Pregnancy and Obamacare: How to Plan Your Maternity Coverage

Marketplace plans cover pregnancy, childbirth and newborn care, but a covered service is not always free and not every doctor or hospital is in your network. Review the specific plan, providers, costs and newborn enrollment ahead of time.

1. Identify Your Exact Plan

An insurer may have several networks with different referral, deductible, drug and authorization rules. Gather the Summary of Benefits and Coverage, provider directory, formulary, policy, member card and member-services number. Give the exact plan name and member ID when contacting the plan or provider.

2. Referrals and Prior Authorization

HMO, POS, PPO and EPO network and referral rules differ. Federal protections generally permit direct access to an in-network OB-GYN for covered obstetric and gynecological care without a referral or prior authorization; other specialists or services can have different rules. Confirm the provider's network and the service's requirements with your plan. A referral to a specialist differs from prior authorization of a particular test, treatment or facility. See HealthCare.gov's doctor-choice protections.

3. Check the Whole Care Team

Confirm the OB-GYN practice and possible delivery providers, maternal-fetal medicine specialist, delivery and backup hospitals, labs, imaging, anesthesia, pediatrician, lactation, mental health and postpartum services. A provider accepting an insurer's name does not necessarily participate in your exact plan network.

4. Typical Maternity Benefits

Subject to the plan's coverage, medical-necessity and cost-sharing rules, benefits can include prenatal visits, tests, medically necessary imaging, pregnancy complications, inpatient delivery, medically necessary cesarean delivery, anesthesia, postpartum care, newborn hospital care and formulary drugs. Marketplace plans cannot deny coverage or charge more because you are already pregnant. Benefits begin on the plan's effective date.

5. What May Cost More?

Deductibles, copays, coinsurance and network rules still apply. Ask about noncovered or nonmedically necessary additional ultrasounds, private rooms, non-formulary drugs, some genetic tests, doulas, cord-blood storage, required authorizations and fertility treatments. Before a high-cost service, confirm the billing code, coverage, network, authorization and estimated cost.

Federal surprise-billing protections can apply to covered emergency services and many covered out-of-network services at an in-network hospital, including certain anesthesia, pathology and newborn care. Their scope and exceptions depend on the situation. See CMS consumer protections.

6. Family Deductibles and Maximums

Family plans may have individual and family deductibles and out-of-pocket maximums. Some use embedded deductibles, others aggregate deductibles. Premiums, noncovered services and many out-of-network charges generally do not count toward the in-network maximum. Check the family rules in your Summary of Benefits and Coverage.

7. Preventive Does Not Mean Every Visit Is Free

Certain in-network women's preventive services may be covered without a copay or coinsurance, but not every prenatal visit, ultrasound, diagnostic test, treatment, emergency visit or hospital stay is a free preventive service. A service associated with symptoms, an abnormal finding or complications may be billed differently; the plan applies its coverage and coding rules.

8. Arrange Required Approvals

Ask the practice and insurer which services require authorization, such as specified imaging, genetic testing, specialist care, equipment or inpatient admission, and retain the authorization number. Prior authorization is not a final payment guarantee: eligibility on the date of service, covered benefit, medical necessity, coding and network can still affect the claim.

9. Prepare Before Delivery

Before the third trimester when possible, review the hospital and delivery team, related providers, preregistration or admission notification, and the approved in-network breast-pump supplier. Check accumulated deductibles and the out-of-pocket maximum and prepare documents for newborn enrollment.

10. Enroll Your Newborn Promptly

Birth can create a Marketplace Special Enrollment Period, generally within 60 days, and qualifying coverage can begin on the date of birth. If you already have Marketplace coverage, HealthCare.gov says you can generally add the baby to your current plan or enroll the baby in a separate plan; the existing family members generally cannot switch plans until open enrollment merely because the baby is born. Other qualifying circumstances and state marketplaces may differ. Report the birth and check eligibility promptly. See HealthCare.gov's pregnancy and newborn guidance.

Registering a baby at the hospital does not itself complete Marketplace, employer, Medicaid or CHIP enrollment. The baby's claims and cost sharing may be separate. Pregnancy alone generally does not create a federal Marketplace special enrollment opportunity, although other events or state rules may apply. Medicaid and CHIP accept applications throughout the year, subject to eligibility.

If a claim is denied, review the EOB, itemized bill, diagnostic and procedure codes, referrals, authorization, network and newborn enrollment, then request correction or appeal within the plan's deadlines.

General education, not individual medical, legal, tax or insurance advice. Benefits, networks, authorizations and eligibility vary by plan and state; the plan documents, Marketplace, Medicaid/CHIP agency and providers control.