One of the many things you may worry about when you find out you're pregnant are your finances, and right at the top of the list comes being able to pay for prenatal care, labor, and delivery. Will your health insurance cover pregnancy? What if you don't have health insurance?
This worry is not without warrant. The United States is the country with the highest costs for childbirth in the world. On average, U.S. hospitals charged moms with employer-provided insurance about $32,000 on average for vaginal births and $51,000 for Cesarean deliveries. With such looming figures hanging over the heads of expectant parents, it's no wonder that health insurance for pregnancy and childbirth is a top-level concern.
n the United States are usually covered, too, although with varying degrees according to plan and location.
The affordable care act
Every nation handles the details of health care differently. At this time, healthcare coverage in the US is in a multi-year period of transition as outlined by the Affordable Care Act (ACA or, informally, Obamacare). The US government defined a baseline set of regulations that must apply to all Americans but each state can enhance federally mandated regulations according to local demand.
Three basic forms of health insurance in the US
Private health insurance, Medicare, and Medicaid represent the three most basic forms of health insurance available to Americans today.
- Private Health Insurance — According to statistics from the US Centers for Disease Control and Prevention (CDC), 58% of the American population is covered by private health insurance programs. Most of these plans cover working adults and their families. Insurance premiums are deducted from an employee’s paycheck according to the benefits s/he chooses. Many American employers do not provide healthcare insurance coverage for their employees.
- Medicare — Senior citizens, retirees, and younger people with certain disabilities receive medical benefits in the public Medicare program, a federal insurance program. During working years, each American’s paycheck is reduced by a certain percentage to fund the Medicare program, with the expectation each worker will receive the benefits of these payroll deductions after retirement or if a catastrophic illness or injury should cut short one’s natural working life.
- Medicaid — This public program is a joint effort between state and federal governments. It provides medical coverage to children and their families who meet low-income requirements.
Other health insurance plans in the US
For various reasons, not every American is covered under the basic three forms of health coverage. Additional types of health insurance coverage include:
- SCHIP — This federal / state partnership provides insurance to qualified children and their families when household income is higher than Medicaid limits but no other form of insurance is available to them.
- TRICARE — Military personnel, their dependents, and many retired military personnel receive health insurance coverage through TRICARE (funded by the US Department of Defense Military Health System).
- Veterans Health Administration (VHA) — Funded by the US Department of Veterans Affairs (VA), VA benefits provided at VA facilities are available to all veterans who saw active duty in the US military, air, or naval services and were honorably discharged of their duty.
- Indian Health Service (IHS) — This program administers medical and public health services to Alaska Natives and members of American Indian Tribes recognized by the federal government. It is funded by the US Department of Health and Human Services.
Individual states also provide specific programs within their borders. Coverage for infertility, maternity, newborns, and other women’s reproductive services varies widely by state.
Will my existing health insurance cover pregnancy care?
Maternity care and childbirth are considered essential health benefits, meaning that qualified health plans which are mandated by the Affordable Care Act must cover these services. If you have Marketplace insurance (also known as ObamaCare) or Medicaid, your pregnancy will be covered. Both of these types of insurance pay for all pregnancy care.
Maternity care and childbirth are considered essential health benefits.
Private insurance obtained through your employer have varying copayments and deductibles. In this case, as soon as you are planning to become pregnant, you should contact your insurance carrier directly and find out how much you will have to pay out of pocket. Get also everything in writing.
What is covered in pregnancy and maternity care?
The Affordable Care Act requires the following services to be covered:
- All prenatal care: exams, blood tests, ultrasounds, birth classes
- Any treatment that might be necessary due to a pregnancy or birth complications: cesarean section, all surgical procedures, NICU, epidurals, incubators
- Any condition that might be brought on or worsened by pregnancy such as diabetes and high blood pressure
Will my baby be covered?
All Marketplace insurance offers a special enrollment period for new babies. This coverage will be in effect from the day your baby is born. Private insurance companies follow the same rule.
I just got new insurance and I'm already pregnant. Will I be covered?
Pregnancy is considered a preexisting condition, and the Affordable Care Act mandates that all pre-existing conditions are covered, including pregnancy. Commercial insurances may have different rules, and you have to contact the company directly, preferably before changing jobs or before pregnancy, but at the lastest when you find out that you are pregnant.
Does Medicaid cover pregnancy and childbirth?
Medicaid covers all pregnancy-related expenses as well as care for your new baby. You must meet a certain income level to be eligible. Even if you applied for Medicaid previously and were denied, you may want to apply again now that you are pregnant. Rules have changed and you may now qualify. Many clinics will help you apply for Medicaid and you should let them help you apply.
What is CHIP?
Children’s Health Insurance Program (CHIP) is another state-based medical insurance program. CHIP requires you to apply and fall within a certain income level.
Will my insurance cover all healthcare providers?
Your insurance may not necessarily cover many or all expenses. Some commercial insurance companies may pick and choose which doctors are covered in their network. If you use a healthcare provider out-of-network, you will have additional costs which you must pay. Always ask the doctor's office first before your first visit to find out if the doctor accepts fully your insurance.
- Some Ob-Gyn doctors will charge you directly, and you are expected to pay the fee in full. You can then submit the invoice to your insurance and hopefully your insurance will reimburse you some or all of these fees.
- Other doctors may bill your insurance first, then after they received the insurance payments they may bill you the difference.
- Many doctors will fully accept your insurance payments or they are part of a network, and you may not have to pay anything in addition to what the doctor received from the insurance.
Many midwives and doulas are not covered by health insurance and expect you to pay them directly.