Maternity benefits under healthcare plans are often misunderstood. They can range from straightforward to more complex than you'd expect, depending on your employer's plan type. In non-grandfathered individual and small-group plans, maternity and newborn care are an essential health benefit under the Affordable Care Act (ACA), so those plans must cover pregnancy, childbirth, and newborn care. But how these benefits interact with deductibles, copays, out-of-pocket maximums, and other benefits like FSAs and HSAs varies a lot.
The real question for HR leaders is cost and care. That's where a preventive-first approach pays off. WellthCare works alongside existing plans to encourage preventive visits, including prenatal care, which improves maternal outcomes and reduces downstream claims.
What the ACA Requires for Maternity Coverage
Under the ACA, all non-grandfathered individual and small-group plans must cover maternity and newborn care. This includes:
- Prenatal care (doctor visits, screenings, and lab work)
- Labor and delivery services (hospital stays, midwife services, and certain interventions)
- Postpartum care (follow-up visits, lactation support, and mental health services)
- Newborn care (immunizations, wellness checks, and initial hospital stay)
But large employer self-funded plans, which cover most Americans, aren't required to cover essential health benefits, though most do. That's an important nuance for benefits leaders. You can customize maternity coverage, but guardrails apply. The Pregnancy Discrimination Act requires employers with 15 or more employees to cover pregnancy-related expenses on the same basis as other medical conditions. And any coverage you offer must stay compliant with ERISA, HIPAA, and any state mandates.
How Maternity Benefits Work Inside Your Existing Health Plan
An employee gets pregnant. Under a standard PPO or HDHP, the typical sequence looks like this:
- Prenatal visits: Often covered as preventive care with no cost sharing under the ACA's preventive services rules (Section 2713), but it depends on how your plan defines "preventive." Some plans require cost-sharing for extra ultrasounds or genetic testing.
- Delivery and hospitalization: This is where deductibles apply. Among employer plan enrollees, a vaginal delivery averages about $15,700 in total spending and a cesarean section about $29,000, according to Peterson-KFF Health System Tracker. The employee pays the full deductible and then 20% coinsurance on an 80/20 plan, which can leave the employee paying thousands of dollars out of pocket.
- Newborn care: The baby must be enrolled within 30 days of birth under an employer plan (60 days for marketplace plans), and coverage is retroactive to the birth date. After that, newborn care is subject to the plan's cost-sharing rules.
- FSA/HSA impact: Many employees drain their FSA or HSA on maternity deductibles. This creates financial anxiety and often delays care.
What Maternity Claims Cost Employers
For employers, maternity claims are expensive. A complicated delivery or NICU stay can exceed $100,000; the average NICU stay costs roughly $70,000 and complex cases can run past $1 million. Yet many of these complications are preventable with consistent prenatal care. That's why prevention is a cost-containment strategy.
How WellthCare Improves Maternity Benefits for Employers and Employees
WellthCare isn't a replacement for your health plan. It works alongside it to reduce waste and reward healthy behavior. WellthCare is the first Health-to-Wealth Benefit System that operates without rip-and-replace, adding to any employer's existing plan with no disruption. It delivers in four ways:
- $0-co-pay care used first: Employees get preventive maternity care (scans, labs, education) at no cost through WellthCare before filing a claim with the traditional plan. This reduces out-of-pocket strain.
- Earned reward dollars at the WellthCare Store™: For completing prenatal actions like regular check-ups or lab work, the employee earns real, spendable dollars to use on health-supporting products such as maternity support belts, breast pumps, and vitamins, with no reimbursement paperwork.
- Automatic retirement contributions: Employers commit savings to employees' retirement accounts, and verified prenatal actions are tracked along the way. That compounding growth matters most to families already planning for a child's future.
- Lower employer spending: When employees use WellthCare first, fewer claims hit the primary plan. Over time, that controls premiums and helps self-funded employers avoid large claims.
What About Self-Funded Plans and Maternity?
For employers with a self-funded health plan, maternity benefits can feel unpredictable. That's where the WellthCare Readiness Index™ comes in. After 6 to 12 months of WellthCare usage, the system generates a data-driven report showing:
- Whether recommended preventive care, including prenatal care, is being completed across the covered population in aggregate
- Which preventive gaps exist that could lead to high-cost complications
- Whether transitioning to WellthCare Complete™ (a fully integrated self-funded solution) could reduce costs by a projected 30 to 45 percent, including maternity claims
Key Compliance Considerations for Maternity Benefits
You also need to keep these rules in mind:
- ERISA: Maternity benefits must be disclosed in the Summary Plan Description (SPD). Any changes to coverage require proper plan amendment and communication.
- HIPAA: Maternity-related health information is protected and cannot be used for discrimination in plan eligibility or pricing.
- ACA Section 2713: Preventive services for women, including prenatal care and breastfeeding support, must be covered without cost-sharing. This rule applies to self-funded plans too, not just individual and small-group plans.
- Newborns' and Mothers' Health Protection Act: Group health plans must cover a minimum hospital stay after delivery and may not require an earlier discharge.
- State laws: Some states add requirements on top of the federal floor, such as mandatory coverage for doula services.
Pregnancy Accommodations and Pumping Breaks: The PWFA and PUMP Act
Coverage is only half the story. Two federal laws from 2023 govern how employers treat pregnant and nursing workers, and neither one is about the health plan.
The Pregnant Workers Fairness Act (PWFA) took effect June 27, 2023, with a final EEOC regulation effective June 18, 2024. It requires employers with 15 or more employees to provide reasonable accommodations for known limitations related to pregnancy, childbirth, or related medical conditions, unless doing so would cause undue hardship. Common accommodations include schedule changes for prenatal appointments, light duty, and additional breaks.
The PUMP Act, a 2022 amendment to the Fair Labor Standards Act, gives most nursing employees the right to reasonable break time and a private space that is not a bathroom to pump for up to one year after their child's birth. Its enforcement remedies took effect April 28, 2023.
These rules don't change the deductibles or copays on your plan, but they do change how a maternity episode plays out for an employee. Pairing compliant coverage with compliant accommodations removes the two biggest friction points in one pass.
Final Takeaway for HR and Benefits Leaders
Maternity benefits don't have to be a cost center or a headache. Pair a preventive system like WellthCare with your plan and you move from paying claims reactively to building health and wealth proactively. Employees get the care they need at no out-of-pocket cost, build wealth for their family's future, and employers see fewer claims and lower costs.
Maternity care shouldn't drain an employee's savings or an employer's budget. With the right system, it can become a powerful moment for trust, retention, and long-term health. Make it work for everyone.
This article is for general information only and is not legal, tax, or medical advice. Employers should consult their own advisors.