Maternity Health Insurance Coverage During Pregnancy
For many people, giving birth is the single most important yet expensive healthcare event in their lives. Having proper health insurance and maternity coverage is vital for expectant mothers.
There's no way around it: having a baby is expensive. And it's only getting more expensive. According to the New York Times, childbirth costs have tripled since 1996. Maternity and newborn care is the biggest cause of hospital payouts for Medicaid and most insurers. Total yearly costs for births across the country top $50 million.
The average cost for a vaginal birth is around $30,000. That number jumps to $50,000 for a caesarean section. In other words, having adequate insurance is absolutely crucial during pregnancy.
Even with insurance, it's still expensive. A survey by Childbirth Connection found that women with insurance still pay about $3,400 for childbirth.
Fortunately, there are numerous insurance options for pregnant women. This article will cover different insurance types, their implications for expectant mothers, and important questions to ask insurers.
Affordable Care Act Maternity Coverage
One of the main goals of Obamacare was expanding coverage for expectant mothers. Previously, most individual plans excluded maternity care. But now, the ACA mandates that individual plans cover the following:
- All prenatal care visits. And not only that, but policies must cover them without charging a copay. Also, you don't need to get a referral from your primary care physician before you can see a prenatal care provider like an OB/GYN, nurse midwife, or nurse practitioner.
- Screenings for infections that can affect your baby during pregnancy. Examples: chlamydia, gonorrhea, hepatitis B, and syphilis. They'll also screen for gestational diabetes, iron-deficiency anemia, Rh incompatibility, and more.
- Most childbirth (delivery) costs. As well as many related hospital and emergency services.
- Breastfeeding equipment - such as breast pumps - and counseling. See gov for more information on how qualified health plans have to help expectant and new mothers with their breastfeeding needs.
- Newborn screenings for congenital hypothyroidism, hearing problems, phenylketonuria, and sickle cell anemia.
The ACA also mandates that insurers cannot charge higher rates to pregnant women or charge uncapped out-of-pocket fees for healthcare. Be aware that individual plan offerings vary from state to state. Check your state's health insurance marketplace for specific details on coverage offerings.
Employer-Sponsored or Job-Based Maternity Coverage
How about employer-sponsored or job-based health plans?
If you work for a large employer, their insurance plans probably don't have to follow Obamacare's rules. That doesn't mean they won't properly cover maternity or pregnancy costs. Most employer plans provide coverage that's at least as good as your average marketplace or individual plan.
You'll need to look over your policy to see which aspects of your pregnancy it covers, and to what extent. If you're looking for specifics, read over your policy's Summary of Benefits and Coverage document.
If you can't find that document, or if you can find it but it doesn't make a lick of sense, contact your insurer. Someone there will able to answer your questions about the types of maternity or prenatal care your policy does and doesn't cover. Ask questions if you're confused or unsure about anything.
Both are important if you want to avoid what a lot of parents call "surprise" bills. Surprise medical bills are always a bummer. They're an even bigger bummer after a pregnancy. Being pregnant means taking many trips to see physicians and specialists. It also often means one or more trips to the hospital. All those trips can be expensive--especially if they're to providers outside your plan's network.
The best way to keep pregnancy costs in check is to become well acquainted with your health plan and your network of care providers. That'll prevent you from racking up unexpected--and unexpectedly high--bills.
Medicaid or CHIP Maternity Coverage
You should check even if you failed to qualify for either program in the past. Many states have expanded them recently. They now cover more people and care than ever before.
Why Medicaid or CHIP? Each of these programs covers pregnant women and their children in several ways. It's hard to share specific details here because every state has different eligibility requirements and benefit options. Still, you can expect their maternity coverage to be similar to what you'd get if you enrolled in a marketplace plan.
Unlike marketplace plans, you don't have to wait for open enrollment to apply for Medicaid or CHIP. You can do so at any time of the year.
Also, while you can apply for Medicaid and CHIP through your local (state) agency, you also can do so by applying for a marketplace plan. As you fill out that application, it'll tell you if you qualify for either of these programs.
Important Types of Maternity Care
If you're looking for maternity coverage, there are a ton of services and types of care to consider. While shopping around, check that any potential insurance plan offers coverage for the following services:
If your pregnancy is uncomplicated, you'll probably see your obstetrician, physician, or midwife at least once per month through the end of the second trimester. During the third trimester, that may increase to every other week or even weekly. At any rate, don't be surprised if any plan requires you to cover small copayments for each of these checkups.
Additional lab work
It's possible your doctor will want to do some lab work that's above and beyond what was detailed earlier in this article. Your health insurance should cover those tests and screenings if they're considered medically necessary. If you're at all worried your plan won't cover a certain screening or test, though, speak up. Have a chat with your insurer before you get it on your schedule.
Your care provider may want you to have one or more ultrasounds over the course of your pregnancy. These can be quite expensive if you pay for them out of pocket, so be sure your health plan covers any ultrasounds your doctor recommends before agreeing to them. It should cover them especially if the ultrasound is needed.
This procedure looks for genetic disorders or conditions like Down syndrome. If your doctor suggests you have an amniocentesis test done, contact your insurance company. Should you go ahead with it without confirming that it's covered, you could be on the hook for thousands of dollars. Fortunately, most plans cover these tests if they're determined to be medically necessary.
This expense might seem minor compared to what you could shell out for an amniocentesis test. Still, these classes are important--they help you prepare for the delivery of your baby. Thankfully, most health insurance policies cover them, and that saves you as much as a few hundred dollars.
Once again, review any policy's Summary of Benefits and Coverage to be sure which of these costs it covers or doesn't cover. That also will help you educate yourself about any copayments or co-insurance costs that may be your responsibility. And if that review doesn't make everything clear, pick up the phone and call (or send an email to) your insurance company.
Maternity Coverage Questions You Should Ask Your Insurer
When you're gearing up to have a baby, there are tons of costs to consider. Get in touch with your current or potential healthcare provider and ask these vital questions:
- How much is my monthly premium with this plan? And how much is my deductible?
- What kinds of copays or co-insurance costs come along with it?
- Is there a network associated with this plan? If so, what are its rules regarding in-network and out-of-network care? Or what are its rules regarding in-network and out-of-network providers and specialists? And what about hospitals?
- Will I need to get referrals to see specialists? Or will I need to have some or all my prenatal or maternity care pre-authorized?
- What kinds of health screenings does this plan cover? How about diagnostic tests? Or lab work?
- Does this plan cover ultrasounds? Or amniocentesis procedures?
- Will it cover birthing classes?
- What if I have a high-risk pregnancy? What kinds of care does this plan cover in that kind of situation?
- Do I need to contact you (the insurance company) when I'm admitted to the hospital for labor and delivery?
- Does this plan cover a private hospital room or suite? Or do I have to share a room?
- How much inpatient hospital time does the plan cover after delivery? Will it cover an extended stay if it's medically necessary?
- What if I want to use a nurse midwife? Or what if I want to have my baby in a birth center or at home? Will this plan cover any or all situations?
- Will this plan cover my baby's nursery stay?
- Will it cover the costs of a NICU stay, if one is needed?
- Does it cover my newborn's first set of pediatrician appointments? How about vaccinations?
- How do I add my newborn to my plan? Or what do I need to do to make sure my baby is covered from the moment of delivery?
Frequently Asked Questions
Q: Can I get health insurance if I'm already pregnant?
A: Yes, you can get health insurance if you're pregnant. That wasn't always true before the Affordable Care Act passed in 2010. At that time, insurance companies could treat pregnancy like a pre-existing condition. As such, they sometimes denied coverage or charged more for it.
This is no longer the case thanks to the ACA. So, if you're pregnant and can't get health coverage through a job, check out your state insurance marketplace. Just know you may need to wait until the next open enrollment period begins to buy a policy.
Q: Does becoming pregnant make me eligible for a special enrollment period (so I can buy a marketplace insurance plan)?
A: No, it doesn't. Giving birth does make you eligible for a special enrollment period, however. If you buy a plan during that 60-day period, by the way, it should cover your baby from the moment of delivery.
Q: What kinds of maternity care does health insurance usually cover?
A: Most health plans cover a wide range of pregnancy costs. That range usually spans prenatal care, labor, delivery, and postnatal care, too.
This is true whether you're talking about marketplace policies or those bought directly from an insurance company. It's also true of small group plans.
Although large employers usually don't have to include this kind of coverage in the health plans they offer employees, they often do anyway.
Q: Does Medicaid cover maternity care and childbirth?
A: Yes. So does the Children’s Health Insurance Program (CHIP) program. Every state runs its Medicaid and CHIP programs slightly differently, though, so reach out to your local agency to learn more about how it covers maternity care and childbirth.
Q: How much does it cost to have a baby?
A: The short answer: a lot. Especially if you don't have health insurance.
That said, several factors determine just how much a pregnancy or delivery costs. One is where you live. Another is where you give birth. Complications can play a pretty major role, too.
Health insurance usually pays for most of these costs, but not all of them. If you're uninsured, though, you could be charged $30,000 to $50,000 for the delivery alone.
Q: What if I need help paying for health insurance during my pregnancy?
A: First, see if you qualify for Medicaid or CHIP coverage. These state-run programs help people in need. (CHIP is for people who earn too much for Medicaid.)
To see if you're eligible for either program, contact your state's agency. Another option is to apply on line for a marketplace plan. When you do that, it'll let you know if you qualify for Medicaid or CHIP.
Q: How can I find out exactly which forms of prenatal or maternity care my plan covers?
A: Look at your plan's Summary of Benefits and Coverage document. It should tell you everything you need to know about these services and costs--as well as many others. If it doesn't, or if you can't make sense of it, reach out to your insurance company for clarification.
Q: Are any health plans not required to cover maternity or prenatal care?
A: Some grandfathered health plans (plans that were first written years ago and have since been renewed) don't have to provide this kind of coverage. If you have one of these policies, you might want to shop around for a new one when the next open enrollment period begins. It's possible you'll be able to find a marketplace or
individual plan that better covers you in these areas. Plus, it probably won't cost any more than your existing one. Before you start comparing plans, though, check out our article, "Choosing the Best Health Insurance Plan for a Pregnancy." It'll tell you everything you need to know about the subject and help you make the best decision for you and your baby.
Q: Do Obamacare plans cover midwives?
A: Some do, some don't. Or more specifically, some plan networks include midwives, and some don't. So, if you'd like a midwife to provide your prenatal or maternity care, thoroughly review provider lists while shopping for marketplace plans.
Q: Do other kinds of health insurance plans cover midwives?
A: Again, some job-based, large group, small group, or individual health plans do cover midwives, and some don't. The main issue here is likely to be finding a policy that has a network that includes these caregivers. As a result, if you're shopping for health insurance, take a close look at a plan's network if you need or want it to pay for you to see a midwife during your pregnancy.
Q: Is there anything I need to know about maternity care that health insurance usually doesn't cover?
A: Something many Americans don't know about is that the law doesn't require large group plans (plans offered by companies with more than 51 employees) to provide full maternity coverage to a policyholder's dependent children.
Basically, your employer-sponsored plan may well cover some prenatal care, but it doesn't have to cover labor and delivery costs.
That may come as quite a shock to some people, especially considering the ACA now allows children to remain on their parents' health plans until they turn 26.
QuoteWizard.com LLC has made every effort to ensure that the information on this site is correct, but we cannot guarantee that it is free of inaccuracies, errors, or omissions. All content and services provided on or through this site are provided "as is" and "as available" for use. QuoteWizard.com LLC makes no representations or warranties of any kind, express or implied, as to the operation of this site or to the information, content, materials, or products included on this site. You expressly agree that your use of this site is at your sole risk.