Pregnancy insurance: How to find out what's covered

With a few exceptions, pregnancy – including prenatal care, childbirth, and newborn care – is covered by qualifying health insurance plans. But you'll likely have co-pays, deductibles, and/or coinsurance to pay.

In this article

• Will my insurance plan cover my pregnancy?
• When should I tell my insurance about my pregnancy?
• What if I'm pregnant with no insurance?
• Can I get maternity insurance if I'm already pregnant?
• What pregnancy and newborn services are covered for free?
• Does insurance cover childbirth?
• How much will I pay for tests, procedures, and other medical care?
• What's the most I could end up paying in a worst-case scenario?
• When do I need pre-authorization? Do I need to call my insurer when I go to the hospital?
• How can I find out what kind of breastfeeding and breast pump benefits I have?
• How to add your baby to your insurance
• What can I do if I get a "surprise" bill?

Will my insurance plan cover my pregnancy?

The Affordable Care Act ("Obamacare") requires all plans on the Health Insurance Marketplace or Medicaid to cover prenatal care, childbirth, and newborn care, even if you were pregnant before your coverage started. These are considered essential health benefits. So whether you receive health insurance through an employer or directly on the Marketplace (the federal government's site for health plan shopping and enrollment), you should have coverage.

There are exceptions. Small employers (those with fewer than 50 employees) don't have to provide healthcare coverage, but if they do, they must include maternity care. And group plans aren't required to provide complete maternity coverage for dependent children, even though adult children can remain on their parent's healthcare plans through age 26. (At this time, prenatal care must be covered, but there's no requirement for providing labor and delivery coverage.)

Some older plans, known as grandfathered health plans Opens a new window , aren't required to cover pregnancy, childbirth, or preventive care. A grandfathered plan is a health plan that existed on March 23, 2010, before the Affordable Care Act went into effect, and has not been significantly changed since then. If you have one, you may not receive some of the protections offered by qualified plans. For example, a grandfathered plan isn't required to provide free preventive care or pregnancy and childbirth coverage.

To find out whether your plan is grandfathered, call your plan provider. If you do have a grandfathered plan, carefully review your pregnancy and childbirth coverage. You may want to switch to a new health plan. You can switch to a new plan during the open enrollment period or when your grandfathered plan year ends, but check with your insurance company ahead of time about how to cancel your plan.

When should I tell my insurance about my pregnancy?

There's no rush to tell your insurance immediately about your pregnancy. You're automatically covered for maternity benefits. But there may be advantages to reporting your pregnancy sooner rather than later.

For one thing, your insurer may have free resources for pregnant women that you can access now. These resources might include help finding a healthcare practitioner in your network and phone access to support and advice from nurses, as well as prenatal care information or parenting classes.

Also, if you have Marketplace coverage and report your pregnancy, you'll automatically be forwarded to your state agency that handles Medicaid or CHIP (the Children's Health Insurance Program), if you're eligible. This might mean more affordable coverage for you.

To update your status on your Marketplace account (which the government recommends doing within 30 days of any change), visit Healthcare.gov, log into your Marketplace account, and select "Report a Life Change" from the menu. Or call the Marketplace call center at 1-800-318-2596.

Once your baby is born, you'll want to add them to your coverage (see below).

What if I'm pregnant with no insurance?

If you have no insurance and are unable to sign up for coverage now (because you're not in the enrollment period), you may have some other options:

• Medicaid Opens a new window covers pregnancy and childbirth, and you may qualify now that you're pregnant, even if you didn't qualify before. You can enroll in Medicaid year-round.
• CHIP Opens a new window , the Children's Health Insurance Program, covers prenatal care, childbirth, and baby care during pregnancy and for 60 days after delivery. You may qualify for CHIP, even if you don't qualify for Medicaid. You can also enroll in CHIP year-round.
• Community-based health centers Opens a new window provide health care services to those in need. These receive federal funding and often offer a sliding scale, depending on the ability to pay for services.
• Some Planned Parenthood Opens a new window centers offer free or low-cost prenatal services. Even if they don't, they may be able to point you to other resources in your area.
• Hill-Burton facilities Opens a new window are public and nonprofit facilities that received financial assistance under the Hill-Burton Act (passed in 1946 to provide loans for healthcare facilities). These facilities are required to offer free or reduced-cost health care to those with incomes below the Federal poverty guidelines. (Some facilities have a higher allowable income.)
• Talk with your local Health Department Opens a new window . They may be able to provide you with information on maternity resources in your area.

Can I get maternity insurance if I'm already pregnant?

To get maternity insurance through a Marketplace health care plan, you need to enroll during the annual open enrollment period – usually in the fall. There are special enrollment periods, and you qualify for these during life events such as moving or losing other coverage. But being pregnant doesn't qualify you for special enrollment. (A child's birth does, however.)

You can apply for Medicaid or CHIP at any time, though. And you'll also be eligible for a special enrollment period for Marketplace coverage if you had Medicaid or CHIP coverage that ended or is ending soon. Indicate on your application that your state agency found you ineligible for Medicaid or CHIP.

You can shop for private health insurance outside of the marketplace through some insurance companies, agents, brokers, and online health insurance sellers. Note that if you buy a plan outside the marketplace, you won't be eligible for tax credits or other savings based on your income.

Also, make sure any plan you buy is a qualified health plan. That means it meets all the requirements of the health-care law, including covering pre-existing conditions, providing free preventive care, and not capping annual benefits. Check any potential plan's offerings against this list of what marketplace health insurance plans cover Opens a new window .

What pregnancy and newborn services are covered for free?

The Affordable Care Act requires all qualified plans to provide many pregnancy, children's health, and well-woman benefits for no extra cost. These benefits must be provided without charge for a copayment or coinsurance, even if you haven't met your yearly deductible. For pregnant and postpartum women and newborns, these benefits include:

• All preconception and prenatal care visits. You don't need a referral from your primary care provider to see a prenatal care provider.
• Folic acid supplements: Experts recommend that all women of child-bearing age take 400 micrograms of folic acid a day to reduce the risk of having a baby with a neural tube defect.
• Alcohol misuse screening and counseling: All public health officials in the United States recommend that pregnant women avoid alcohol entirely.
• Tobacco use screening, intervention, and counseling: Special expanded counseling for pregnant women.
• Rh incompatibility screening: Your blood will be tested to determine your Rh status at your first prenatal care appointment. Follow-up testing is covered if you're at higher risk. (If there's a chance this blood protein is incompatible with your baby's, you'll need to take certain precautions.)
• Iron-deficiency anemia screening: Your blood will be tested for anemia at your first prenatal care appointment and again later in pregnancy.
• Gestational diabetes screening: You'll most likely get screened for gestational diabetes between 24 and 28 weeks of pregnancy, or at your first prenatal visit if you're at high risk.
• Preeclampsia prevention and screening for pregnant women with high blood pressure.
• Infection screening: Screenings for infections that can affect your baby during pregnancy, such as hepatitis B, gonorrhea, and urinary tract infections (UTIs).
• Breastfeeding support and supplies: Comprehensive lactation support and counseling from trained providers during pregnancy and postpartum. Includes breast pump purchase or rental (more on this below).
• Contraception counseling: All contraceptive methods approved by the Food and Drug Administration, including sterilization procedures, and patient education and counseling. (Some religiously affiliated employers may be exempt.)
• Maternal depression screening for moms at well-baby visits.
• For newborns: Gonorrhea preventive medication for the eyes and newborn screening, including screening for congenital hypothyroidism, hearing problems, vision problems, phenylketonuria (PKU), and sickle cell anemia.

Again, many insurers have free programs that are designed to help women have a healthy pregnancy. Call your plan to see whether they have a program for you and how you can enroll.

Does insurance cover childbirth?

Yes, labor and delivery are covered by qualified insurance plans. But they're usually not free. You'll likely have co-pays, deductibles, and/or coinsurance to pay.

Learn about the average cost of birth, with and without insurance.

To find out what you'll pay, ask your insurer exactly what they cover and exactly what will be out-of-pocket expenses. Ask your insurer which local hospitals are in your plan's network (costs will depend on the provider's contract with your insurance company.). Find out how long a hospital stay is covered after delivery, and whether you'll have to share a room. If you're interested in alternative delivery options, like a birth center or home birth, ask about coverage for those.

There are a host of charges typically associated with delivery, including a hospital or facility fee, a provider fee for prenatal care and birth, an anesthesia fee, costs for the pediatric examination, and incidental charges for supplies or equipment. Your practitioner's office can help you gather this information ahead of time and help you guesstimate what your costs may be.

Keep in mind, though, that neither the insurance company nor your healthcare provider will be able to guarantee a specific cost for you. They can't predict any special tests or procedures you may need, from something small (an extra hospital gown) to something like an induction, to something not so minor (an emergency procedure for you or your baby). A ballpark figure is often the best you can do.

How much will I pay for tests, procedures, and other medical care?

Usually, the best way to determine your costs is to talk to the staff at your healthcare provider's office. They should be able to help you figure out approximately what you'll pay for everything from prenatal tests to delivery. Then call your insurance plan and see if they can confirm those approximate costs.

Look at your health plan's Summary of Benefits, which will include the expected costs of maternity care. The Marketplace provides the same summary form for various health plans so you can compare them. Go to HealthCare.gov's See plans & prices to compare plans available to you.

Call your insurance company if you can't find the information you're looking for or if you have questions. Keep careful records of the answers you get and make sure to note the name of the person you spoke to and the date you called.

Also ask about coverage in the event that your baby has complications and needs to spend some time in the neonatal intensive care unit (NICU). NICU costs can cause your bills to climb significantly. How much depends on how long your baby's stay is, which specialists see them, and what services they need.

To minimize costs, make sure that all of your healthcare providers are in your plan's network. (Ask before you head to any healthcare provider.) That includes the practitioner who cares for you during your pregnancy, your anesthesiologist during labor, your baby's doctor, and any specialists you know you'll need. For example, you'll need to see a maternal-fetal medicine specialist (MFM) if you have any chronic conditions that would make your pregnancy high-risk. Be aware that insurance companies will pay less for out-of-network care, or it may not be covered at all.

Unfortunately, sometimes an in-network medical facility will use out-of-network staff. They may not warn you when you're about to be treated by a practitioner who is out-of-network. That's when you may end up with a surprise bill. (See below on what to do about surprise bills.)

So it's always a good idea to ask before each procedure if all the staff who will be billing you are in-network. You may not be able to get a straight answer because in most states, hospitals are not required to tell patients if their staff is in-network, and the practitioners themselves may not even know. In some cases, there may be no in-network practitioner available. But it's worth asking.

What's the most I could end up paying in a worst-case scenario?

According to the Health Care Cost Institute, childbirth accounts for about four out of every five dollars spent on maternal-newborn health care. The average cost for childbirth (with employer-sponsored insurance) averages $13,811. But the cost varies a great deal, depending on where you live – from $8,361 in Arkansas to $19,771 in New York.

Cesarean deliveries are more costly than vaginal deliveries. The average cost of a vaginal birth is $12,235, while the average cost of a c-section is $17,004.

Find out if you have an annual out-of-pocket maximum and how that works. This is defined as the highest amount your insurer will ask you to pay for medical costs for the year. Once you've paid this amount, your insurer generally covers 100 percent of other medical costs you have for the remainder of the year.

However, read the fine print to find out what's included in this amount. It almost always includes your yearly deductible. But it doesn't necessarily include premiums or out-of-network costs. (Some plans have a separate, higher out-of-pocket maximum for out-of-network care.) And you will still be responsible for amounts that are considered more than "reasonable or customary" for any service.

And remember that your pregnancy may start in one year and end in another, but your plan will only count the costs you paid in each calendar year toward your annual maximum for that year. On the other hand, your doctor's office may bill for everything at once, including prenatal care and delivery. You'll want to work this out with your healthcare provider's office.

Thanks to the Affordable Care Act, qualified plans are no longer permitted to have limits on the total amount an insurance company will pay for your care each year. Grandfathered plans (see above) may still have limits.

If you're concerned about being able to pay your healthcare bill:

• Ask the hospital or birthing center if they offer a sliding scale.
• Talk with the hospital or center about setting up a payment plan.
• Ask about various rates. Does the hospital offer a self-pay discount rate, or a charity rate, for example? Some hospitals do but don't advertise their availability.
• To reduce costs, you may want to consider having a midwife rather than an ob-gyn (if your pregnancy isn't high risk), and/or delivering your baby at a birth center rather than a hospital.

When do I need pre-authorization? Do I need to call my insurer when I go to the hospital?

Many plans require pre-authorization for certain services and procedures, such as ultrasound and amniocentesis. Most of the time, your practitioner's office will call your insurance company for pre-authorization when making plans for your prenatal care and delivery. But it's a good idea to confirm this.

Check your plan to find out whether you need to get pre-authorization for hospital admission or whether you need to call them when you get admitted. (In most cases, your healthcare provider will obtain pre-authorization when you begin your prenatal care.)

By the way, many hospitals will have you register online in advance of your delivery stay. This is not a pre-authorization.

How can I find out what kind of breastfeeding and breast pump benefits I have?

You'll have to call your plan to find out. All qualified plans (except for grandfathered plans) are required to provide free breastfeeding support, counseling, and equipment for as long as you nurse your child. These services may start before the birth.

The pump provided may be either a rental unit or a new one you'll get to keep. Your plan may determine whether the covered pump is manual or electric, the length of the rental, and whether you get it before or after delivery.

Health plans will often follow a doctor's recommendations on what's medically appropriate and some require pre-authorization from your doctor. By the way, don't be disappointed if you end up with a hospital-grade rental pump. These pumps are the highest quality and work as well or better than any retail pump.

Take advantage of counseling and support services. Most hospitals provide a free consultation with a staff lactation consultant (or a nurse with training in this area) during your stay, but breastfeeding problems may arise after you leave the hospital.

Find out ahead of time what kind of counseling services are covered. Ask about breastfeeding classes before birth and find out which lactation consultants you can see after you leave the hospital and how many visits are covered.

How to add your baby to your insurance

If you have Marketplace coverage when your baby is born, you can simply add your baby to your coverage. (You qualify for a special enrollment period when your baby is born, which means you don't have to wait until the annual enrollment period to sign your baby up for coverage.) Go the Healthcare.gov account and choose "Report a Life Change." You have 60 days to report the change.

When you update your account, the government will let you know if your baby may be eligible for Medicaid or CHIP. You may also qualify for savings that might lower your monthly premium, now that you have a baby.

If you have insurance through your employer or a private plan, ask your insurance provider what the procedure is for adding your new baby to your plan. In most cases, your child will be automatically covered under your plan for the first month after birth.

What can I do if I get a "surprise" bill?

What happens if you use an out-of-network provider without knowing it, for example, and end up with a big bill? Call your insurance provider and see what they can do. Some plans will cover the cost, especially if they originally told you the service was in-network.

Other places to find help with unexpected bills:

• Your healthcare provider's staff. They're often skilled at working with patients on these problems.
• A medical billing advocate. This is a person who will evaluate your bills for errors and duplicate or unreasonable charges and then negotiate with the hospital or insurer for relief on your behalf. You can find medical billing advocates through the Alliance of Claims Assistance Professionals Opens a new window . Some charge an hourly rate of $100 to $200. Others charge a percentage of your savings, typically 15 to 35 percent of the reduction in your bills they achieve.

And for help with your insurance coverage:

• Health insurance counselors Opens a new window can help you make sense of insurance information on the Marketplace and are available free of charge. You can visit one in person, over the phone, or via email. A counselor can help you figure out if you're eligible for benefits (like Medicaid) or credits. They can also help you determine what kinds of plans are best for you and how much they'll cost. Then they'll help you enroll.

Learn more:

• Choosing a hospital for your labor and delivery
• How to make a birth plan
• Pregnancy and work: Your complete guide
• How to have a healthy pregnancy and baby

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