MMC Benefits Handbook
Maternity
Who is eligible for maternity coverage?
Maternity coverage is available to eligible covered participants.
Is maternity coverage subject to prior authorization?
No. Prior authorization within 48 hours is not required for the initial hospital admission.
You must notify the prior authorization service if the mother or her newborn stay in the hospital longer than 48 hours after a vaginal delivery or 96 hours after a Cesarean birth. This notification must occur within 24 hours of the determination to extend the stay.
Does the Plan cover prenatal visits?
Note that routine prenatal care, as defined by the Department of Health and Human Services, is covered with no cost sharing in-network.
The Plan covers routine prenatal and postnatal visits, including labs and tests at:
What will the Plan pay for the doctor's charge for delivering the baby?
The Plan covers charges for delivery of the baby at:
  • $275 to $950 copay / stay (based on provider and location) for in-network providers and $2,850 copay / stay for out-of-network providers. There is only one copay for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copay will apply to the baby's services.
What will the Plan pay for the doctor's charge for examining the baby?
The Plan covers the charges for your baby's first examination in the hospital at:
  • $275 to $950 copay (based on provider and location) for in-network providers and $2,850 copay for out-of-network providers. There is only one copay for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copay will apply to the baby's services.
A child is covered at birth as long as the baby meets the child eligibility requirements and is enrolled within 60 days of the birth. Eligibility requirements are described in the Participating in Healthcare Benefits section.
What will the Plan pay for hospital charges for the mother and the baby?
The Plan covers hospital charges for maternity admissions at:
  • $275 to $950 copay (based on provider and location) for in-network providers and $2,850 copay for out-of-network providers. There is only one copay for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copay will apply to the baby's services.
The Plan covers newborn nursery care at:
  • $0 copay for in-network providers and $60 copay for out-of-network providers. There is only one copay for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copay will apply to the baby's services.
A child is covered at birth as long as the baby meets the child eligibility requirements and is enrolled within 60 days of the birth. Eligibility requirements are described in the Participating in Healthcare Benefits section.
The mother and the newborn child are covered for a minimum of 48 hours of care following a vaginal delivery and 96 hours following a Cesarean section. However, the mother's provider may — after consulting with the mother — discharge the mother earlier than 48 hours following a vaginal delivery (96 hours following a Cesarean section).
You must notify the Claims Administrator within 24 hours of a determination to extend the stay.
Does the Plan cover midwife services?
The Plan covers midwives who are in practice with a network group at:
  • $275 to $950 copay (based on provider and location) for in-network providers and $2,850 copay for out-of-network providers. There is only one copay for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copay will apply to the baby's services Certified nurse midwives are covered under the childbirth/delivery copay.
What is the wellness program for Maternity?
Surest has a maternity benefit guide located at https://www.surest.com/blog/maternity to help you navigate your maternity journey. Surest also has clinical advocates who can help assess your maternal risk and answer any questions you have about your benefits. If you have issues or risk factors that need special attention, the clinical advocate will put you in touch with a nurse case manager who will work with you to find ways to lower your risks.
If my dependent child has a baby does the Plan cover the newborn child?
Unless the newborn meets the definition of an eligible child and is covered under the Plan, medical care for the newborn, whether in or out of the hospital, is not covered.