Women's health programs
The care that has to be covered.
Well-woman visits, cancer screenings, contraception, maternity and newborn care, and breastfeeding support. Most of it is covered with no cost sharing when you stay in network, and none of it depends on a pre-existing condition.
Preventive care
Covered with no cost sharing when you stay in network.
Federal rules require most plans to cover this set of services without a copay, coinsurance, or deductible. The list is updated as clinical recommendations change, and the details of age and interval follow those recommendations.
- Well-woman visits, the annual preventive visit where screenings and counseling for the year get planned
- Mammograms to screen for breast cancer at the recommended ages and intervals
- Cervical cancer screening with a Pap test, HPV testing, or both, depending on age
- Genetic counseling and BRCA risk assessment for women with a family history that meets the criteria
- Contraceptive counseling and FDA-approved contraceptive methods as prescribed by your clinician
- Breastfeeding support and counseling, plus a breast pump and supplies
- Screening for gestational diabetes during pregnancy, and for diabetes after a pregnancy affected by it
- Prenatal visits, including screening for preeclampsia through blood pressure checks
- Screening and counseling for interpersonal and domestic violence
- HIV screening and counseling, and screening and counseling for sexually transmitted infections
- Osteoporosis screening for women at the recommended ages and risk levels
- Screening for anxiety and depression, including during pregnancy and after birth
Maternity and newborn care
An essential health benefit, pregnancy included.
Pregnancy, maternity, and newborn care is one of the 10 essential health benefits, and a plan cannot turn you down or charge you more because you are already pregnant.
- Prenatal care visits, routine labs, and recommended screenings during pregnancy
- Labor and delivery, including hospital care for the birth
- Postpartum care for the birthing parent, including a postpartum visit and depression screening
- Newborn care in the hospital and the well-child visits that follow
- Breastfeeding equipment, support, and counseling for the duration of breastfeeding
- Coverage cannot be denied or priced higher because you are pregnant when you apply
Where your coverage comes from
The same benefits, administered differently.
What is required is broadly similar. What differs is who sets the network, when you can change plans, and what help with the cost is available.
Individual and family plans sold through the marketplace must cover all 10 essential health benefits, including maternity and newborn care, and must cover the preventive services above with no cost sharing in network. You choose the plan, so you also choose the network and the drug list.
- Enroll during Open Enrollment, which runs from November 1 through January 15 in most states, or after a qualifying life event such as a birth, a marriage, a move, or losing other coverage.
- A premium tax credit may lower your monthly cost, and cost-sharing reductions can lower your deductible and copays if your income qualifies and you pick a Silver plan.
- Before you enroll, check that your OB-GYN, your preferred hospital, and any specialist you see are all in the plan network. Hospital and clinician networks are set separately.
- Medicaid and CHIP cover pregnancy-related care in every state and have no enrollment window, so it is worth checking eligibility any time of year.
Employer plans are set up by your employer, which picks the insurer, the network, and how much of the premium the company pays. Non-grandfathered employer plans still have to cover in-network preventive services with no cost sharing, and large employer plans generally include maternity coverage.
- Changes usually happen during your employer open enrollment window, or within 30 days of a qualifying life event, which is a shorter deadline than the marketplace allows.
- Some employers with religious or moral objections are exempt from the contraceptive coverage requirement. Federal rules describe how an accommodation can still provide coverage in some of those cases, so ask your benefits administrator what applies to your plan.
- Grandfathered plans, which have existed largely unchanged since March 2010, do not have to follow the preventive services rules. Your plan documents state whether the plan is grandfathered.
- Employer plans often add benefits beyond the minimum, such as fertility coverage, lactation consultants, or maternity support programs. Read the summary of benefits rather than assuming.
Making the benefit work for you
Book the well-woman visit, then use it to plan the year.
The annual preventive visit is the one appointment that sets up everything else: which screenings are due at your age, whether a family history changes the schedule, what contraception fits your plans, and which referrals you need. Confirm the visit is billed as preventive when you schedule it, bring a list of medications and family history, and ask which of the recommended screenings are due this year rather than waiting to be told.
By the numbers
Dates and rules worth remembering.
- Essential health benefits, maternity included
- 10
- In-network cost sharing for covered preventive services
- $0
- To enroll after a birth or adoption
- 60 days
- Open Enrollment begins in most states
- Nov 1
Good to know
Common questions about women's health coverage.
Which preventive services are actually free?
Under the Affordable Care Act, most plans must cover a defined list of preventive services with no copay, coinsurance, or deductible when you use an in-network provider. The women's portion of that list comes from guidelines supported by the Health Resources and Services Administration, alongside services rated A or B by the U.S. Preventive Services Task Force and immunizations recommended by the CDC advisory committee. No cost sharing applies to the screening itself. If a screening leads to diagnostic testing or treatment, normal cost sharing can apply to that follow-up care.
Is contraception covered without a copay?
Most plans have to cover contraceptive counseling and the full range of FDA-approved contraceptive methods as prescribed, with no cost sharing, when you use an in-network provider. A plan may apply reasonable medical management, such as covering a generic without cost sharing and charging for the brand-name equivalent, but it must have a process to waive that if your clinician says a specific product is medically necessary for you. Some employers with religious or moral objections are exempt, and grandfathered plans are not subject to the requirement, so check the plan documents.
Does every plan cover maternity care?
Individual, family, and small group plans that follow the Affordable Care Act must cover pregnancy, maternity, and newborn care as one of the 10 essential health benefits, and coverage applies even if you are already pregnant when you enroll. Large employer plans generally include maternity coverage as well. Short-term plans and health care sharing arrangements are not required to cover maternity care, and often exclude it.
Can I change plans when I have a baby?
Yes. Having or adopting a child is a qualifying life event that opens a Special Enrollment Period, and you generally have 60 days from the birth or adoption to enroll or change plans. Coverage for the new child can usually be backdated to the date of birth or adoption. Marriage, a move, and losing other coverage are also qualifying events.
Do I need a referral to see an OB-GYN?
Non-grandfathered plans that require you to designate a primary care provider must let you see an in-network OB-GYN for obstetric and gynecological care without a referral. Plan rules still apply to the network itself, so confirm that the clinician and the facility are both in network before the visit.
What if my claim for a preventive service is billed with cost sharing?
It happens, often because of how the visit was coded or because part of the visit was diagnostic rather than preventive. Ask the provider office to review the coding first, and if the charge still looks wrong, file an appeal with your plan. Keep the explanation of benefits and any notes about what was discussed at the visit.
Coverage where you live
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