Maternity health coverage long overdue

About 90 percent of individual health insurance plans don't provide coverage of maternity care, but health reform will deliver that coverage starting in 2014.

John (not his real name) is a successful self-employed remodeling contractor who’s used to the challenges of running his own business. Unfortunately, he’s still struggling with the challenge of covering his family’s health care expenses, including his wife’s recent pregnancy.
And he’s not alone. John’s family is one of millions of American families that purchase health insurance outside the group market – and that means he’s also part of a huge group of Americans whose health plans provide little or no maternity coverage.

A 2009 study by the National Women’s Law Center of 3,600 individual health plans around the country found that nearly 90 percent of them don’t cover maternity care.

The same study found that while some insurers offer maternity riders, women may still be denied coverage if they have had a cesarean section in the past, or for other reasons.

For the millions who need maternity coverage, reform is long overdue.

taken by surprise

Though John decided several years ago to take his chances and not pay for his own individual health coverage, his wife has been covered continuously under her own individual (non-group) policy. They both thought the policy provided any coverage she might need, he says.

John admits in hindsight that they hadn’t actually given much thought as to whether maternity was covered by the policy. Not surprising, considering that the couple had believed they were unable to conceive – and had already adopted a child.

Then, a year ago, John’s wife did become pregnant. His wife’s first prenatal exam showed the child and mother were both doing just fine. But John’s inquiry to his wife’s insurance carrier revealed her maternity coverage was not. Her plan simply didn’t cover maternity expenses.

The couple ended up paying for all of their maternity expenses – a bill that included around $5,000 for a midwife and $1,000 for the birthing facility plus doctor visits. John estimates the couple paid around $7,000 – a heavy financial burden, but nothing compared to what he was told they would have paid had their child had been delivered in a hospital.

“My understanding was that we would have paid 20 to 30 grand for the hospital, the doctors, the exams,” says John.

the high costs of maternity care

John’s right. Having a baby without coverage is playing roulette with your finances.

A study by the March of Dimes showed that in 2007, average maternity expenses for a vaginal delivery without complications – including prenatal and postpartum care – were nearly $11,000.

But those are average costs – and they could go up dramatically if there were problems with the birth or if the child needed intensive care. Pregnancies that result in a C-section delivery can easily cost twice as much or more.

prospects for maternity care

That’s a harrowing prospect for about 18 percent of American women who don’t have group health insurance, but who also don’t meet the income requirements for Medicaid.

If these women are hoping to have the costs of a pregnancy covered, they’re likely shopping in the individual insurance market. But for now, women with individual plans have limited options.

Even though some insurers in the individual market do offer maternity riders, costs and limitations on benefits vary from plan to plan. One notable common limitation on maternity riders is a waiting period of a year or more. If you become pregnant during that waiting period, you’re out of luck, and you will pay.

The future does appear brighter for individual health plan policyholders who need maternity coverage. In 2014, the playing field will be leveled for all women who are pregnant or may become pregnant. That’s when provisions of the Affordable Care Act (ACA) kick in, changing the rules on maternity care.

The most substantial change: starting in 2014, new individual, small business and health insurance exchange plans will be required to cover maternity care as an “essential benefit.”

In addition, employer-sponsored plans and new individual plans will not be allowed to deny coverage for a pre-existing condition – and that includes pregnancy. As it stands, only 12 states currently mandate that individual health plans cover maternity care.

maternity coverage until 2014

What can pregnant women – and women who think they’ll become pregnant – do before the Affordable Care Act kicks in?

• Advocates for health reform advise that you read your individual health insurance plan’s fine print, and if you feel you have been unduly denied coverage, contact your state insurance department’s consumer assistance program.
• If you can’t get your hands on a health plan with maternity coverage, contact your state or county health department for advice on possible assistance and to see if your state has expanded eligibility in its Medicaid program for pregnant women. Three states (Wisconsin, Iowa and District of Columbia) include pregnant women up to 300 percent of the federal poverty level.
• Another option is to ask your insurance broker or health plan if they will sell you a maternity rider on your plan, or on the plan you’re thinking of buying. Rates vary, but a rider could add a couple of hundred dollars per month to the cost of insurance. And remember, you may face a waiting period of as much as a year or more before the rider kicks in.
• If you can’t get coverage and you end up paying out of pocket, you’re not alone in asking for help. Both hospitals and obstetrician/gynecologists are used to getting the question, so they likely have prepaid rates for handling a pregnancy. Call around and try to get the best rate for a doctor and hospital you feel comfortable using. You might get a discount for paying ahead of time.

Journalist Arlene Karidis, whose career as a health reporter spans two decades, also authored our recent report on women and health insurance, and our three-part series about the Affordable Care Act and how it’s already helping many of the people who need it most.

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Tags: maternity, maternity care, maternity coverage, postpartum, pregnancy, pregnant, prenatal