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What is the cost of having a baby with health insurance?

What is the cost of having a baby with health insurance?

Pinning down the cost of having a baby can be challenging, because what you’ll pay depends on a multitude of factors, including where you live, whether you have any delivery complications, the specifics of your health plan and, of course, whether you have health insurance at all.

If you’re expecting (or plan to be) and you want to know how health coverage will affect your costs, here’s what you need to know.

How much does it cost to have a baby?

In the United States as of 2020, the average cost of childbirth – from pregnancy to delivery and postpartum care – was $18,865. (This was the total cost for people with large-group coverage. Out-of-pocket costs were significantly lower).

Most of those costs are associated with delivery: The average cost of a vaginal delivery was about $11,500 and the average cost of a cesarean section (or c-section) was more than $17,000.* But the full range of costs also includes outpatient office visits prior to delivery and – especially with c-section deliveries – care during recovery. (Note that these are average costs and that there’s significant variation in delivery costs from one state to another.)

How much will it cost to have a baby if I have health insurance?

Fortunately, having health insurance can greatly decrease the amount that you’ll pay for these childbirth-related costs. According to the study referenced above, the average out-of-pocket cost of childbirth for people enrolled in a large-group health plan was just $2,854 – meaning insurance picked up over $16,000 of the costs of the average pregnancy and childbirth.

Note that the numbers in that study are based on a national average and include people with employer-sponsored large-group coverage, which tends to have lower out-of-pocket cost-sharing than the coverage offered by smaller employers and purchased in the individual market.

Your out-of-pocket costs

If you have health insurance – either through an employer, through the Marketplace or through Medicaid – your own costs will be determined by the specifics of your health coverage and the medical care that you end up needing.

When you have insurance, you’ll typically end up paying the plan’s deductible, as well as coinsurance up to your out-of-pocket maximum – which can be as high as $9,100 in 2023 for most types of of coverage. (Grandfathered and grandmothered health plans do not have to comply with this out-of-pocket cap, nor do health plans that aren’t regulated by the ACA, such as fixed indemnity plans or short-term health insurance.) Depending on how your plan is structured, you may or may not reach the plan’s out-of-pocket maximum.

Costs with plans that have a low deductible

Consider a plan that has a low deductible – let’s say $1,000 – and then 20% coinsurance up to the maximum allowable out-of-pocket limit ($9,100 in 2023). The insurer’s network-negotiated rate for the birth would have to be over $40,000 in order for your coinsurance to reach the out-of-pocket cap. Although costs do vary by area, that would be unusually high for an uncomplicated birth.

Costs with plans that have a high deductible

Now, consider a plan that has an $8,500 deductible (and the same $9,100 out-of-pocket cap). With this plan, you would almost certainly meet the full out-of-pocket maximum with the cost of the birth. That’s because the additional allowed charges would only need to be $3,000 in order to hit the out-of-pocket maximum, since 20% of $3,000 is $600, and the deductible accounts for the other $8,500.

What childbirth costs are covered by health insurance?

All medically necessary care related to pregnancy and childbirth will generally be covered by most health plans. (The exceptions are rare. They include grandmothered and grandfathered plans, although if the plan is employer-sponsored, it would still have to include maternity coverage if the business has 15 or more employees. Large-group health plans do not have to cover labor and delivery costs for dependents. And policies that aren’t regulated by the ACA – such as short-term health insurance or fixed indemnity plans – do not have to include maternity coverage.)

But “covered” doesn’t necessarily mean that the health plan will pay the bill. Depending on the specifics of the health plan, the cost of some services will be counted toward the deductible, or shared between the patient and the health plan (i.e. with a copay or coinsurance). The health plan will generally not start to pay 100% of the cost of covered services until the out-of-pocket maximum has been met.

All plans sold in the Marketplace, and most employer-sponsored plans, will fully cover (i.e. with no out-of-pocket charges) the cost of prenatal checkups as well as several screenings, including Hepatitis B, preeclampsia, gestational diabetes, and Rh incompatibility, since those are among the preventive care benefits that are fully covered as a result of the ACA. But other prenatal care, including ultrasounds and some lab work, can be subject to whatever cost-sharing (copays, deductible, coinsurance) the health plan requires.

And the costs associated with the birth itself, including charges for the hospital, obstetrician or midwife, anesthesiologist, etc. will also tend to be subject to deductibles and coinsurance, and not fully paid by the health plan until the out-of-pocket maximum is met.

All non-grandfathered health plans must fully cover the cost of breastfeeding support/counseling and breastfeeding supplies, including a breast pump.

What childbirth costs are not covered by health insurance?

All medically necessary healthcare costs associated with pregnancy and childbirth must be covered by most health plans (under essential health benefit rules for individual and small-group plans, and the Pregnancy Discrimination Act for large-group plans and self-insured plans).

But health plans generally do not have to cover optional complementary therapies, such as prenatal massage therapy. They also don’t have to cover doula care, unless a state requires it. (So far, only Rhode Island does, although other states are considering this). Note that state laws do not apply to self-insured plans, which cover the majority of people with employer-sponsored health coverage.

Does health insurance cover a home birth?

A home birth may be quite a bit cheaper than a hospital birth, assuming you don’t end up needing to be transferred to the hospital during the birth. Your health insurance may cover this, but it will also depend on your state’s licensing laws, since insurers will only contract with medical professionals who are licensed in the state, and some states don’t license professional midwives who facilitate home births.

If you’re considering a home birth, you’ll want to discuss the issue of insurance coverage with any midwives you’re interviewing. If they are contracted with certain health plans, they can give you the details. Depending on the plan’s deductible and out-of-pocket maximum, you may find that you still pay all or nearly all of the cost yourself, but having it count towards the deductible may help you avoid additional out-of-pocket costs later in the year.

You can also reach out to your health plan directly to see if they have any in-network midwives who assist with home births, and start with that list to narrow your search for a midwife.

Do all health plans cover maternity care?

Most health insurance plans in the United States do cover maternity care. This has been the case for most employer-sponsored plans since the late 70s, and it’s been true for the individual and very small-group market since 2014, due to the ACA. Here’s more about how the ACA changed maternity coverage and other rules that apply to various types of coverage.

However, there are still some plans that are not required to cover maternity care. They include grandmothered and grandfathered plans, as well as “excepted benefit plans“ that don’t have to comply with the ACA. So coverage such as short-term insurance, fixed indemnity plans, and travel insurance often do not include maternity benefits. It’s also important to note that while young adults can remain on a parent’s health plan until age 26, large-group health plans are not required to cover labor and delivery costs for dependents.

How can I pick the best health plan if I’m pregnant?

If you’re pregnant and picking a plan for next year – either from options offered by your employer or options available in the Marketplace – you’ll want to consider these factors:

Deductibles. Look closely at your plan’s deductible. When it comes to plan deductibles, there’s tremendous variation across health plans. They can have deductibles that range from $0 to $9,100 in 2023. And although out-of-pocket maximums can’t be more than $9,100, they can be quite a bit less. So the only way to know how much childbirth will cost is to know the details of the person’s health plan.

Thanks to price transparency initiatives, it’s easier than it used to be to get accurate cost estimates from hospitals, and similar pricing transparency took effect for health plans as of 2023. But even when pricing is made fairly transparent, it’s not always possible to know what the costs will be ahead of time, since medical complications can arise at the last minute. However, the out-of-pocket maximum does ensure that even in if the birth ends up being much more complicated and expensive than expected, your out-of-pocket costs will be capped.

Networks and providers. Regardless of the health plan you choose, it’s important to select in-network medical providers in order to keep costs as low as possible. You’ll want to ensure that your doctor and hospital are in-network. But thanks to the No Surprises Act, you no longer need to worry about balance billing from out-of-network ancillary providers who may be involved with your care at an in-network hospital, such as anesthesiologists or assistant surgeons.

It’s important to note, however, that the No Surprises Act does not apply to birth centers. So if you’re planning to use a birth center, you will want to make sure anyone who might be involved in your care there is in-network with your health plan.

Subsidies. If you’re buying a plan in the Marketplace and you’re eligible for cost-sharing reductions, selecting a Silver-level plan can really help to keep your out-of-pocket costs down. Cost-sharing reductions are especially strong if your household income isn’t more than 200% of the federal poverty level. (In the continental United States, that amounts to $27,180 for a single person in 2023, and $55,500 for a household of four. Note that the 2022 FPL numbers are used to determine 2023 subsidy amounts.)

If you’re not eligible for cost-sharing reductions, you might still find that a Gold plan is a better overall value than a Bronze plan once you account for both the premium and the expected out-of-pocket costs. And in some areas, Gold plans are surprisingly affordable, due to some pricing rules that states have adopted over the last several years. Here’s an overview of how all of this works, and what to keep in mind when you’re considering plans at each metal level.

So don’t just pick the plan with the lowest premiums, and make sure you consider all the options before deciding. In most states, the default display for Marketplace plans is to show the lowest-priced plans first, which will generally mean you’ll see quite a few Bronze plans before you get to the Silver and Gold plans. But given that you’re quite likely to meet or nearly meet the plan’s out-of-pocket maximum once you give birth, you’ll need to be sure you’re accounting for that when you’re selecting a plan.

Can I enroll in health insurance if I’m pregnant?

Pre-existing conditions, including pregnancy, are no longer an obstacle when it comes to enrolling in private health coverage. But regardless of medical history, the opportunity to enroll is limited to an annual open enrollment period and special enrollment periods that are generally linked to specific qualifying life events. This is true for both employer-sponsored coverage and self-purchased individual/family coverage obtained through the Marketplace or outside the Marketplace, although the specific dates and rules do vary depending on the type of coverage.

Outside of open enrollment, you can’t sign up for coverage unless you experience a qualifying life event. In most states, pregnancy does not count as a qualifying event, but five states and Washington, DC do allow a special enrollment period triggered by pregnancy.

Although enrollment in private plans is limited to open enrollment and special enrollment periods, Medicaid enrollment is available year-round. Medicaid eligibility is income-based, but the income limits are much higher for a person who is pregnant, meaning you might qualify while pregnant even if you haven’t been eligible for Medicaid in the past.

And a pregnant woman seeking a Medicaid eligibility determination is actually counted as two people – one plus the number of children expected to deliver. (Marketplace subsidy eligibility determination counts only the expectant mother until the child is born.) That will push the family lower on the percentage-of-poverty-level scale once the woman is pregnant, and being lower on that scale makes a person more likely to be eligible for Medicaid.

More than four out of ten births are covered by Medicaid, and this coverage has no out-of-pocket costs for pregnancy-related services. So if you’re pregnant and uninsured, you’ll definitely want to reach out to your state’s Medicaid office (select your state on this map for contact info) to see if you can qualify for coverage.

* This analysis was based on the allowed amounts established by network agreements between insurers and hospitals. The actual billed amounts can be significantly higher, but if in-network medical providers bill above the allowed amount, the additional charges must be written off, per the provider’s contract with the health plan.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for

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