So You're Pregnant? Here's What You Need to Know About Your Maternity Coverage and Benefits

Things have changed under the ACA, but "covered" doesn't necessarily mean "free."

Apr 27, 2014 at 12:30PM

Pregnancy can be one of life's most exciting phases as you prepare to welcome a new family member -- but it can also be one of the most stressful, especially as the details of your maternity coverage start to bog you down.

Beyond getting the nursery ready and steeling yourself for months of sleep deprivation, there's the issue of paying for your week-to-week costs of pregnancy, including doctor visits and the delivery itself. By understanding your insurance plan's maternity benefits, you can dispense with at least one worry. Here are the basics of what you need to know about your maternity coverage.

Maternity coverage is universal -- sort of
A major component of the Affordable Care Act is its requirement that, as of this past Jan. 1, insurance plans must cover maternity care. It used to be easy to find yourself left out of coverage, especially if you didn't have an employer-sponsored plan -- only 6% of pre-ACA plans on the individual market included maternity coverage. The out-of-pocket expenses for an uncomplicated pregnancy in the pre-ACA era could total more than $10,000, according to one 2008 study. A more recent study reports total charges for maternal and newborn care to be between $30,000 and $50,000 for vaginal and cesarean births, respectively. While these charges are subject to negotiation by you or your insurance company, these massive amounts emphasize the importance of having insurance coverage for pregnancy care, and knowing which unexpected costs of having a baby will arise.

The ACA solves this problem -- to an extent. Maternity is among 10 "essential benefits" that health insurers must offer, along with chronic disease management, emergency services, and prescription drugs. And you cannot be denied coverage or charged higher premiums for being pregnant.

But the U.S. Department of Health and Human Services has not explicitly stated which maternity services have to be covered, meaning that states have a degree of discretion regarding what is required to be covered. Uncertainty has reigned about whether some services, such as midwifery, birthing centers, and home births, are covered in certain states, so it's important to check with your insurer on exactly what's covered as you plan your prenatal care and delivery.

"Covered" doesn't mean free
No matter what kind of plan you have, chances are you'll face significant out-of-pocket costs. For years, deductibles and copays for employer-sponsored and individual plans have been rising. A deductible is the amount you have to pay before your insurance kicks in, and a copay is a fixed amount you pay when you receive a service -- $30 for a doctor visit, for example.

The average annual deductible for a single person covered under an employer-sponsored plan in 2013 was $1,135, according to a Kaiser Family Foundation survey. However, in "high-deductible" plans, which offer reduced monthly premiums, that number can exceed $5,000. The deductible does not, however, apply to preventive care, which are free services that include routine visits to your OB/GYN and breast-feeding support, supplies, and counseling.

A high deductible, if unexpected, could present a major expense for new parents just when they're stretching their budget to pay for formula, diapers, and other new-baby expenses. It pays to know what you'll owe long before the due date arrives.

Not all networks are created equal
When you choose your health-care providers for maternity care, make sure they're "in network" for your insurance plan. Seeing a provider within your insurer's network means you'll avoid any out-of-network charges -- and you can only access free preventive care through an in-network provider.

If you go to a health-care provider who's not part of the network, one of two things can happen. In the best-case scenario, you'll have to pay "out-of-network" rates -- this will be the case if you have a PPO plan -- which translates directly to higher out-of-pocket costs. If you have an HMO plan (or various other types that don't cover out-of-network services), you'll be responsible for the full bill.

To be sure if the doctor or hospital you're considering is in network, check your insurer's provider directory.

Alternative birthing places may be less expensive -- but may not be covered
Home births are estimated to be 60% less expensive than hospital births. But it is not clear whether midwives and/or birthing centers will be covered by all plans, in all states. Consider your individual needs before choosing where you will give birth.


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4 in 5 Americans Are Ignoring Buffett's Warning

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Jun 12, 2015 at 5:01PM

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David Hanson owns shares of Berkshire Hathaway and American Express. The Motley Fool recommends and owns shares of Berkshire Hathaway, Google, and Coca-Cola.We Fools don't all hold the same opinions, but we all believe that considering a diverse range of insights makes us better investors. The Motley Fool has a disclosure policy.

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