What is included in maternity and newborn care under ACA?
How does my ACA insurance cover prenatal, maternity, and newborn care services?
All ACA-compliant health insurance plans are required to cover prenatal, maternity, and newborn care as part of the essential health benefits (EHBs) package. This means that your ACA plan will provide comprehensive coverage for you and your baby throughout your pregnancy, during labor and delivery, and after your baby is born. Here’s a detailed look at how ACA plans cover prenatal, maternity, and newborn care services:
1. Prenatal Care Coverage
Prenatal care refers to the healthcare you receive while you’re pregnant to ensure a healthy pregnancy and delivery. ACA plans must cover the following prenatal services at no additional cost to you:
Routine prenatal checkups: Regular visits with your healthcare provider to monitor the health of you and your baby throughout pregnancy.
Screenings: Tests to check for conditions like gestational diabetes, high blood pressure, and infections that may affect your pregnancy.
Ultrasounds: Imaging used to monitor the baby’s development and check for any potential complications.
Blood tests: Tests to monitor your health and check for issues such as anemia or Rh incompatibility.
Nutritional counseling: Guidance on healthy eating habits during pregnancy.
Vaccinations: Recommended vaccinations, such as the flu shot and Tdap vaccine (to protect against whooping cough).
Folic acid supplements: Recommended for women who may become pregnant to prevent birth defects.
Preventive prenatal services are covered with no copayment, coinsurance, or deductible when provided by an in-network provider.
2. Maternity Care Coverage
Maternity care covers labor, delivery, and hospital stays. ACA plans must cover the following maternity services:
Labor and delivery: Coverage includes all the necessary medical services during childbirth, whether through a vaginal delivery or C-section.
Hospital stays: Coverage for hospital care after delivery, which typically includes up to 48 hours after a vaginal birth and 96 hours after a C-section.
Anesthesia and pain management: Coverage for epidurals or other forms of pain relief during labor and delivery.
Midwife services: If your plan includes in-network midwives, their services during delivery may also be covered.
Complications: Any complications during delivery, such as emergency C-sections or additional surgeries, are covered under your maternity benefits.
Your out-of-pocket costs, such as deductibles, copayments, or coinsurance, will depend on your plan’s cost-sharing structure. However, maternity services are covered like any other medical service under your plan.
3. Newborn Care Coverage
Once your baby is born, ACA plans cover necessary newborn care services, including:
Hospital newborn care: Routine medical care for the baby immediately after birth, including newborn screening tests, vaccinations, and monitoring.
Pediatric visits: Coverage for the baby’s first pediatric appointments, where a doctor checks the baby’s health, growth, and development.
Newborn screenings: State-mandated screenings for various conditions, including hearing loss, metabolic disorders, and congenital heart defects.
Breastfeeding support: Coverage includes access to lactation counseling, breastfeeding support, and breast pumps (usually provided as a rental or purchase option through the plan).
Circumcision: If you choose to have your baby circumcised, many ACA plans cover this procedure as part of newborn care.
4. Costs for Prenatal, Maternity, and Newborn Care
Your costs for prenatal, maternity, and newborn care under an ACA plan will vary depending on your plan’s cost-sharing rules, including:
Deductibles: You may need to meet your annual deductible before your insurance starts paying for certain services, such as hospital stays during delivery.
Copayments and coinsurance: You may have copayments for doctor visits, ultrasounds, or other prenatal services, and coinsurance for hospital services.
Out-of-pocket maximum: Once you reach your plan’s out-of-pocket maximum, your insurance will cover 100% of any additional covered costs for the rest of the year.
5. Coverage for Preventive Services at No Cost
Preventive services related to pregnancy, such as prenatal visits and certain screenings, are covered at no cost to you. These services are provided without requiring you to meet your deductible, copayment, or coinsurance as long as you receive care from an in-network provider.
6. How to Access Prenatal, Maternity, and Newborn Care Services
In-network providers: To avoid higher costs, make sure to see in-network obstetricians, midwives, and pediatricians. Your plan will cover more of the costs if you use providers within the network.
Hospital selection: Check with your plan to see which hospitals or birthing centers are in-network for labor and delivery.
Breastfeeding support: Contact your insurance provider to understand how to access breastfeeding supplies and counseling services.
7. Special Enrollment for Your Newborn
After your baby is born, you can add your child to your ACA plan through a Special Enrollment Period (SEP). You have 60 days after the birth to enroll your baby in a health plan, ensuring that your newborn has health coverage right away.
Key Takeaways:
Prenatal care, maternity services, and newborn care are covered by all ACA-compliant health plans, ensuring you and your baby receive comprehensive care before, during, and after birth.
Preventive prenatal services, like checkups and screenings, are covered at no cost to you when provided by in-network providers.
Coverage for labor and delivery includes hospital stays, anesthesia, and newborn care, with cost-sharing determined by your specific plan.
For help navigating your prenatal, maternity, and newborn care coverage, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
