June 17, 2015 — Health insurers in the U.S. are not required to cover labor and delivery costs for dependent children, despite various other coverage requirements mandated under the Affordable Care Act (PL 111-148), Kaiser Health News/NPR's "Shots" reports.
According to KHN/"Shots," the ACA mandates that insurers cover prenatal care as a preventive health service without cost-sharing. Meanwhile, under the ACA, maternity and newborn care are considered essential health benefits and must be offered in individual and small group health plans.
Further, large businesses are required to provide health plans that cover maternity care for their employees and workers' spouses under the Pregnancy Discrimination Act of 1978. However, large employers are not required to extend complete maternity care coverage to employees' dependent children, who are allowed to remain on their parents' health plans until age 26 under the ACA.
In May, the federal government issued a clarification on the ACA's mandates, noting that preconception and prenatal care must be covered without cost-sharing for dependent children in all health plans that do not have grandfathered status under the law.
Study: Labor and Delivery Costs Account for Majority of Maternity Care Costs
Carol Sakala -- director of the National Partnership for Women & Families' Childbirth Connection, which commissioned a study on overall maternity care costs -- said, "The payments that are made are highly concentrated in" labor and delivery costs.
Specifically, the study found that consumers in 2010 paid an average of $2,244 and $2,669 out-of-pocket for vaginal and cesarean births, respectively, while insurers paid an average of $18,329 and $27,866. According to the study, hospitalization costs accounted for between 81% and 86% of overall maternity costs.
Coverage Gaps Common, Spur Legal Challenges
Benefits analysts say gaps in maternity coverage for dependents are common. However, there are no data on how many larger companies' insurance plans do not include such coverage.
According to KHN/"Shots," the coverage gaps spurred the National Women's Law Center in 2013 to file sex discrimination complaints under the ACA with HHS' Office for Civil Rights. Specifically, NWLC filed lawsuits against five employers that do not extend maternity coverage to dependent children (Andrews, "Shots," Kaiser Health News/NPR, 6/16).