How Do Payers Cover Prenatal, Postpartum Care for Pregnant People?

Medicaid

Medicaid is the largest payer for maternity care in the country, covering more than 40 percent of births. Federal law requires states to provide Medicaid and Children’s Health Insurance Program (CHIP) coverage for eligible people during pregnancy and 60 days postpartum.

In March 2021, the American Rescue Plan (ARP) gave states the authority to expand postpartum coverage to a full year through a state plan amendment. As of November 2023, 40 states and Washington, DC, have implemented the 12-month extension and five states plan to implement the coverage expansion.

Two states (Utah and Wisconsin) have proposed limited coverage extensions, while three states (Idaho, Iowa, and Arkansas) have yet to expand Medicaid postpartum coverage.

While income limits may still stand for coverage of pregnancy-related care, most states have extended Medicaid and CHIP coverage to pregnant people with incomes up to or over 185 percent of the federal poverty level (FPL).

When individuals with Medicaid give birth, their newborn is automatically enrolled in Medicaid coverage and will maintain their eligibility for at least one year.

Coverage of specific services varies by state, a 2022 KFF study of 41 states and Washington, DC, indicated. All reporting states covered prenatal vitamins and ultrasounds for pregnant people, but some states imposed utilization controls, such as quantity limits and medical necessity requirements.

Less than half of states reported covering childbirth and parenting education classes for Medicaid beneficiaries, while just 12 states covered group prenatal care. Meanwhile, the majority of states covered dental services, low-dose aspirin, blood pressure monitors, continuous glucose monitors, and nutritional counseling.

For postpartum and delivery care, over half of the states covered home births, most covered unlimited postpartum visits, and almost all states covered postpartum depression screening and treatment. Doula services and fertility care coverage were less common.

Breastfeeding support is also an important aspect of postpartum care. States are required to cover breast pumps and consultation services for Medicaid expansion beneficiaries under the Affordable Care Act’s (ACA) preventive services requirement. However, there is no coverage requirement in non-expansion states.

Medicare

While Medicare is most known for covering care for adults 65 and older, the public program also provides coverage for those under 65 with qualifying disabilities or conditions.

Medicare covers care during all stages of pregnancy under Parts A and B, but coverage is limited to medically necessary services. The coverage period spans from the start of pregnancy to six weeks after delivery and includes prenatal visits, labor and delivery, postpartum care, and other medically necessary tests or treatments.

The program does not cover childcare, support services, or other non-medical expenses related to pregnancy and childbirth.

Medicare Part A will cover inpatient hospital services, including delivery and hospital stays. After individuals meet their Part A deductible, Medicare generally covers 80 percent of the amount for hospital services, while the beneficiary pays the remaining 20 percent.

Medicare Part B covers medical services furnished in a physician’s office or order by a physician and provided in a clinic or outpatient setting. Similar to Medicare Part A, beneficiaries are responsible for 20 percent of the payment after meeting their Part B deductible.

Medicare may also provide coverage for screening services if a doctor orders them, such as Hepatitis B virus infection screening, HIV screening, and sexually transmitted infection screening and counseling.

Beneficiaries with Medicare Advantage plans will likely receive additional benefits during pregnancy and may be responsible for different costs, depending on the plan they are enrolled in.

ACA Marketplace

The ACA requires all health plans on the health insurance marketplace to cover a range of services during pregnancy, childbirth, and postpartum. Pregnancy, maternity, and newborn care is one of the ten essential health benefits of the ACA that all marketplace plans must cover.

These plans cover all prenatal care visits with no co-pay, labor and birth services, birth control, and breastfeeding support, including visits with a lactation consultant, breastfeeding equipment, and breast pumps.

On a broader level, marketplace plans cover regular health check-ups, hospital care, and emergency services for all enrollees, pregnant or not.

For people who want to enroll in marketplace coverage, being pregnant does not make someone eligible for a special enrollment period, but giving birth does.

Commercial

Most commercial plans cover maternity care through pregnancy and the postpartum period. However, the extent and cost of coverage varies by plan.

According to ValuePenguin, Blue Cross Blue Shield, Aetna, and Kaiser Permanente are the best health insurance plans for pregnant people, as of November 2023.

Over 90 percent of doctors in the United States accept Blue Cross Blue Shield insurance. In addition, the payer offers several programs designed specifically for pregnant people, including one that pairs expectant parents with a personal nurse to help guide them through their pregnancies.

Aetna offers cheaper plans than Blue Cross Blue Shield and has a maternity program that facilitates member access to information on maternal and prenatal care. Kaiser Permanente boasts high member satisfaction scores, allows the option of seeing an obstetrician or a certified nurse midwife for pregnancy care and delivery, and offers a program connecting pregnant people to other expecting parents in their area.

For pregnant people seeking coverage, public and private payer options are available, but their choice may depend on their specific needs.