Maternity coverage varies widely between plans, and the details matter before you get pregnant
Maternity coverage is not automatic in all health insurance plans, and the rules about what is covered, when coverage starts, and what you pay out of pocket differ sharply between plans. Some plans cover prenatal care from the first visit; others have waiting periods. Some charge a single copay for the entire pregnancy and birth; others charge separately for each visit, ultrasound, and hospital stay. Federal law requires most plans sold through the Affordable Care Act marketplace and most employer plans to cover maternity and newborn care, but the cost-sharing — what you actually pay — can range from nearly nothing to thousands of dollars depending on your plan choice and your income.
The time to understand your coverage is before you need it. If you are planning to become pregnant, reviewing your plan's maternity benefits now means you can switch plans during open enrollment if your current plan has gaps. If you are already pregnant, you may still have options depending on your situation and where you live.
Key Takeaways
- Federal law requires most health plans to cover maternity and newborn care, but your out-of-pocket costs depend on your specific plan's deductible, copays, and coinsurance.
- Waiting periods for maternity coverage vary by plan type — employer plans often have none, while individual marketplace plans may have waiting periods depending on your state.
- Prenatal care, labor and delivery, and postpartum care are typically covered, but you should confirm what your plan covers for ultrasounds, genetic testing, and complications.
- If you are uninsured or underinsured, you may be able to enroll in a marketplace plan outside the normal open enrollment period if you are pregnant or just had a baby.
- Your out-of-pocket maximum limits what you pay in a year, but hospital bills for birth can still exceed that amount depending on complications and your plan type.
What federal law requires plans to cover
The Affordable Care Act requires most health insurance plans — including those sold on the federal and state marketplaces, most employer plans, and most Medicaid plans — to cover maternity and newborn care as one of ten essential health benefits. This means prenatal visits, labor and delivery, and postpartum care must be included. However, "covered" does not mean free. Your plan must offer the service, but you still pay your share through deductibles, copays, and coinsurance.
Plans are not required to cover everything related to pregnancy. Fertility treatment, for example, is not an essential health benefit, so many plans do not cover it. Complications of pregnancy are covered, but some plans may classify certain treatments as experimental or not medically necessary, which can create disputes. The best way to know what your specific plan covers is to call the customer service number on your insurance card and ask directly about maternity benefits, or log into your plan's website and read the summary of benefits and coverage document, which lists what is and is not covered.
Waiting periods and when coverage begins
Waiting periods for maternity coverage depend on your plan type and where you live. Most employer-sponsored plans have no waiting period — maternity coverage begins as soon as your coverage begins, even if that is the first day of employment. Some employer plans do impose a waiting period, typically 9 to 12 months, but this is less common and varies by employer.
Individual marketplace plans sold through Healthcare.gov or your state's marketplace generally have no waiting period for maternity coverage if you enroll during the annual open enrollment period (usually November through January). However, if you enroll outside open enrollment — for example, because you just moved or lost other coverage — some states allow waiting periods. A few states have no waiting period at any time. Your state's marketplace website or a marketplace navigator (a free counselor funded by the federal government) can tell you the rules in your state.
Medicaid rules vary by state. Some states cover maternity from the date you are found may be able to access; others have waiting periods. If you are pregnant and uninsured, contact your state Medicaid office or your local health department to learn about emergency Medicaid or pregnancy-specific programs, which may cover you regardless of waiting periods.
What maternity services are typically covered
Most plans cover the core maternity services: prenatal office visits, lab work and blood tests, ultrasounds, labor and delivery (including hospital stay), and postpartum visits for you and the newborn. However, the details vary. Some plans cover all ultrasounds; others limit the number. Some cover genetic screening and testing; others do not. Some cover complications like gestational diabetes management; others may deny coverage if they classify it as a pre-existing condition (though this is rare under current law).
Newborn care is covered for the first few days after birth, including screening tests and vaccinations. However, if your newborn needs extended hospitalization or specialized care, confirm with your plan whether that is covered under your plan or the newborn's separate coverage. Many plans automatically cover a newborn for the first 30 days after birth; after that, you must enroll the baby in your plan or add them to your coverage.
Services often not covered include doula or midwife services (unless the midwife is employed by a hospital), childbirth classes, lactation consulting, and fertility treatment. Some plans cover these as add-ons or through wellness programs, but you have to ask. Mental health care during pregnancy and postpartum depression treatment are covered as essential health benefits, but access depends on your plan's network of mental health providers.
Out-of-pocket costs: deductibles, copays, and coinsurance
Your out-of-pocket costs for maternity care depend on three things: your deductible, your copays, and your coinsurance. Your deductible is the amount you pay out of pocket before your insurance starts paying. If your deductible is $1,500 and you have prenatal visits, ultrasounds, and lab work that cost $2,000 total, you pay the first $1,500 and your plan pays the rest (minus any coinsurance). Some plans waive the deductible for prenatal care, meaning you pay copays only; others do not.
A copay is a flat fee you pay at each visit — for example, $25 per prenatal visit or $250 for labor and delivery. A coinsurance is a percentage of the cost you pay after your deductible is met — for example, 20% of the hospital bill. Your plan's out-of-pocket maximum is the most you will pay in a year for covered services. Once you reach it, your plan pays 100% of covered costs for the rest of that year. Out-of-pocket maximums for 2024 range from around $9,000 to $10,000 for individual coverage and $18,000 to $20,000 for family coverage, though these amounts change yearly.
Hospital bills for labor and delivery can easily exceed your out-of-pocket maximum, especially if there are complications or a cesarean section. Ask your hospital's billing department for an estimate before you give birth so you know what to expect. Some hospitals offer payment plans if you cannot pay the full amount upfront.
Switching plans or enrolling if you are uninsured
If you are currently insured but your plan has poor maternity coverage, you can switch plans during the annual open enrollment period (usually November 15 through January 15). However, if you are already pregnant, you cannot switch plans outside open enrollment unless you have a may have access to life event — and pregnancy itself is not considered a may have access to event in most states. Check your state's marketplace rules; a few states do allow plan changes for pregnancy.
If you are uninsured and pregnant, you may be able to enroll in a marketplace plan outside the normal open enrollment period. The rules vary by state. Some states treat pregnancy as a may have access to life event that allows enrollment year-round. Others do not. Contact your state's marketplace or call 1-800-318-2596 (the federal marketplace helpline) to learn what options are available to you. You can also contact your local health department or a community health center to learn about Medicaid or other programs that may cover your pregnancy.
If you are on Medicaid and become pregnant, you remain covered through the end of the month after your pregnancy ends (the postpartum period), even if your income changes. This protection is federal law, so it applies in all states. After the postpartum period ends, your Medicaid coverage may end unless you remain may be able to access for other reasons.
Employer plans versus marketplace plans
Employer-sponsored plans and marketplace plans both must cover maternity care under federal law, but they differ in important ways. Employer plans typically have lower out-of-pocket costs if your employer subsidizes the premium, and they usually have no waiting period. However, you cannot change plans outside open enrollment even if you are pregnant, and your coverage ends if you leave the job.
Marketplace plans give you more flexibility — you can compare plans side by side, and if you may have access to for subsidies based on your income, your premium and out-of-pocket costs may be much lower. However, marketplace plans vary more widely in their maternity coverage details, and some have waiting periods. If you are self-employed or between jobs, a marketplace plan may be your best option. If you are employed, compare what your employer offers to what is available on the marketplace; sometimes the marketplace plan is cheaper even with employer coverage available.
Frequently Asked Questions
Does my plan cover a home birth or birth center?
Coverage depends on your specific plan. Some plans cover certified nurse midwives and birth centers; others do not. Call your plan's customer service line and ask whether out-of-hospital births are covered in your network. If your plan does not cover it, you may still have the option to pay out of pocket, but confirm the cost before you commit.
What happens if I have a complication like gestational diabetes?
Complications of pregnancy are covered as part of maternity care under federal law. This includes gestational diabetes screening, monitoring, and treatment. However, your plan may require you to use in-network providers or may have limits on how many visits or tests are covered. Ask your doctor to confirm that any specialists or tests are in-network before you proceed.
Do I need to enroll my newborn separately, or are they automatically covered?
Most plans automatically cover your newborn for the first 30 days after birth. After that, you must enroll the baby in your plan or add them as a dependent. You usually have 30 to 60 days after birth to add your newborn; check your plan's rules. If you miss the important date, you may have to wait until the next open enrollment period to add them.
What if I am on Medicaid and earn too much to stay on it after pregnancy?
Federal law requires states to keep you on Medicaid through the end of the month after your pregnancy ends, regardless of income changes. After that period ends, your coverage may end. Before it does, contact your state Medicaid office to learn about other programs you may be able to enroll in, such as a marketplace plan with subsidies based on your new income.
Can I use my health savings account (HSA) to pay for maternity care?
Yes. If you have an HSA, you can use it to pay for deductibles, copays, and coinsurance related to maternity care. However, you cannot use HSA funds to pay for insurance premiums unless you are receiving unemployment benefits. Ask your HSA provider for a list of maternity-related expenses that may have access to.