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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:
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at least 48 hours of inpatient hospital care for mom
and baby after a normal delivery;
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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:
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a home nurse visit for you and the baby within 48
hours after discharge; or
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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
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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
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