Pregnancy and Insurance: Are You Covered?

Expert advice and tips for moms-to-be

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Pregnancy can be unpredictable—and so can insurance! Some things are covered, some things are not. What happens if you change jobs in the middle of a pregnancy? Do you lose your coverage? What if your baby has special needs and requires care from the neonatal intensive care unit?

Julie Kelsey, from Germantown, Maryland, was very frustrated with her insurance after the birth of her son. “I received a bill after my son was 18 months old for something that the insurance company kicked back,” Kelsey says. “The hospital blamed the insurance company—the insurance company blamed the hospital. Everyone was sure that it was my responsibility. It was horrible and very annoying.” 

Insurance doesn’t have to be so confusing. The secret is knowing who to go to when you have questions and knowing what your carrier covers as soon as you know that you are pregnant.

A Preexisting Condition?

A major concern for women who are considering switching jobs while pregnant is wondering if their labor and delivery costs will be covered. 

Rae Lee Olson, a spokesperson for Life and Health Insurance Foundation for Education (LIFE), a nonprofit organization that strives to educate Americans about the role personal insurance plays in proper financial planning, as well as a Principal for the Vita Benefits Group, says that pregnant women no longer have to be concerned that pregnancy will be considered a preexisting condition. 

“A law called HIPAA (passed in the 1997) prohibits group insurance carriers from excluding pregnancy under a preexisting condition clause,” Olson says. “Therefore, as long as a woman has continuous coverage (without a gap of more than 63 days), then a pregnancy could not be considered a preexisting condition under a new group insurance plan.” 

It is important to remember that the insurance for your new job may not kick in for up to three months. That may leave you uninsured for a period of time. Check to see how long you can keep your current insurance and see if there is any way you can extend coverage until your new insurance takes over. It may cost you extra money, but remaining covered during all of your pregnancy is vital.

Who Can Answer Your Questions?

One of the issues many women have with health insurance is where to find the answers to their questions. Olson says that many companies have a human resource department that usually has someone who specializes in health insurance and policies. 

“Typically there is a contact in the Human Resources department for questions on employee benefit plans,” Olsen says. “Who you contact typically depends on the size of the company you work for. For example, in a very large company, there may be a dedicated benefits persons to assist you with questions. In a medium-sized company, your general HR representative may be the contact. In a smaller company, you may be directed to the insurance broker or agent who assisted your employer setting up the coverage. You should always feel free to ask when you have questions about your coverage.”

Sometimes a company goes through an independent agent for their insurance needs. Renee Guariglia, the executive vice president of Falcon Associates, Inc., an employee benefits company, says that while many employees go to human resources or directly to the insurance carriers for insurance questions, if the company uses an independent agent that is the person to contact. 

“As their agent, our job is to know the benefits inside and out,” Guariglia says. “An HR person has so many other tasks that they are responsible for—knowing insurance benefits should not be one of them. If the HR person misspeaks, then there is the additional liability for the misinformation. So don’t be afraid to ask your agent or broker questions on your health benefits. That is what they are there for.”

3 Things You Need to Know

The following tips will help pregnant women navigate the ins and outs regarding insurance coverage:

  1. Don’t assume that once your baby is born that she will be automatically added to your health insurance. You must complete an application to add your baby to your plan within 30 days of the birth and return it to your HR person as soon as possible for processing. Guariglia recommends that the employee bring the application home early and start completing as much as possible beforehand. Then once the baby is born, they only need to insert the baby’s information and can immediately return to their HR person for processing.
  2. If you are covered under an HMO plan, you will want to confirm the office visit and hospital co-payment amounts. If you are covered under a PPO plan, you will want to confirm the deductible, the office co-payment and the out-of-pocket maximum amount. With regard to office visit co-payments, you may also want to confirm whether there is one co-payment for each office visit or one co-payment for the entire pregnancy.
  3. According to Olson, there is an important federal law that protects women from being shooed out of the hospital too soon after delivery. In general, group health plans may not restrict benefits for a hospital stay for childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a Cesarean section. If a mother wants to return home early, she may do so, but insurance benefits cannot be restricted and force her (or the baby) to leave the hospital sooner than 48/96 hours after delivery.

4 Questions to Ask

  1. Is pre-authorization required for any care including ultrasounds, hospital stay, or additional testing outside of normal pregnancy care?
  2. Does the plan limit the number of inpatient hospital days for regular delivery? C-section?
  3. If there are complications, who needs to contact the insurance company?
  4. Does the plan limit the number of days my baby can remain in the hospital?

Navigating the confusing waters of insurance coverage while pregnant doesn’t have to take away from the joy of your impending birth. Just remember to be vigilant, be questioning, and be informed.

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