California health insurance - Individual health insurance - Maternity and Individual health plans

Maternity and Your California Health Insurance Plan

Q: Does individual health insurance in California cover maternity?

Yes, maternity care is considered an essential health benefit under the Affordable Care Act, so individual and family plans sold in California are generally required to include it. This applies to plans offered both on and off Covered California. Coverage typically includes prenatal visits, labor and delivery, and postpartum care.

Q: How is maternity typically billed to a California health plan?

Maternity care is generally billed in two ways: prenatal visits as individual office visits, and labor and delivery as a facility (hospital) stay. Your deductible and out-of-pocket costs will depend on your specific plan's metal tier and network, so reviewing your plan documents or speaking with a licensed agent is recommended.

Q: Which metal tier plan is best for maternity coverage in California?

Higher metal tiers (Gold or Platinum) typically have lower out-of-pocket costs at the time of care, which can be valuable for a planned pregnancy involving multiple visits and a hospital stay. To compare current plan options and costs, you can get an individual and family quote or speak with a licensed agent.

Q: Can I enroll in a Covered California plan when I become pregnant?

Pregnancy itself is not a qualifying life event that triggers a Special Enrollment Period, so timing your coverage before becoming pregnant is generally advisable. However, other life changes—such as losing other coverage—may qualify you to enroll outside Open Enrollment. A licensed agent can help you evaluate your current enrollment options.

Q: Is there a waiting period for maternity coverage on California individual plans?

Under the ACA, individual and family plans in California generally cannot impose waiting periods specifically for maternity benefits, as it is a required essential health benefit. However, plan-specific cost-sharing (deductibles, copays) still applies. Contact a licensed California agent or visit compare California carriers to understand how different plans handle maternity costs.

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Things have changed quite a bit on the maternity front in terms of California health insurance so we need to update this information.

We'll look at how pregnancy affects underwriting, how maternity is covered, and what to expect come Jan 1st, 2014 when Health Reform is launched in earnest.

So let's jump in.

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Maternity And Most California Plans Now

One of the biggest changes which has already happened on the individual family market is that all plans must offer maternity coverage in California effective July 1st, 2012.

This applies to new plans and to existing plans on the market...even the Grandfathered health plans from before 3/23/2010.

This is a big change since we lost most of our non-maternity plans when health reform passed. The remaining ones spiraled in cost so a great majority of California health insurance shoppers chose plans which did not include maternity.

That's no longer an option.

On one hand, it's great to take this question mark out of the equation as some women would try to decide between a plan that covers maternity and one that doesn't.

On the other hand, enrollees within a certain age band will see their costs go up quite a bit as a result of this change but that seems to be the new trend where richer benefits are mandated but premiums reflect the added benefit.

Maternity will be required in the Jan 1st, 2014 change nationwide but California led the way there.

Until we get to Jan 1st, 2014, being pregnant can still affect your ability to qualify for coverage.

We did address the options available with more detail at our options for pregnant woman page.

The net effect is that there are various State and Federal options we can look at but it's important to know that a California carrier can decline coverage currently for adults that are pregnant.

Health Reform and Maternity in California

Coverage will be guaranteed issue come Jan 1st 2014 and maternity will be covered.

Again, this will be reflected in the plan costs.

Maternity coverage falls under the core benefits of a given health plan.

This means that the main deductible applies followed by a coinsurance percentage until you hit your out of pocket maximum.

If maternity is a benefit that you foresee needing in the short term, make sure to look at the true max out of pocket since maternity is so expensive.

A simple delivery can run $10K while a simple (if that fits) C-section can run $20K. My first born was $90K and my second born was $160K because they came early (they're both great, by the way).

We really want to look at that back end for when we stop paying altogether for covered benefits,

in-network. The HSA's are actually good on this front as they tend to have some of the lowest max out of pockets on the market although smaller bills are subject to the main deductible.

You can access the online application here:

How Maternity Is Usually Billed To a Health Plan

Doctors usually use a an universal or group bill which means that they require some installments up front and bill most of the charges after delivery.

The hospital or facility is always the biggest charge anyway.

Depending on your plan, well-baby and well child checks up make be coverage as preventative benefits. Double check with your policy to make sure.

Always use in-network providers (doctors, labs, hospitals, etc) to pay the lowest amount out of pocket.

Keep in mind that although your deductible/max might be met, baby will have a separate deductible/max for medical services he or she incurs.

Until 2014, this guide will help you protect from the high cost of maternity in California. Please let us know if we can go over any questions with you.

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Frequently Asked Questions

▸ Does individual health insurance in California cover maternity?

▸ How is maternity typically billed to a California health plan?

▸ Which metal tier plan is best for maternity coverage in California?

▸ Can I enroll in a Covered California plan when I become pregnant?

▸ Is there a waiting period for maternity coverage on California individual plans?

The answers above are general information about California health insurance and may change as rates, plans, and rules are updated each year. They are not a substitute for personalized advice. For current, personalized guidance, please contact us, email help@calhealth.net, or call 800-320-6269. Serving California since 1994.