options:
- A Humana Gold 2500 plan pays 100 percent of the first $500 for diagnostic imaging and lab tests. After that, the woman pays the full cost until she reaches her $2,500 deductible. Then, she continues to pay 20 percent of the costs, until she reaches her out-of-pocket maximum of $3,500 for that calendar year.
- With a Cigna plan, she’ll pay 30 or 40 percent of the cost of the test (depending on the specific plan) or even the entire cost until she reaches her deductible (up to $6,100) or out-of-pocket limit.
- If she has a plan from Assurant, she’ll first pay her deductible ranging from $0 to $6,600 depending on the plan, then coinsurance of 0 to 50 percent. Under the company’s Silver 002 plan, for example, she would pay the first $2,000 as a deductible, then 50 percent of the costs, up to an out-of-pocket limit of $6,350.
Because of such variations from plan to plan, it’s important to check the details of your own, so you understand what costs you will ultimately pay. If you want to minimize your expenditures, it’s also essential to get all of your care from in-network providers, since out-of-network options can leave you with even higher out-of-pocket costs.
And keep in mind, if your pregnancy spans two calendar years (like if you become pregnant in September, and deliver the following June), you will be subject to your deductible, copays, and coinsurance for both calendar years. To calculate your worst-case scenario, (which happens not uncommonly, if you need many tests throughout your pregnancy) multiply your out-of-pocket max by two for a ballpark estimate. Also consider what you’re paying annually in premiums, which are not included in the out-of-pocket max. It may make sense to switch to a plan with a lower cap on out-of-pocket costs, when you know you’ll be getting a lot of medical care - like when you’re expecting a baby.
In spite of the ACA’s attempts to make sure everyone gets the healthcare they need, out-of-pocket costs for something as common as a sonogram can still hurt one's wallet.