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Pregnant? Here’s what to ask your insurance company.

by Michael Murphy / February 18, 2015

Thinking of getting pregnant?

Pregnancy is a time of anticipation, high emotions and life-changing moments. With all of the excitement, it can be easy to overlook health insurance.

When it comes to health insurance and pregnancy, taking the time to sort through costs, coverage and options can lead to a well-thought-out delivery. To avoid surprises, you’ll want to know what’s covered — and what’s not — under your current health insurance plan. 

Special Enrollment Period

Essential Benefits

General Questions to Ask Healthcare Provider

Questions Specific to Maternity & Prenatal Care


Special Enrollment Period

Having a baby qualifies you for a Special Enrollment Period (SEP). This means that after you have your baby, you can enroll in or change Marketplace coverage even if it’s outside the Open Enrollment period. When you enroll in the new plan, your coverage can be effective from the day the baby was born.

Even during Open Enrollment, it may make sense to apply for coverage with an SEP. With most Marketplace coverage, if you enroll by the 15th of the month, coverage begins the first day of the next month. If you enroll with an SEP, coverage can begin the day the baby is born, even if you don’t enroll until up to 60 days after the birth.

If you already had Marketplace coverage, you can do one of two things when your baby is born:

  • Keep your current plan and add your child to your coverage
  • Change to a different Marketplace plan

Maternity care and childbirth — services provided before and after your child is born — are essential health benefits. This means all qualified health plans inside and outside the Marketplace must cover them.


Essential Benefits

The essential health benefits include at least the following items and services:

  • Ambulatory patient services (outpatient care you receive without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

Additional benefits include:

You receive this coverage even if you were pregnant before your coverage starts. Under the health care law pre-existing conditions are covered, including pregnancy. Health plans sold inside and outside the Marketplace must provide a Summary of Benefits and Coverage document. Some grandfathered individual health plans — the kind you buy yourself, not the kind you get through a job — aren’t required to cover pregnancy and childbirth.


General questions to ask a health care provider

  • Does my health care provider and birth facility accept my health plan?
  • Does my plan cover things related to pregnancy such as breast pumps, childbirth classes or doula care?
  • Can I add my baby to my health care plan after they are born?
  • Do I have coverage if my baby needs to stay in the hospital?
  • What are the plan's rules regarding in-network and out-of-network healthcare providers? What about hospitals? If the plan provides greater coverage for in-network providers and hospitals, ask for a directory of ones in your area.
  • Will you need a referral from your primary care doctor to see an obstetrician? Although most plans don't require this, they might require a referral for a specialist in the event of complications?
  • How long of a hospital stay will the plan cover after delivery? Will the plan cover an extended stay if medically necessary?
  • Does the plan have an annual reimbursement limit? If it does, then it won't pay for healthcare costs that exceed that limit.
  • Must you contact the health insurance company when you're admitted to the hospital for labor and delivery? Some health plans will penalize you financially if you don't call shortly after your admission.


Questions specific to maternity and prenatal care

  • What are my maternity benefits? Do I have medical, dental and vision benefits?
  • What are my deductible and co-payment amounts for maternity care?
  • Does the plan cover prenatal and maternity care? If you work for an employer with 15 or more employees, a federal law requires that your plan cover your pregnancy-related medical bills.
  • Will you need preauthorization for any of your prenatal or maternity care?
  • What coverage does the plan provide for prenatal tests such as ultrasounds and amniocentesis procedures?
  • If you want to use a certified nurse midwife or deliver your baby in a birth center or at home, find out what coverage your plan provides in these situations. Most plans cover a certified nurse midwife, and some will pay for delivery at certain birth centers or at home.

Platinum Group is a full service human capital management (HCM) resource that allows businesses to manage their payroll, benefits compliance, track time and attendance and other various human resources functions in a way that maximizes efficiency and eliminates redundancies with the platform, iSolved. For more information about Platinum Group or to schedule a demo of isolved please visit our website.

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Michael Murphy

Michael Murphy

Michael is the founder of Platinum Group. His passion is in helping businesses to simplify their employee management and accounting processes.