Group Health Insurance and Pregnancy Coverage: What Families Should Know

While prenatal care plans are required under the Affordable Care Act, not everyone knows how health insurance could affect them during a pregnancy. Group medical insurance for pregnancy can help families manage what is often their largest medical expense, and the rules apply to large and small employers. With this guide, families will gain valuable information about what is typically covered in a maternity plan, how to choose among affordable maternity insurance options, and more.

What Group Health Insurance Covers for Pregnancy

Understanding how coverage works in family health insurance plans is important, but people often come to this subject undereducated. UnitedHealthcare reported that in 2024, about two in five women didn’t know the details of the maternity coverage provided by their health insurance plans. For expecting and possibly expecting families, knowing what is covered or not covered helps with planning.

Usually Covered

These aspects of maternity care are usually covered by insurance plans:

• Prenatal visits
• Medically required ultrasounds
• Labor and delivery
• Postpartum care
• Newborn care
• Breastfeeding support and counseling

The exact details of the coverage may vary between plans. One plan might set a specific out-of-pocket total for the cost of all maternity-related events, while another may set coinsurance or coverage minimums for each billed item. It’s also common to have different coverage for in-network and out-of-network providers. For example, a plan might cover 80% of an in-network provider’s bill, but only half or less of an out-of-network provider.

Usually Not Covered

Aspects of pregnancy, labor, or delivery that do not fall under the category of medically required may not be covered by insurance:

• Birthing classes
• Doulas
• Specific hospital requests, such as a private room when semi-private rooms are available

Like dental insurance coverage in Texas, maternity healthcare plans usually have a list of specific exclusions. Plan members should evaluate these benefits and ask for clarification before planning a pregnancy, whenever possible.

Employer-Sponsored Health Insurance and Maternity Care

Group health insurance plans for pregnancy through an employer can help families shoulder the expenses of prenatal care and childbirth. Most large or small business group health insurance plans require compliance with the Affordable Care Act. The ACA requires that any employer offering health insurance must provide maternity coverage. Employers often offer health insurance as a way to:

• Provide a way for hard-working employees to handle the expenses of growing a family
• Entice prospective employees to apply
• Encourage entry-level workers to stay with the company longer

The costs of coverage vary, depending on the plan and the employer. Some organizations have employees cover a certain portion of premiums, along with copays and deductibles. Others may cover all premiums for the employee but require the family to pay part of the premiums for a spouse or dependents.

In addition, Texas is one of several states offering a voluntary paid family leave program. As with Texas vision insurance, the voluntary aspect allows employers to decide whether to participate in the program. For businesses that elect to pay into the maternity leave coverage program, employees may be able to receive some portion of their regular pay for a set number of weeks, while they are home recovering and tending to the newborn.

Pregnancy and Pre-Existing Conditions

Although the passage of the ACA meant that most plans could no longer refuse coverage for pregnancy and pre-existing conditions, not all plans available to U.S. families meet these requirements. Understanding what counts as a pre-existing condition can help families determine if this situation applies to them.

What Is a Pre-Existing Condition?

A pre-existing condition is an ongoing condition or illness that a person had prior to entering into coverage for a specific plan. These conditions might include asthma, diabetes, cancer, and even pregnancy.

Does Pregnancy Count as a Pre-Existing Condition?

Although pregnancy can technically be a pre-existing condition, ACA rules dictate that pre-existing conditions must be covered under most insurance plans. As such, pregnant women cannot be excluded from group insurance coverage if they are pregnant, even if they became pregnant before they got the insurance.

How Do Group Health Insurance Plans Handle Pre-Existing Conditions?

Group health insurance benefits must meet ACA requirements for coverage. This means that a group plan cannot use a pre-existing condition as a reason to refuse to cover, charge more, or deny coverage to a plan member, their spouse, or dependents.

Are All Health Insurance Plans Compliant With the ACA?

ACA-compliant health insurance plans require maternity coverage, but not all plans meet this standard. While all individual plans purchased on the marketplace offer maternity coverage, older plans that existed before the passage of the ACA, called “grandfathered plans” will not cover maternity.

Comparing Group and Individual Plans for Pregnancy

When the ACA became law, many more people became eligible to elect individual insurance plans on the ACA marketplace. This change allowed families to determine where they would get their coverage — through their employers or on the Health Insurance Marketplace. Texas health insurance options often have different coverage and advantages, so it’s important to invest time comparing group and individual insurance before deciding.

What Is the Difference Between Group and Individual Insurance Plans?

The coverage that families receive often depends on whether they choose a group or individual health plan. Group health plans usually come from an employer, but they might also come from a union or association. These plans spread out the insurance costs among the group. Individual insurance includes plans purchased on the ACA marketplace, where the insurer spreads out the cost among people who buy that particular plan.

Group Insurance Pros

• Lower costs
• Wider networks
• Often better maternity benefits

Group Insurance Cons

• Employers may offer only one plan
• Members may have no say in cost sharing or coverage changes
• Contractors or part-time employees may not be eligible

Individual Insurance Pros

• Individuals can select the precise amount of coverage they want
• Families can switch plans yearly, to accommodate changing needs

Individual Insurance Cons

• Coverage usually costs more
• Costs can potentially rise hundreds or thousands of dollars per year
• Some non-ACA compliant plans may not cover maternity

Small Business Health Insurance and Pregnancy Coverage

Small business health insurance plans are always required to cover maternity care under the ACA. That said, the way they cover them offers plenty of variability. Small businesses often choose one of these three approaches:

• Fully Insured: The plan provides for all expenses, but the business may pay more for coverage if they don’t use it enough to justify the cost.
• Self-Insured: Companies pay to insure their employees personally, which can sometimes cost less but is somewhat unpredictable.
• Level-Funded: Businesses get the advantage of full coverage when the costs exceed the plan’s maximum, but may get a refund in years where they don’t use it all.

Choosing the Best Group Plan for Families

Before choosing among options for Texas health insurance for families, it’s important to consider the following:

• Size of the network
• Availability of in-network providers in the area
• Whether all the likely providers at the delivery hospital are covered by the insurance, since some may not or be considered out-of-network
• Coinsurance and deductibles
• Out-of-pocket maximums
• Maternity-specific benefits like prenatal care, folic acid supplements, and delivery at the preferred hospital
• Pediatric coverage for newborns
• Maternity leave policies, where applicable

The details can help flesh out how much families must save in order to have their preferred maternity care options.

FAQs About Pregnancy Coverage in Group Health Insurance

Can You Join a Group Plan While Pregnant?

Under the rules of the ACA, you can join a group plan while pregnant. Group plans are not permitted to discriminate against pregnant women or refuse coverage for pre-existing conditions.

Does Group Insurance Cover Pregnancy?

Group insurance plans are required to cover pregnancy, even for very small businesses. If the group offers insurance, it must provide maternity coverage as part of the plan.

What Type of Health Insurance Is Best for Pregnancy?

The best health insurance for pregnancy depends on the person’s health care needs, region, and available funds. Families should evaluate the group coverage offered to determine if it meets their needs.

Is It Better to Have HMO or PPO When Pregnant?

The right choice between HMO or PPO depends on the family. HMO plans tend to cost less but have a limited network of providers, while PPO plans cost more for a wider network.

How Do Families Choose the Best Group Plan for Pregnancy?

To choose the best group plan, families should evaluate their budget and their goals for maternity care and delivery. Premiums, network availability, out-of-pocket costs, coverage exclusions, and other aspects can make it easier to decide.

How Do Group Plans Cover Maternity Leave?

Group insurance plans may or may not cover paid maternity leave, since most states do not require it. Most full-time working adults, however, are eligible for unpaid leave under the U.S. Family and Medical Leave Act.

Which Health Insurance Gives Pregnancy Coverage?

All ACA compliant group and individual health insurance plans provide pregnancy coverage. The amount of coverage and its limitations depend on the plan.

Choose the Right Maternity Coverage for Your Family

When evaluating maternity coverage in group health plans, the details make all the difference. Professional assistance can help you make the right decision for your situation. Need maternity coverage for your family? Request a free health insurance quote from Selected Benefits today.