Health Insurance Plans With Maternity Coverage – Before the Affordable Care Act (ACA), three out of four health plans did not cover maternity care. Currently, all ACA-compliant plans cover maternity care as an essential health benefit, meaning they are legally obligated to help pay for pregnancy-related costs. Is there bread in the oven? Here’s what you can expect from health insurance.
If you choose to receive your maternity care from a certified professional midwife (CPM) instead of a traditional obstetrician, many insurance plans, including Medicare, will help cover your costs. In fact, 32 states legally require health plans to cover CPM services. Home births are not always covered by insurance, depending on your specific plan choices.
Health Insurance Plans With Maternity Coverage
Want a 2022 health plan that includes pregnancy and maternity coverage? Enter your zip code below to receive personalized planning recommendations tailored to your pregnancy and birthing needs.
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Complex pregnancies cost between $9,000 and $25,000. That’s why health insurance is so important. All ACA-compliant plans cap your annual medical expenses in the thousands of dollars (also known as the out-of-pocket maximum). What you actually pay for your pregnancy depends on many factors, including your specific health plan, where you live, and where you’re having your baby.
The best way to estimate the costs of childbirth is to look at the “Fairness Summary”. This is a document that explains how your insurance will pay for different medical expenses. You can find it by googling “[your plan] summary of benefits.” The obstetrics department will be its own department. At the end of the document, SBC includes a scenario that estimates how much a typical pregnancy would cost.
How do you read the SBC? Let’s look at an example. How to view SBC for Kaiser Silver HMO plans:
Having children is a qualifying activity. This means you can choose a new plan that covers your entire family within 60 days of the birth
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Add your child to your current plan. We recommend comparing your options to see if a new health plan can help your growing family save money.
Looking for a 2022 health plan? Enter your zip code below and get personalized planning recommendations in about 10 minutes.
Medicine covers more than four out of ten babies nationwide. The survey asked states about the specific maternity services they cover. The scope of pregnancy-related services that states cover is shaped by many factors, and states have wide latitude in determining income eligibility, defining birth care services, and applying utilization controls such as prior authorization and preferred drug lists (PDLs).
Although coverage for some pregnancies varies depending on eligibility, the vast majority of states offer comprehensive health insurance coverage for all pregnancies. Most states have structured contracts with managed care organizations (MCOs) to provide medical services, and plans may vary in their coverage of specific services. The survey’s questions are based on state Medicare policies and coverage under fee-for-service policies, which are typically the basis for MCO coverage.
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In addition to coverage, states also have discretion over reimbursement methods, which can affect beneficiaries’ access to maternity services. For example, maternity care is often reimbursed as a bundled payment that includes all professional services provided during childbirth, including prenatal care, labor and delivery, and postpartum care and separate facility fees. Such payments for an episode of care can help states manage costs and encourage maternity providers to coordinate care across the board. Bundled payments also make it more difficult to track the delivery of component services that may be included in the bundle, such as health education or counseling.
This report details the findings of 41 states and DC on the availability and utilization of services for prenatal care and delivery, maternity services, counseling and support services, substance abuse services, breastfeeding support, and postpartum care fees. .
Prenatal care monitors the progress of the pregnancy and detects and addresses potential problems before they become serious for the mother or baby. Increasing the number of pregnant women receiving care during the first trimester is one of the national goals of the federal government’s Healthy People 2030 initiative. Prenatal care includes a variety of services, including counseling providers who provide important information about the progress of the pregnancy, fetal development assessments, screening for genetic abnormalities, prenatal vitamins, and ultrasounds. Access to regular prenatal care provides an opportunity for early detection of pregnancy problems and is associated with lower rates of certain pregnancy-related complications.
All responding states reported coverage of prenatal vitamins and ultrasound for pregnant women, but some states implemented restrictions on use. While states are not required to cover over-the-counter drugs, they must cover over-the-counter prenatal vitamins. The majority of states reported that prenatal vitamin and ultrasound coverage was consistent across eligible groups, with the exception of Oklahoma (for prenatal vitamins) and Utah and Mississippi (for ultrasound).
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Each country reported using utilization controls to manage the benefits of prenatal vitamins, including day limits, total claims, and entry on Preferred Drug Lists (PDLs) (Table 1). Two states, Iowa and Pennsylvania, require prior authorization, although Pennsylvania says it only requires prenatal vitamins. Alaska and Wyoming report that Medicare requires a prescription to cover prenatal vitamins. Washington reports that not all vitamin supplements are covered. The state also noted that there may be differences in coverage among MCOs.
Quantitative restrictions and medical necessity claims were the most commonly used control modes reported for ultrasound. Most states report limiting ultrasounds to two or three per pregnancy, allowing additional if medically necessary. Pennsylvania only covers one ultrasound per pregnancy, while Utah allows up to 10 ultrasounds in a 12-month period. Oklahoma includes two ultrasounds per pregnancy, but allows one additional ultrasound to identify or confirm a suspected fetal or maternal abnormality. Two states, Indiana and West Virginia, only cover ultrasound on a “medical need” basis. Indiana does not include routine ultrasounds or ultrasounds for sex determination, and West Virginia covers ultrasounds based on criteria for high-risk pregnancies established by ACOG.
There are a variety of support services available to help people with pregnancy, childbirth and the postpartum period. These include prenatal education classes, infant and parent education classes, and prenatal care.
Less than half of respondents reported that pregnancy included childbirth and parenting. Fifteen states offer childbirth education classes through their medical assistance programs, and 14 include infant care/parenting classes (Table 2). 11 states include Arizona, Colorado, DC, Delaware, Hawaii, Illinois, Indiana, Michigan, Oregon, Pennsylvania and Wisconsin with two services. States that include these courses coordinate coverage with all eligible coverage routes in the state.
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Most states that include these programs offer separate reimbursements to providers. Eleven states pay separately for midwifery education, five pay as part of an office visit, and seven pay separately for childcare/parenting classes. Colorado prohibits the provision of prenatal and child care services during prenatal visits. Wisconsin provides prenatal and child care services to women only if they are enrolled in the state’s Prenatal Care Coordination Program for those at risk of adverse pregnancy outcomes.
Only 12 of the states surveyed reported that their Medicare coverage includes prenatal care. Group prenatal care typically involves a group of eight to ten pregnant women meeting with a health care provider for 90 minutes to two hours to discuss questions and concerns. Research shows that pregnant women who participate in prenatal care have more knowledge about prenatal care, feel more prepared for labor and delivery, have higher rates of preterm birth and lower birth weight, and are more likely to initiate breastfeeding. Three states—California, Texas, and Utah—restrict the number or duration of group prenatal care. Texas limits prenatal care to a maximum of 10 visits every 270 days and limits group visits to a total of 20 prenatal visits for pregnant women. Utah maintains a limit of eight sessions in a 12-month period. California Medi-Cal has 27 hours. Colorado specifies that group prenatal care is only available to individuals enrolled in a special program for beneficiaries with high-risk pregnancies, and Maryland does not currently include prenatal care, but the state reports it is working toward 2022.
39 of the responding states cover dental services for Medicare enrollees. Five of these states prohibit coverage of emergency dental services. There is some evidence that pregnant women are at increased risk of developing periodontal disease during pregnancy, and that the mother’s dental health is related to the future dental health of her child. The national health program covers pediatric oral health screening, diagnosis and treatment
