What Does Health Insurance Cover During Pregnancy and Postpartum?

Positive pregnancy test! Yay! 

Now what? 

First, take a deep breath, smile, and remember this moment.

You’re feeling joy, excitement, and there are probably a lot of questions. 

One of the first things you can tackle is understanding your insurance pregnancy coverage. It isn’t nearly as glamorous as decorating your baby nursery, but understanding your coverage thoroughly will help you avoid unexpected costs and ensure you receive the necessary care. 

What Does Health Insurance Cover During Pregnancy?

Chances are, your health insurance will cover the vast majority of your pregnancy, birth, and postpartum care. Under the Affordable Care Act, pregnancy and maternity care is an essential health benefit, so all ACA-compliant plans must cover prenatal care, labor and delivery, and postpartum care. 

A few exceptions are older “grandfathered” plans and some short-term insurance plans, which may exclude pregnancy coverage. If you don't know if your plan covers pregnancy care, call the number on the back of your insurance card to find more information about your specific plan and options.

Covered care doesn't necessarily mean free, however. In most cases, it means that your plan will pay a share after you've met your deductible. For some plans, there is also a copay (a flat fee per visit) or coinsurance (a portion of the fee, like 20%). Your plan's out-of-pocket maximum is the most that you'll pay in a given year for care. Many people reach their out-of-pocket maximum in the year that they give birth, just because there are so many medical appointments during that year.

Note that out-of-hospital midwifery care (at a birth center or at home) is not typically covered by health insurance, so many people pay for this care out of pocket.

Prenatal Care: What's Typically Covered

The majority of standard prenatal care is covered by insurance. This includes all visits with your provider, whether it be an obstetrician, a family practice physician, a midwife, or other provider.

Prenatal care covered by insurance includes:

• Prenatal visits 
• Standard prenatal labs and screenings
• Ultrasounds, including the 20 week anatomy scan  (additional scans may require prior authorization)
• Genetic testing, like NIPT and carrier screening (coverage varies by plan)
• Physical therapy, such as seeing a pelvic floor therapist

Some insurances will cover additional care or medical needs, such as prenatal vitamins, gestational diabetes tools (like a glucometer or meetings with a diabetes educator) and more.

Labor and Delivery: What's Typically Covered

Your insurance will cover most of what you experience during your labor and birth as well. This includes all aspects of hospital birth. Some birth centers may be covered, and typically home birth is not. Coverage for labor and delivery includes:

• OB or midwife fees
• Medications
• Epidural and anesthesia
• Cesarean birth (C-section)
• Care for your baby, like seeing a pediatrician at the hospital
• NICU care (usually covered but there may be additional costs)

Postpartum Care: What's Typically Covered

After birth, much of your care will be covered, particularly care that you experience at the place where you gave birth. Coverage for postpartum care includes:

• Postpartum provider visit with physician or midwife (often, insurance covers just one visit)
• Newborn pediatric visits and vaccines
• Lactation consulting (some plans may not cover this fully, so check with your insurance!)
• Postpartum mental healthcare with a psychiatrist or therapist
• Physical therapy, like pelvic floor PT

Here at Partum, we can connect you with the postpartum care you need, like a lactation consultant, a therapist, or pelvic floor PT. We work with your insurance to make coverage as easy as possible for you. 

What's Usually NOT Covered

While a lot of your care will be covered, you may find there's some care you want or need that isn't covered by your insurance. Here are some examples of care that is usually not covered by insurance: 

• Doula care: While doula care historically has been an out-of-pocket expense, that is rapidly changing, and some members may have doula care covered by insurance. You may also have other options to pay a doula, like FSA/HSA and employer plans like Carrot or Maven. 
• Childbirth education classes are generally not covered 
• Placenta encapsulation is not covered

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Questions to ask about your insurance plan

We’ve put together a list of questions to ask your company’s HR department and/or your insurance regarding your perinatal care coverage. When you understand your benefits and what’s covered, you can plan well and avoid unexpected cost before and after giving birth. 

Before you call your insurance company, have a pen and paper handy to take notes. Get the answers in writing (ask them to follow up with you via email) and note the rep's name and call reference number. 

General Pregnancy Coverage Questions

1. What perinatal care services are covered under my plan?

   - Ask for a detailed breakdown of covered services for prenatal, labor and delivery, and postpartum care.

2. Do I need to notify the insurance company once I become pregnant?

   - Understand any required notifications or documentation to ensure coverage.

3. Are there any pre-authorization requirements for specific services or tests?

   - Check if certain procedures need prior approval to be covered. Many families are blindsided when they find out that a c-section sometimes requires prior approval, even if you don’t plan to have one!

Prenatal Care Questions

4. How many prenatal visits are covered, and what is the cost for each visit?

   - Clarify if there are limits on the number of visits and what your copayments or coinsurance will be.

5. Which prenatal tests and screenings are covered, and are there any restrictions?

   - Ask about coverage for ultrasounds, blood tests, genetic testing, and other screenings.

6. Are prenatal vitamins and supplements covered under my plan?

   - Find out if you can get coverage or discounts for prenatal vitamins.

7. Is there coverage for prenatal classes or childbirth education classes?

   - Check if you can receive reimbursement or direct coverage for these educational services.

Labor and Delivery Questions

8. What is covered during labor and delivery, including hospital or birthing center costs?

   - Ask about the specifics of coverage for various delivery settings and services.

9. Does my plan cover midwife-assisted births, birth center birth or home births?

   - Understand the extent of coverage for alternative birthing options.

10. What are the costs associated with labor and delivery, such as copayments, coinsurance, and deductibles?

    - Get a clear picture of potential out-of-pocket costs.

11. Is pain management during labor, such as an epidural, covered?

    - Check if specific pain management techniques or medications are included in your coverage.

12. Are cesarean sections fully covered, and are there any additional costs?

    - Ask about coverage for both planned and emergency cesarean deliveries.

Postpartum Care Questions

13. What postpartum care services are covered, and for how long?

    - Find out the coverage details for follow-up visits and any limitations on duration. Your fourth trimester, or those early months home with your baby require a totally different set of support services. We know about 1 in 7 birthing people experience postpartum depression or anxiety. And 92% of women report struggling with breastfeeding three days after giving birth (read: when they’re home and a lactation consultant isn’t just down the hospital corridor.)

14. Does my plan cover postpartum mental health services?

    - Ask about coverage for mental health support, including counseling or therapy for postpartum depression.

15. Are lactation consultant services covered, and if so, how many visits are allowed?

    - Clarify the extent of coverage for breastfeeding support and any limits on consultations.

16. Does my plan cover postpartum physical therapy or rehabilitation services?

    - Check if you can receive support for postpartum recovery, including physical therapy.

Newborn Care Questions

17. What newborn care is covered immediately after birth, and for how long?

    - Ask about the coverage for initial newborn assessments, screenings, and the first few days of care.

18. How long can my newborn remain on my plan before needing separate coverage?

    - Understand the timeline for adding your baby to your insurance plan.

19. Are newborn immunizations and check-ups covered, and what are the associated costs?

    - Confirm the coverage for routine immunizations and pediatric visits.

Network and Provider Questions

20. Which hospitals, birthing centers, and healthcare providers are in-network for perinatal care?

    - Ask for a list of covered facilities and providers to avoid higher costs associated with out-of-network services.

21. Do I need a referral to see specialists, such as maternal-fetal medicine experts?

    - Understand if you need referrals for specialist visits and how to obtain them.

22. Are there any limitations or restrictions on choosing a specific obstetrician or midwife?

    - Check if your preferred healthcare provider is covered under your plan.

Cost and Billing Questions

23. What is my deductible, and how does it apply to perinatal care?

    - Understand how your deductible affects the cost of perinatal services and whether you’ll be responsible for a co-pay at the time of service.

24. Are there any out-of-pocket maximums for perinatal care, and what do they include?

    - Ask about the maximum amount you will have to pay out of pocket for perinatal care within a year.

25. Are there any additional costs for out-of-network services, and how can I avoid them?

    - Understand the potential costs for using out-of-network providers, the process for reimbursement, and how to stay within your network.

26. Does my plan offer any maternity or childbirth benefits that I should be aware of?

    - Inquire about any specific benefits or programs related to maternity care that your plan might offer like lactation support, night nanny benefit, or pregnancy support programs.

Additional Considerations

27. Are there any coverage limitations for high-risk pregnancies or complications?

    - Ask about the coverage specifics for high-risk pregnancies or complications that may arise.

28. Does my plan cover genetic counseling or testing for inherited conditions?

    - Check if genetic counseling and related tests are included in your coverage.

29. Are tele-health services for prenatal or postpartum care covered?

    - Find out if virtual visits for prenatal or postpartum care are covered and any associated costs.

30. What resources or support does the insurance company offer for expectant parents?

    - Ask about any available support services, educational materials, or assistance programs for pregnant individuals.

It's a lot of ground to cover, but getting all of this fact-finding out of the way early will help ensure a smooth process in the months to come.

Do I Need to Notify My Insurance Company When I'm Pregnant?

No, you do not need to notify your insurance company when you're pregnant. You do, however, need to add your newborn to your insurance plan within 30 to 60 days of their birth (if you want your baby to have insurance coverage). The exact number of days you have to add them varies by plan. Set a calendar reminder after baby's birth to make sure you do this! 

If you have insurance through your employer, notify your HR department after your baby's birth. If you're pregnant or planning to be during open enrollment, it might be a good idea to compare plans during this time window, too.

If you have a marketplace plan, pregnancy is usually not a qualifying life event (with a few states, like California, being an exception to this rule). A newborn's birth is a qualifying event, however. This means that you can add your baby to your plan or switch plans.

Understanding Your Deductible and Out-of-Pocket Maximum

You may not have paid much attention to deductible and out-of-pocket maximum amounts before, but in a year when you give birth, it's important to do so. Most plans reset out of pocket max and deductibles on January 1st. If your due date is near the beginning of the year, that can affect how much you end up paying. 

Once you hit your out of pocket max for the year, your insurance will cover 100% of the rest of your healthcare. If you have a NICU stay or a high risk pregnancy, that often means you hit your out of pocket max before the end of the year.

It's worth understanding the difference between family deductible vs individual. An individual deductible applies to one person, while family deductible Is the whole amount your household has to pay before full coverage kicks in for everyone. Once your baby is born, they're a separate person on your plan, so their care counts towards the family deductible. 

FAQs

What does insurance cover for pregnancy?

Health insurance covers the vast majority of care that you will need for your pregnancy, including prenatal care, labor and birth, postpartum care, and more. Specific services will vary based on the plan you have, as well as the state you live in. 

Do I need to notify my insurance company that I'm pregnant?
No, you don't. If you want your newborn to have insurance coverage, though, you need to add them to your insurance within 30 to 60 days of birth. The number of days allotted will depend on your plan.

Does insurance cover a doula?

In some cases, insurance may cover doula care, There are other ways to pay for a doula if your insurance doesn't cover doula care, such as FSA/HSA and employer plans like Carrot or Maven.

Does insurance cover lactation consultants?

Usually, insurance does cover lactation consultants, otherwise known as International Board Certified Lactation Consultants or IBCLCs. This means that clinical breastfeeding support, breastfeeding supplies, and more are covered under the Affordable Care Act. The level of coverage, including number of visits, can vary widely between plans, so check with your insurance to find out how much lactation care is covered for you. 

Does insurance cover postpartum therapy?

Yes, health insurance should cover any mental health care you need before, during, and after pregnancy. Postpartum therapy with a credentialed mental health care professional will be covered by your insurance, although there may be specific limitations under your plan.