Paying for a NICU Stay: Insurance, Medicaid, SSI, and Financial Help

This page is general information, not legal or financial advice. Rules change, and every plan, state, and hospital is different. Before you make a decision, check with your insurer, your state’s Medicaid agency, Social Security, or the hospital’s financial counselors.

Why NICU bills are so large

A NICU stay means round-the-clock specialized care, often for weeks or months. That adds up fast. One large study of commercially insured babies across the U.S. (Aetna claims, 2008–2016) found that infants with a preterm birth code averaged $76,153 in medical spending in their first six months of life, compared with $6,370 for full-term infants. Babies born at 24 weeks averaged $603,778 (all figures in 2016 dollars). Beam et al., Journal of Perinatology, 2020.

Those are amounts billed to the insurer, not what families paid. What you owe depends on your coverage, your deductible and out-of-pocket maximum, and the help described below. The point is simple: the bills can look enormous, and it’s worth working through every option.

Adding your baby to insurance

Your baby needs to be added to a health plan, and the clock starts at birth. Call your insurer or HR department as early as you can, even from the NICU.

• Employer plans. The U.S. Department of Labor explains that you must notify the plan within 30 days of the birth, and that the child’s coverage will be effective on the date of birth. DOL guidance. Check your plan documents too, and get confirmation in writing.
• HealthCare.gov Marketplace plans. Having a baby is a qualifying life event. You can enroll up to 60 days after the birth, and coverage can start the day of the birth. HealthCare.gov.
• Idaho. Idaho’s marketplace is Your Health Idaho, which lists a 60-day window after a birth (Customer Support: 855-944-3246). Your Health Idaho. St. Luke’s advises contacting your insurance company within 30 days of birth, and notes you may need your baby’s birth certificate and Social Security number. St. Luke’s. Some insurers also want a proof-of-birth letter, so ask your nurse before discharge.

Medicaid and CHIP for babies

If mom had Medicaid when the baby was born, the baby is a “deemed newborn.” Under federal rules, a baby whose birth mother was covered by Medicaid on the date of birth, or by CHIP in states that cover pregnant women through CHIP, is automatically enrolled in Medicaid or CHIP for the first year of life. Families cannot be required to fill out an application, and coverage continues until the first birthday regardless of changes in circumstances. Medicaid.gov. Hospitals still advise telling your Medicaid office about the birth promptly (see the Idaho section below).

If you have private insurance or no insurance, your baby may still qualify for Medicaid or the Children’s Health Insurance Program (CHIP). You can apply any time of year, through your state Medicaid agency or through the Marketplace. HealthCare.gov. To reach your state’s program, call 1-877-KIDS-NOW (1-877-543-7669). InsureKidsNow.gov.

Idaho specifics

• Children’s Medicaid covers Idaho children under 19 who meet income guidelines, and a child can qualify even if the family has other health insurance. Idaho DHW. The department says that generally, children are eligible if household income is below 138 percent of the federal poverty level. It also encourages you to apply even if you’re not sure you qualify.
• Children’s Health Insurance Program (CHIP) is low-cost coverage for children whose family income is too high for Medicaid. There may be a small monthly premium, and a child with private health insurance cannot get CHIP. Idaho DHW.
• Katie Beckett is a Medicaid program for children living at home with long-term disabilities or complex medical needs. These children may qualify even if family income is above the usual Medicaid limits. You apply for Medicaid and Katie Beckett at the same time. Idaho DHW.
• How to apply: online through idalink, by phone at 1-877-456-1233, at a field office, or by mail, email, or fax. Processing can take up to 45 days. Idaho DHW. St. Luke’s advises families with Medicaid to contact the Idaho Medicaid unit within 10 days of birth. St. Luke’s.

SSI for babies with low birth weight

Supplemental Security Income (SSI) is a monthly payment from the Social Security Administration (SSA). A child can be eligible as early as the date of birth. SSA. Under SSA’s listing 100.04, an infant from birth to age 1 meets the low birth weight criteria with:

• A. a birth weight of less than 1,200 grams (about 2 pounds, 10 ounces); or
• B. a gestational age and birth weight of: 37–40 weeks, 2,000 grams or less; 36 weeks, 1,875 grams or less; 35 weeks, 1,700 grams or less; 34 weeks, 1,500 grams or less; 33 weeks, 1,325 grams or less; 32 weeks, 1,250 grams or less.

SSA uses the birth weight on an original or certified copy of the birth certificate, or a medical record signed by a physician. Birth weight means the first weight recorded after birth. SSA listing 100.00.

A few rules worth knowing, in SSA’s words where possible:

• Income and resources still count. SSA considers the child’s income and resources, and those of certain family members living in the child’s household. Meeting the weight criteria alone isn’t enough.
• Hospital stays. “We limit the monthly SSI payment to $30 when children are in a medical facility and health insurance pays for their care.”
• Payments can start right away. SSA says your child may get SSI payments right away, and if the state agency later decides the disability isn’t severe enough, you won’t have to pay them back.
• Review by age 1. SSA reviews babies getting SSI because of low birth weight by their first birthday. If SSA decides the condition isn’t expected to improve by then, it may schedule the review later.

To apply, call SSA at 1-800-772-1213. Have your baby’s Social Security number and birth certificate ready. SSA Publication 05-10026. If SSI is approved, it can matter for other help too. In Idaho, for example, one route into the Katie Beckett program is a disability that meets SSI criteria.

Hospital financial assistance (charity care)

Under federal tax law, tax-exempt hospitals must have a written financial assistance policy that covers, at a minimum, all emergency and medically necessary care. They must post the policy, the application, and a plain language summary on their website. IRS. The CFPB notes that nonprofit hospitals must have programs that provide free or discounted care, and that some states require this too. It also suggests asking about an interest-free payment plan. CFPB. A hospital financial counselor or social worker can help you find the application.

Boise-area hospitals

• St. Luke’s offers financial assistance for emergency or medically necessary care. Eligibility includes living in Idaho, Oregon, Nevada, Utah, or Washington, family income at or below 400% of the federal poverty level, and a completed Financial Care Application with supporting documents. If you have insurance, charges are billed to it first. St. Luke’s financial assistance.
• Saint Alphonsus says all patients may apply, before or after receiving covered services. Eligibility is reviewed case by case based on family size, income, assets, and insurance status. Financial assistance questions for Boise: 208-367-2130 (toll free 1-866-626-7272). Saint Alphonsus financial assistance · FAQ.

Itemized bills and EOBs

You may get bills from more than one provider. Before you pay any of them, CMS suggests a few checks. CMS:

• Ask for an itemized bill listing the cost of each item or service.
• Compare it with the medical record. You shouldn’t be billed for anything that isn’t documented.
• Match it to your Explanation of Benefits (EOB) from your insurer. The “your share” amount should be the same as what’s on the bill.
• Look for duplicates and services marked out-of-network that weren’t. CFPB.

If something doesn’t match, call the billing department and your insurer. Your state’s Consumer Assistance Program or a patient advocate can also help. A simple folder or notebook for every bill, EOB, and call (with date and name) will save you a lot of stress.

Protections under the No Surprises Act

The federal No Surprises Act protects people with most types of health insurance from unexpected out-of-network bills for emergency care, and for non-emergency care related to a visit to an in-network hospital. It also covers air ambulance services. If you’re uninsured or not using insurance, providers generally must give you a good faith estimate, and you may be able to dispute a bill that is at least $400 more than the estimate. Questions or complaints: 1-800-985-3059. CMS.

Time off work: FMLA

The Family and Medical Leave Act gives eligible employees up to 12 workweeks of unpaid, job-protected leave in a 12-month period. Covered reasons include the birth of a child and caring for the newborn within one year, and caring for a child with a serious health condition. Your employer must keep your group health coverage going on the same terms. Generally, you’re eligible if you’ve worked for a covered employer for at least 12 months, for at least 1,250 hours in the past 12 months, at a location with 50 or more employees within 75 miles. Some states add more protections. U.S. Department of Labor.

Help with lodging

If your baby is far from home, ask the NICU social worker about a Ronald McDonald House. You can search for a chapter near your hospital.

In Boise, the Ronald McDonald House at 139 E. Warm Springs Ave. serves parents or guardians of a child 18 or younger being treated at a Boise medical facility. Families must live outside Ada County, and a social worker or physician starts the referral. The recommended donation is $10 a night, and no family is turned away for inability to pay. Call (208) 336-5478. RMHC of Idaho.

More local help is on our Treasure Valley NICU resources page. If you’re keeping track of calls and questions, our questions to ask the NICU team list has room for notes.