What Insurance Covers Pregnancy and Delivery (Cesarean) Best? + FAQ

Pregnancy can be both an exciting and a stressful time. Although pregnancy care is considered an essential health benefit, that doesn’t guarantee you won’t end up with any surprise bills.

Key takeaways:
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    Common health plans that cover maternity care include government-sponsored health plans, employer-sponsored health plans, or marketplace health plans.
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    Standard prenatal and delivery care is covered by insurance according to United States Law.
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    The cost of a C-section will vary depending on your insurance plan but is generally more expensive out-of-pocket.
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    United States hospitals are required to publish transparent prices for consumers to compare healthcare services.

It's important to understand your maternity care coverage to avoid unnecessary charges and to be financially prepared for pregnancy and delivery.

Available maternity health plans

Medicare

Medicare is known for being a government-sponsored health plan for individuals over 65. However, qualifying individuals with a disability may also be eligible for Medicare. Medicare covers pregnancy and delivery care after you have met your deductible. Open enrollment for Medicare is from October to December annually unless you have a qualifying life event, which would allow you to enroll at any point.

Medicaid and Children’s Health Insurance Program (CHIP)

Medicaid is also a public, government-funded health plan. If you meet your state’s income requirements, you can sign up for Medicaid at any time. The state’s income requirements differ during pregnancy. If you didn’t qualify for Medicaid when you were not pregnant, check with your state to see if you qualify for pregnancy-related Medicaid.

CHIP is a government program for individuals who don’t qualify for Medicaid, but may be struggling to afford a private health plan. This insurance mainly aims to benefit infants and children, but some states cover pregnancy care as well.

Employer-sponsored plans

This is a plan that is offered to you through your employer or your spouse’s employer. These plans are usually the most cost-effective private plans because the employer is covering part of the cost of this benefit. Most employer-sponsored plans will have several options to choose between, so it’s important to compare them.

HMO vs. PPO

Many employer-sponsored health plans will offer the option to either sign up for a preferred provider organization (PPO) health plan or a health maintenance organization (HMO) health plan.

A PPO plan offers a higher monthly premium for the benefit of having better coverage for out-of-network costs. PPO plans also don’t require that you establish with a primary care provider (PCP) or that you get specialist referrals. Those elements likely don’t benefit a pregnant person because they will usually be established with an obstetric (OB) provider as their primary provider and they will likely be referred for applicable specialty care by their OB. However, if you often travel across state lines, then a PPO is a great option because you will have better coverage options out-of-network.

An HMO plan has limited out-of-network coverage and requires you to choose a PCP and be referred to any specialist. This is a trade-off for a lower monthly premium. If you believe that you won’t be traveling, won’t need specialty appointments for a chronic condition, and want to see a pregnancy provider in your network, then this is a great low-cost option.

High-deductible plans

A high-deductible plan is usually an option offered by an employer where you pay out-of-pocket for your medical care until you meet the cost of the deductible set by your insurance plan. High-deductible plans will often have lower monthly premiums. Calculate the cost for your family to have a lower premium, high-deductible plan vs. a higher premium low-deductible plan.

Marketplace health plans

Marketplace health plans are typically elected in the following circumstances:

  • An individual is self-employed or a contractor.
  • They do not want to sign up for insurance through their employer.
  • They do not qualify for government-funded health plans.

All marketplace health plans must cover medically necessary pregnancy and delivery care under the Affordable Care Act (ACA), even if you are pregnant before receiving coverage.

Open enrollment for these plans is usually from November 1 to January 15, but it may vary depending on your state.

What coverage is needed during pregnancy?

Standard prenatal care is covered by insurance by United States Law. Prenatal care may include:

  • Labs
  • Tests
  • Ultrasounds
  • Medical appointments with a family medicine OB, OG-BYN, or midwife

It’s important to check with your health plan on what they consider to be ‘standard’. For example, health plans will cover prenatal labs like screenings for urinary tract infections or sexually transmitted infections. However, a plan may not always cover other prenatal labs ordered by a medical provider that they don’t consider to be medically necessary. Many types of genetic testing are not considered to be medically necessary except under specific circumstances, and these tests can cost thousands of dollars.

What coverage is needed during delivery?

During the process of labor and delivery, many standard and emergent procedures may take place. This includes:

Admission to a hospital or birthing center.

Cost of the room, which includes food, amenities, and nursing staff.

Labs, tests, and ultrasounds while admitted.

Laboring and associated procedures.

Delivery and associated services.

Postpartum care, including lactation services and a breast pump.

C-Section vs. vaginal delivery

A C-section is always billed higher than a vaginal delivery. This is because a C-section takes additional staff, including a surgeon, an anesthesia provider, two operating room (OR) nurses, and a surgical technician. Additionally, the cost of occupying the OR and its supplies is also billed. When a C-section occurs, the NICU staff are alerted and must be made available for the care of the newborn in case there are complications with the delivery.

If you don’t have any insurance and are paying completely out-of-pocket for medical care, a C-section will cost more. With insurance, the amount your pay for your delivery varies depending on your plan, deductible, out-of-pocket maximum, and coinsurance. If you have a high deductible or high coinsurance, you will likely be expected to pay more if you deliver via C-section.

FAQ

Read your health plan language

If you already have health insurance, take the time to read the plan language of prenatal, labor, and delivery care. If you’re planning on getting health insurance, shop around for a plan that fits the care you intend to receive and with your health circumstances. Don’t hesitate to call your insurance provider to ask about coverage so you have no surprises when you receive your hospital bill.

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