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Health insurance and pregnancy: Why planning is necessary

health insurance pregnancy

The last thing you want to think about when you or your spouse is pregnant is health insurance. But 13 percent of the 6 million births each year in the United States involve parents who are uninsured.

And for many expectant parents, having a health insurance policy in place doesn’t equate to pregnancy coverage. In most states, just because health insurers can offer maternity coverage doesn’t mean they’re required to do so. In fact, a rule may declare that pregnancy is not a pre-existing condition, but that doesn’t obligate a health insurer to supply maternity coverage.

Although coverage for maternity care is required under the Pregnancy Discrimination Act of 1978, the law doesn’t apply to companies with fewer than 15 employees or to individual policies, according to the Kaiser Family Foundation.

Further complicating matters: Finding insurance after you become pregnant can be difficult (if not impossible) and expensive.

If you are pregnant or are thinking of having a baby, here are some tips that can make it easier — at least in terms of health insurance — to bring a new life into the world:

Check Medicaid. The income levels to qualify are higher for pregnant women than for regular Medicaid patients, says Brigette Courtot, a senior health policy analyst at the National Women’s Law Center in New York City.

Find a job with insurance. Group policies for all but the smallest groups (and individual plans) cannot treat pregnancy as a pre-existing condition, Courtot says. So if an employer’s health plan does offer pregnancy coverage, the plan can’t deny coverage to a pregnant woman by saying she already was “sick” when she applied for insurance. Many companies, such as Starbucks, offer health insurance benefits even for part-time employees.

Look for pregnancy policies. You may find one, but it’s unlikely you’ll qualify if you’re already pregnant. If you do, Courtot says, the cost may be so prohibitive that you’re better off paying out of pocket. In one case, she tells of a pregnancy insurance plan that required a 20 percent co-pay and a $2,000 limit on coverage in the first two years, rising to only $6,000 by the fifth year. Some plans have premiums as high as $1,000 a month. You could end up paying more than you would save, Courtot says. Availability of these policies varies by location.

Hunt for health care discount programs like AmeriPlan. Plug “discount health plans” into a search engine to find others. Brad Imler, president of the American Pregnancy Association in Irving, Texas, also suggests contacting physicians and hospitals to set up a prepayment program as you prepare for the birth of your child. That shows a hospital or physician that you’re less likely to skip out on the tab. “Most people in hospitals and doctor’s offices want to help you,” Imler says.

If you aren’t yet pregnant but are planning on it, start looking for individual health insurance policies now. However, Courtot says that most such policies do not include pregnancy as a matter of course, but rather as a rider that can be added to a policy. Again, these can be expensive and can include extremely limited coverage based on a trouble-free pregnancy and uncomplicated vaginal birth, according to Courtot.

A 2009 study by the National Women’s Law Center of 3,600 individual health policies found that just 13 percent included maternity coverage. In other words, 87 percent of health insurance plans did not offer any maternity coverage, even through riders, as a general rule. In 2010, 12 states mandated coverage of maternity care in the individual insurance market and 17 required it in the small group market, according to the Kaiser Family Foundation.

If you already have health insurance, check your policy now if you’re thinking of getting pregnant, says Susan Pisano, vice president of communication for America’s Health Insurance Plans, a trade group for health insurance companies. “If there is any chance you can become pregnant, you need to know in advance what is covered,” she says.

Ask these questions:

• Are your preferred doctor and hospital part of your insurance plan?

• Are there certain costs that aren’t covered, like having a TV in your hospital room?

• What are the out-of-pocket costs?

The March of Dimes reported in 2007 that the average cost of a U.S. birth was about $7,700, with an extra $3,300 tacked on for a C-section. Those are the costs for insured women, who pay about $500 out of pocket on average. These costs are negotiated in advance by insurance companies. Costs for uninsured patients may be much higher.

Pisano suggests you look at your certificate of coverage or talk to your employer’s HR department to find out exactly what is covered. If you think you no longer need health coverage, consider the implications if you found yourself or your spouse unexpectedly pregnant — could you absorb the costs? Until you know that you or your spouse cannot get pregnant, opt for the coverage.

Some additional benefits for pregnant women are part of the federal health care reform bill that took effect in 2010. Courtot notes that beginning in July 2010, every state was required to develop a plan available for those with pre-existing conditions who have not been insured for at least six months and have been denied coverage. Potentially, a newly pregnant woman who seeks insurance and is denied coverage may — at the end of her pregnancy — be eligible for such a plan. In 2014, plans will be banned from denying coverage based on pregnancy and can’t discriminate against a person by determining she has a pre-existing condition.

However, whether health plans actually will offer maternity coverage isn’t a sure thing. Certain elements of coverage will be considered “essential benefits” that plans must cover. It’s possible that maternity coverage will be included, but Pisano says that issue hasn’t been settled. Courtot says that even if pregnancy is an “essential benefit,” the coverage may not be as comprehensive as some advocates would like, it may not be mandated for individuals or very small groups, and the coverage may be prohibitively expensive.

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