Illinois Insurance Facts Maternity Benefits in Illinois Revised July 2006

Prenatal care is essential for a healthy pregnancy and baby.  Many insurance companies cover prenatal care and delivery, but some do not.  Here are the basic facts about maternity coverage in Illinois.

Who Must Offer the Coverage?

Illinois requires all health maintenance organizations (HMOs) to cover all medical costs associated with pregnancy.  But, Illinois does not require insurance companies to provide normal maternity benefits in either group or individual policies.  However, insurance companies are required to provide benefits for complications of pregnancy such as toxemia or latent diabetes.

Federal law  (Pregnancy Discrimination Act of 1978 which amended Title VII of the Civil Rights Act) requires employers with 15 or more employees to treat pregnancy as any other illness.  Those employers must provide benefits for maternity care.  The employer may provide the benefits directly or through an insurance company.  To find out if you have maternity coverage, ask your employer, check your insurance policy, or call your insurance company’s customer service representative.

If an accident and health or HMO group policy provides maternity coverage that is renewed or issued on or after July 1, 1997, the insurance company or HMO may not exclude or limit maternity as a preexisting condition.

Early Notification

Contact your insurance company or HMO as soon as you know you (or your covered dependent) are pregnant, preferably within the first three months.  Insurance companies and HMOs sometimes offer additional benefits, such as lower copayments, if you contact them early and you follow appropriate prenatal guidelines.  They can also explain what is covered and what you must do to receive maximum benefits.  You will then have an idea of what you will be expected to pay for the pregnancy and delivery.

Post Parturition Care Requirements
215 ILCS 5/356s and 215 ILCS 125/4-6.4

Insurance companies that provide maternity coverage and all HMOs must pay for:

1. at least 48 hours of inpatient hospital care for mom and baby after a normal delivery;
2. at least 96 hours of inpatient hospital care for mom and baby after a cesarean section delivery.

Your doctor is the only person who can decide to discharge you before the minimum time.  If he or she decides you and the baby can be discharged prior to the minimum time, your insurance company or HMO must then provide coverage for:

1. a home nurse visit for you and the baby within 48 hours after discharge; or
2. a doctor’s office visit to check the baby within 48 hours after discharge.

Prenatal HIV Testing
215 ILCS 5/356z.1 and 215 ILCS 125/4-6.5

Insurance companies that provide maternity coverage and all HMOs must pay for prenatal HIV testing ordered by an attending physician, physician assistant or advanced practical registered nurse.

For More Information

1. Call our Consumer Services Section at (312) 814-2427 or our Office of Consumer Health Insurance toll free at (877) 527-9431 or visit us on our website at www.idfpr.com