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How to Get Maternity Health Insurance Coverage

By Don Butterfield on March 23rd, 2010
Health Insurance

The news that you are starting a family can be one of the most wonderful things parents can experience. Unfortunately, a pregnancy can also be the cause of significant stress and expense, particularly for a young family without group health insurance. Although costs vary by region and numerous factors, a vaginal birth can cost $5000 to $10,000, while a cesarean section birth can cost $12,000 or more. Any complications can significantly increase costs.

Maternity Insurance Benefits through Group Health Insurance

Group health insurance is typically insurance that is offered by an employer. Usually, if you or your spouse has access to an employer-sponsored health plan, your childbirth is automatically covered.

According to the US Department of Labor, the Newborns' and Mothers' Health Protection Act offers many protections for new or soon-to-be-new parents. Some of the benefits you may be entitled to with group or employer-sponsored health insurance include:

  • 48-hour stay following vaginal childbirth
  • 96-hour stay following a cesarean section birth
  • Earlier discharge from the hospital can only occur if the attending provider approves after consultation with the mother
  • Neither hospitals nor insurance companies are permitted to offer providers incentives or disincentives for approval of early release
  • No requirement for a pre-authorization (although some plans may require some degree of notice)

In addition, the Health Insurance Portability and Accountability Act (HIPAA) lists the birth of a child as a situation that triggers what is called "special enrollment." This means that even if you or your spouse is not participating in your company's group health plan, your pregnancy entitles you to a special enrollment, even if it is not your company's normal open enrollment period. However, you must request special enrollment in the plan within 30 days of the birth.

HIPAA also states that pregnancy cannot be considered a "pre-existing condition" for those with group health insurance (so a waiting period for coverage of maternity cannot be imposed), and special enrollees cannot be treated as late enrollees.

Maternity Insurance Benefits with Individual Health Insurance

Unfortunately, HIPAA laws do not apply to individual health insurance. An increasing number of individual health insurance plans do not offer maternity insurance benefits. According to an article by the San Francisco Chronicle, approximately 805,000 policyholders in California have health insurance policies that exclude maternity coverage.

The insurance industry rationale is that pregnancy is an expense that can be planned for, unlike other health conditions and diseases. Some health plans do offer add-ons, or riders, to help offset maternity expenses, but many find that these to be of little help.

Even if you already have individual health insurance, it's important to be aware that once you or your spouse become pregnant, it may be difficult to buy a maternity insurance rider of any kind.

Resources for those without Maternity Insurance Coverage

If you have access to group or individual health insurance, consult your plan administrator to learn about your options and any steps you need to take.

Also, according to the U.S. Department of Health and Human Services, women in every state can get some degree of help to pay for medical care and/or prenatal care during their pregnancies. For more information, contact 1-800-311-BABY (2229) and follow the directions to be connected to the Health Department in your area code. For information in Spanish, call 1-800-504-7081.

The bottom line is to do your research, carefully review your benefits, know your rights, and explore community resources.

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