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Does your health insurance include maternity coverage? Posted: April 11th, 2011

By Megg Mueller

For women who are contemplating a pregnancy, the first order of business should be to understand what kind of maternity coverage your health insurance provides.

It is estimated that the average standard delivery cost is about $7,737, and $10,958 for a c-section delivery, according to the Kaiser Health News. These costs don't include pre-natal care, and they are for births that experience no complications. Any problems, and the costs will skyrocket.

Maternity coverage through group health insurance

If you have group health insurance through work, and your company is larger than 15 employees, The Pregnancy Discrimination Act requires group policies to offer maternity coverage. However, what kind of coverage the policy includes can vary greatly.

"For group's over 15 it's required by federal law. But the extent of (the coverage), whether it's extensive or measly is up to them," explains Judy Waxman, Vice President for Health and Reproductive Rights, National Women's Law Center (NWLC). "There are a number of states that have maternity mandates, as they call them, that could affect the businesses with fewer than 15 employees."

According to the Kaiser Family Foundation (KFF), there are 17 states that mandate small group insurance companies to cover or offer coverage for employees. But each state has different requirements; some mandates apply to groups above 15 members, while others require coverage or an offer of coverage for groups with more than five employees. Still others have mandates that apply to HMOs only.

Individual health insurance and maternity coverage

In 2009, the NWLC took a look at more than 3,600 individual health insurance plans available to women and found that only 13 percent of those plans included any type of coverage for maternity care. Unfortunately, many women don't discover this until it's too late.

If you have an individual policy, it's time to dig it out and read the fine print. Plans and coverage varies from one insurance company to the next, so what you had under one health insurance policy might not be what you have now.

Most maternity benefits are sold in the form of a "rider" or policy addition, so if you haven't specifically asked for it, you probably don't have maternity coverage.

If you do have a maternity rider, here are some things to check your policy for:

  • Waiting period. Most riders have heavy restrictions, such as a waiting period before maternity benefits kick in. These waiting periods are often 12 months.
  • Deductible. Some policies have deductibles as high as $10,000.
  • Coverage caps. While many pregnancy-related items might be listed as covered on your policy, some policies include an annual cap. If your coverage cap is low, say $2,500, your maternity coverage will leave you financially responsible for most bills.

Group versus individual health insurance coverage

One distinct difference between group health insurance plans and individual plans is that under group health insurance, pregnancy cannot be considered a pre-existing condition. Health insurance companies almost always consider pregnancy a pre-existing condition on individual health care policies.

Under the Affordable Care Act, however, in 2014 it will become illegal for insurance companies to reject applicants due to a pre-existing condition, including pregnancy. But until then, women with individual health insurance policies, or considering purchasing one, should look closely at their coverage before becoming pregnant.

Consider waiting until 2014 to start a family

If you're currently uninsured and considering starting a family, Waxman says it might be a good idea to wait for the new health care laws to kick in--even if health care reform is still undergoing changes or isn't something you agreed with politically.

"In the Affordable Care Act, maternity care will be required. You should be supporting this law; it is going to get you there," she believes. Despite the political posturing happening around the issue of health care, Waxman also believes that it will become law, but maybe with a few changes.

"It somewhat depends on the economy. If it improves and Obama gets reelected, the law will stay in place. It also depends on the Supreme Court; the suits that are pending will get (there). Those two things could have a detrimental effect, but otherwise, is this Congress going to really change the course of it? Maybe around the edges, but not the basic concepts," she says.