Let’s face it. Having a baby comes with a hefty price tag. This means, preparing for pregnancy requires more than just a trip to see your doctor. To maximize your health benefits and minimize your spending, you’ll also need to look at your health insurance, specifically pregnancy insurance coverage.
If possible, plan ahead. This allows you time to research your coverage options and choose a plan that fits your needs. That said, sometimes pregnancy doesn’t happen at the perfect time. The good news is you have options for prenatal care, even if you’re not insured.
Regardless of your situation, you’ll likely have many questions about maternity insurance and health care, in general. To help you get started, here are three specific questions to ask an insurance provider when you are expecting.
What does pregnancy insurance cover?
Pregnancy insurance covers all essential health benefits related to prenatal care. This can include prenatal visits, prescription drugs, laboratory services, gestational diabetes, delivery costs, and other maternity care essentials. It also covers newborn care. When evaluating insurance options during open enrollment or reviewing your health plan, look at out-of-pocket expenses, copays, deductibles, and coinsurance related to maternity coverage.
Since maternity care is classified as one of the Affordable Care Act (ACA) Essential Health Benefits, as long as you buy a plan that qualifies under the ACA, you’ll have pregnancy coverage. This includes Health Insurance Marketplace and Medicaid plans, which cover care even if your pregnancy begins before coverage starts.
That said, Louise Norris, a licensed health insurance agent out of Wellington, Colo., explains that the exact details of what’s covered in each state can vary depending on the specifics of the benchmark. So, it’s important to understand the details of how your plan works. Additionally, employer-provided coverage, either through the mother or a partner, offers pregnancy coverage; however, you may have a waiting period until your coverage begins.
Certain types of insurance may not offer maternity benefits. If you are under 26 years old and have dependent coverage on another person’s plan, such as a parent’s, or have a student health plan, it may not include pregnancy coverage. The laws vary from state-to-state—be sure to check with your plan. If coverage is not included, consider applying for your own plan during pregnancy through the healthcare.gov marketplace, or for Medicaid coverage (which sometimes offers better coverage).
Insurance companies should be able to provide you with an expected maternity cost, which will give you a good idea of what they will cover and what you can expect to pay, explains Melanie Musson, a health insurance expert with U.S. Insurance Agents. “An insurance policy with a low deductible and low maximum out-of-pocket is best for pregnancy because having a baby is expensive, and you will likely reach your deductible,” she says.
In addition to health insurance for pregnancy and newborn care, you should also familiarize yourself with the Family Medical Leave Act or FMLA. Under FMLA, employers are required to provide eligible employees job-protected and unpaid leave for specified medical and family reasons, such as pregnancy and caring for a newborn, and to maintain group health benefits during the leave. This allows new parents an opportunity to balance work and family responsibilities. If eligible, you can take up to 12 weeks of unpaid leave each year for the birth and care of a newborn child, among other family and medical reasons.
Can you get health insurance if you are pregnant?
Yes, you are eligible to apply for health insurance if you are pregnant. In the past, insurance plans classified pregnancy as a pre-existing condition. This left many pregnant women without health insurance.
But the passing of the ACA changed all of that. If you have a Marketplace plan or Medicaid coverage, you are eligible to receive pregnancy and maternity care even if you apply while pregnant. This also includes insurance coverage through your employer or a partner’s employer and a health plan you buy on your own.
You need to enroll in a health plan during open enrollment or during a special enrollment period if you qualify. According to healthcare.gov, a special enrollment period is a time outside of the yearly open enrollment period that you qualify for if you’ve experienced certain life events such as moving, getting married, losing health coverage, adopting a baby, or having a baby.
As long as you’re applying for an ACA-compliant health plan, Norris says you will not be denied health coverage for prenatal care. However, she does point out that if you’re applying for something like a short-term plan or fixed indemnity plan, the insurance company can reject the application due to a pregnancy. Short-term health plans do not meet ACA guidelines, and most only cover doctor visits and emergency care. Short-term health plans don’t cover pre-existing conditions.
If you earn too much to qualify for Medicaid coverage, some states will cover pregnancy under the Children’s Health Insurance Program (CHIP). This program is better known for providing insurance benefits to children who do not have insurance.
How can you minimize pregnancy costs?
Once you understand how to qualify for insurance or change plans during an open enrollment period, it’s time to take a look at ways to minimize pregnancy costs by using your insurance to the fullest.
Compare health insurance plans during the open enrollment period
A good place to start when choosing a plan is to compare the expected total costs under each available plan during open enrollment, including the monthly premiums plus the out-of-pocket costs you’re expecting to incur for the pregnancy.
“Sometimes a plan with higher out-of-pocket costs ends up being the better value due to lower premiums,” Norris says, “but sometimes you’ll come out ahead by paying higher premiums to get a plan with lower out-of-pocket costs.”
Another way to look at this is to choose a plan that has a lower deductible and coinsurance. The premium will offset this, so it’s important to do the math to decide how much you would be paying ultimately by the end of the year on the premiums versus the deductible amount plus coinsurance.
Understand your insurance policy
Your first money-saving strategy is to call your insurance company. They can tell you how much your health plan covers for maternity care, including doctor visits, delivery costs, C-section coverage, newborn care, and other procedures. Make sure to ask about deductibles, in-network vs. out-of-network costs, hospital stay expenses, coinsurance, and out-of-pocket max. And if you are close to an open enrollment period with your insurance provider, ask about changing plans to help lower overall costs.
Choose in-network when possible
To find an obstetrician, start by looking for a provider and hospital that are in-network. You can locate an in-network provider by accessing your insurance provider’s website. Using in-network healthcare providers can potentially save you a lot of money in out-of-pocket costs. Pay careful attention to provider network requirements and prior authorization requirements. Even if your obstetrician is in-network, the radiologist, anesthesiologist, lab services, or other services may be out of network. “You don’t want to get stuck with a surprise bill because you went to an out-of-network hospital or had an out-of-network anesthesiologist,” Norris says.
Sign up for an FSA or HSA
A flexible spending account (FSA) and health savings account (HSA) are special savings tools that you put money into to pay for certain out-of-pocket costs for medical care. Since you don’t pay taxes on this money, you can minimize pregnancy costs by enrolling in one of these plans.
To be eligible for an FSA, your employer must offer the plan. To take advantage of an HSA, you must have a qualified health plan with a high deductible, and you cannot be on Medicare or Medicaid. “If you select a plan that is HSA-qualified, you can put pre-tax money in an HSA and then use that money to pay your deductible and other out-of-pocket expenses related to the pregnancy (or any other health care needs),” Norris says.
Work with the hospital billing department
Often, hospital billing departments can offer a discount of 10% to 20% for promptly-paid bills, Musson explains. So, if you can pay right away, call the billing department and check if you’re eligible for a discount.
Keep your hospital stay short and simple
Once your doctor gives you the green light to go home, and you feel ready, check out of the hospital as soon as possible. Also, you may be able to defer some services to the outpatient visit, which may be more cost-effective such as non-urgent specialist visits or non-urgent tests (i.e. X-rays, ultrasounds, or some labs). This, of course, depends on your recovery and the baby’s health. If you can keep your stay to the minimum, you can potentially save a lot of money.