Health Insurance for Pregnancy: What’s Not Covered?

You’ve seen the positive test, shared the joyful news, and are diligently attending your prenatal appointments. You have health insurance, so you feel a sense of security, believing you’re covered for this incredible journey. Then, the first explanation of benefits (EOB) arrives, and a wave of confusion—and sometimes panic—hits. A hefty bill for a “non-covered” service stares back at you. Welcome to the complex, often frustrating world of what pregnancy health insurance doesn’t cover.

In an era where maternal health outcomes, especially for women of color, are a critical public concern, and where the financial burden of healthcare is a top stressor for families, understanding these coverage gaps isn’t just prudent—it’s essential for your physical, mental, and financial well-being. Let’s pull back the curtain on the common, and sometimes shocking, exclusions in pregnancy-related insurance coverage.

The High-Tech, High-Cost Conundrum: Fertility and Conception

For many, the pregnancy journey begins long before a positive test. Here, coverage often hits its first major wall.

Fertility Treatments: A Financial Mountain to Climb

Most standard health insurance plans in the U.S. offer little to no coverage for assisted reproductive technologies (ART). In vitro fertilization (IVF), a process that can cost $15,000 to $30,000 per cycle, is frequently excluded. Intracytoplasmic sperm injection (ICSI), genetic testing of embryos (PGT-A), and even many forms of intrauterine insemination (IUI) may be deemed elective. While a growing number of states have fertility coverage mandates, these laws vary widely and often have strict eligibility requirements, leaving countless individuals and couples to shoulder the immense cost alone.

Preconception Counseling and Genetic Carrier Screening

Thinking ahead is smart medicine, but insurance doesn’t always agree. Comprehensive preconception visits that go beyond a standard physical may not be fully covered. Advanced genetic carrier screening panels, which can test for hundreds of conditions like cystic fibrosis or spinal muscular atrophy, are often denied if there’s no documented family history. Insurers may label them “screening” rather than “diagnostic,” forcing you to choose between paying out-of-pocket or going without potentially vital information.

The Prenatal Period: Not Every Test and Comfort is Covered

Once pregnant, you might assume all necessary care is included. Not quite.

"Elective" or "Non-Medically Necessary" Ultrasounds

While ultrasounds for dating, the anatomy scan, and growth monitoring are typically covered, others are not. That early “viability” scan at 8 weeks? It might be denied if the insurer deems it too early. A 3D/4D “keepsake” ultrasound is almost never covered. More critically, if your provider orders additional ultrasounds for concerns like measuring cervical length or checking placental position, you might face pushback from the insurer requiring lengthy pre-authorizations or denying claims retrospectively.

Alternative and Complementary Therapies

Pregnancy can bring discomfort, and many seek relief through chiropractic care (specifically the Webster technique), acupuncture for nausea or pain, or specialized prenatal massage. While evidence supports their efficacy, most insurance plans categorize these as alternative medicine and provide no coverage. The same often goes for seeing a registered dietitian for pregnancy nutrition unless you have a specific diagnosis like gestational diabetes.

Genetic Diagnostic Testing: NIPT and Beyond

Non-invasive prenatal testing (NIPT), a simple blood test to screen for chromosomal abnormalities, is now commonplace. Coverage, however, is not universal. Many insurers only cover it for women over 35, those with a high-risk screening result, or other specific risk factors. If you’re under 35 with a low-risk pregnancy and want the test for peace of mind, you could be billed $800 to $1,500 out-of-pocket. More invasive diagnostic tests like amniocentesis are covered when medically indicated, but the associated genetic counseling might not be.

The Big Event: Labor, Delivery, and Hospital Stay Surprises

This is where bills can skyrocket due to unexpected gaps.

Out-of-Network Providers: The "Drive-By" Delivery

This is a notorious trap. You meticulously choose an in-network hospital and an in-network OB/GYN. But during your delivery, an out-of-network anesthesiologist administers your epidural, or an out-of-network neonatologist assesses your newborn. You have no choice in the matter, yet you receive a separate, staggering bill for their services—a practice known as “surprise billing.” While the federal No Surprises Act offers some protection, it’s not a catch-all, and navigating disputes can be a nightmare during postpartum recovery.

Doula and Midwife Support

Doulas—trained professionals providing physical, emotional, and informational support—are proven to reduce cesarean rates and improve birth outcomes. Yet, they are almost never covered by private insurance, despite their role in mitigating costly interventions. Similarly, while certified nurse-midwives (CNMs) are increasingly covered for delivery, birth center or home birth fees with licensed midwives may not be.

"Routine" vs. "Complicated" Delivery

Insurers have specific billing codes for a “routine” vaginal delivery and a “complicated” one (e.g., with forceps, vacuum, or extensive repair). The definition of “complicated” can be subjective and lead to your delivery being billed at a higher rate, increasing your coinsurance responsibility. Furthermore, if your labor stalls and you need Pitocin, that medication and the associated monitoring can trigger additional charges.

The "Fourth Trimester": Where Support Often Vanishes

The U.S. healthcare system’s focus often ends abruptly at birth, but a new parent’s needs are just beginning.

Postpartum Mental Health Care

Despite the American College of Obstetricians and Gynecologists recommending a comprehensive postpartum visit within three weeks, insurance may only cover one “routine” visit at 6 weeks. More critically, screening and treatment for postpartum depression and anxiety are inadequately covered. Finding an in-network therapist or psychiatrist who specializes in perinatal mental health and is accepting new patients can be nearly impossible, forcing many to pay cash for this essential care.

Lactation Support Beyond the Basics

While the Affordable Care Act mandates coverage for lactation support and breast pump equipment, the details are murky. A single visit with a lactation consultant in the hospital might be covered, but ongoing, at-home support for issues like latch problems, low supply, or mastitis often is not. High-quality, hospital-grade pumps may require a higher co-pay or specific medical justification.

Newborn Care Before Enrollment

Your baby needs to be added to your insurance policy, usually within 30 days of birth. But what about the care they receive immediately after birth—the pediatrician exams in the hospital, the newborn screening tests, or any necessary nursery stay? There can be a dangerous gap. It’s crucial to proactively add your newborn to your plan retroactively to their birthdate to avoid claims being denied during this vulnerable period.

Navigating the Gray Areas: High-Deductible Plans and Out-of-Pocket Maxes

Even covered services come with a catch. The rise of high-deductible health plans (HDHPs) means you could be responsible for the first $5,000, $7,000, or more of your maternity care before insurance starts paying its share. Prenatal visits, labs, and the delivery itself all chip away at this deductible. Then, after meeting it, you still face coinsurance (e.g., 20% of costs) until you hit your out-of-pocket maximum. A straightforward pregnancy can easily cost thousands out-of-pocket; a complicated one can reach that maximum in a heartbeat.

Becoming Your Own Advocate: A Practical Action Plan

Knowledge is your primary defense. Don’t wait for bills to surprise you. * Read Your SPD (Summary Plan Description): This dense document is your contract. Search for terms like “maternity,” “infertility,” “home health,” and “durable medical equipment.” * Call and Ask Specific Questions: Contact your insurer. Ask: “What is my coverage for genetic carrier screening before pregnancy?” “Is NIPT covered for my age and risk profile?” “What is the network status of anesthesiologists at my chosen hospital?” * Get Pre-Authorizations in Writing: For any non-emergency procedure or test, insist your provider obtains a pre-authorization number from the insurer. Keep a record. * Appeal Denials: If a claim is denied, appeal. Often, a letter from your doctor explaining the medical necessity can overturn a denial. * Plan Financially: Use your insurer’s cost estimator tools, understand your deductible and out-of-pocket max, and start saving in a Health Savings Account (HSA) if you have an HDHP.

The journey to parenthood is transformative. It should not be bankrupting. By shining a light on these common coverage exclusions, you empower yourself to ask the hard questions, budget realistically, and focus on what truly matters—your health and the health of your growing family. The system may have gaps, but your preparedness doesn’t have to.