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 picking out your nursery colors, but understanding your coverage thoroughly will help you avoid unexpected costs and ensure you receive the necessary care. 

Start here: insurance coverage 101

Your pregnancy insurance coverage, also known as perinatal care, refers to the health care provided to a mother and her baby from the time of conception through the first year of life. It includes prenatal care, doctors visits,  labor and delivery, and postpartum care. Insurance coverage for perinatal care is essential for ensuring the health and well-being of both the mother and the baby.

The best place to start is often your company’s HR department. They’ll be able to explain the full picture of what is covered and point you to additional benefits you have access to outside of your insurance (like a doula allowance or night nanny benefits). You can always call your insurance provider but it is often difficult for customer service reps to share a general overview of your coverage. (They’re much better at telling you if a specific service is covered and for that you’ll need the CPT code.)

First, let’s cover some basic insurance terminology (why don’t they teach this stuff in high school?)

-Copay/Co-payment: A co-payment is a fixed amount that a patient pays for a covered healthcare service, typically at the time of service. The insurance plan covers the rest of the cost. For example, you might have a $20 copay for a doctor's visit. This typically counts towards your out-of-pocket maximum.

-Coinsurance: Coinsurance is the percentage of costs a patient pays after meeting their deductible. For instance, if your plan has 20% coinsurance, you pay 20% of the cost of covered services, and the insurance pays the remaining 80%. This also typically counts towards your out-of-pocket maximum.

-Deductible: A deductible is the amount you pay for covered healthcare services before your insurance plan starts to pay. For example, if your deductible is $1,000, you pay the first $1,000 of covered services yourself.

-CPT Code: CPT (Current Procedural Terminology) codes are a set of medical codes used to describe medical, surgical, and diagnostic services. They are used by healthcare providers to report procedures and services to payers for reimbursement. Each code corresponds to a specific service or procedure.

Your insurance, whether it is private health insurance through your employer like BlueCross BlueShield, United Healthcare, Cigna, and Aetna, or an ACA Marketplace plan will likely include coverage for both in-network and out-of-network services. 

You can still get reimbursed for out-of-network care by submitting a superbill to your provider.

Before you schedule time with any providers it helps to understand your plan’s pregnancy coverage. To help, we’ve put together a list of questions to ask your HR Department regarding your perinatal care coverage, enabling you to plan effectively and avoid unexpected costs.

Questions to ask about your insurance plan

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!

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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.

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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 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.

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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.

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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.

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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.

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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.

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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.

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It's a lot, we understand. Whether you're looking for specific information on, say, Blue Cross Blue Shield pregnancy coverage or if your Aetna plan requires pre-registering for a c-section you don't plan on having, getting all of this out of the way early will help ensure a smooth process in the months to come.

If you are a Medicaid family, perinatal care is available to you and your state’s department of health and human services should have a hotline or a website for you to visit. (For our clients in Illinois you can find more information here.)