Federal law bars pregnancy from being considered a pre-existing condition, which means if you change health plans while you're pregnant, your new insurer can't deny claims related to your pregnancy. But a variety of loopholes means pregnant women could still lack insurance coverage for their prenatal care if they don't do some careful planning.Under a law known as HIPAA, the Health Insurance Portability and Accountability Act of 1996, health insurers cannot consider pregnancy a pre-existing condition. So, unlike illnesses such as diabetes, they can't deny you coverage when you go from one job to another and switch health plans. (For more, see our story on HIPAA.)

"It was not good public policy to have a pregnant woman with no access to health insurance," says Kansas Insurance Commissioner Kathleen Sebelius. "We want to encourage prenatal care and regular checkups during the course of a pregnancy, and having pregnancy as a pre-existing condition would block access to health care."

Plenty of Exceptions to the RulesUnfortunately, there are a lot of "buts" to HIPAA. For one thing, HIPAA doesn't apply to someone who previously had no health coverage at all and then gets into a group health plan through a new job. So if you had no insurance, got pregnant, then landed a new job with insurance, your new health plan would not have to immediately cover your pregnancy; you might have to sit out a pre-existing condition waiting period — a period that could be longer than your pregnancy — and in the meantime pay for your doctor visits yourself.

Second, HIPAA applies only to group health plans. So if you have individual insurance and are pregnant, then buy group health insurance, you again could be subject to a pre-existing condition waiting period. Likewise, if you move from one individual health plan to another individual health plan, you might not get pregnancy coverage at all, you might have to sit out a waiting period, or, if you are offered insurance that covers your pregnancy, you might find it's very expensive.

See the pattern yet?

"HIPAA is really the only protection against pregnancy being treated as a pre-existing condition, and there are lots of people to whom HIPAA rules don't apply," Sebelius notes.

Eligibility Waiting Periods PossibleHere's another scenario. Say you have group health coverage and then switch jobs, your new health plan has a one-month eligibility period before it begins, and you're pregnant. What can you do? "Probably nothing," Sebelius warns. The health plan isn't required to cover your pregnancy until the plan takes effect. While that might not be a problem if you're early in your pregnancy and you don't mind paying for a prenatal visit or two out of your own pocket, it could be trouble if you're in your eighth or ninth month and have no coverage, even temporarily.

The COBRA OptionCalifornia Program Helps Pregnant WomenWhile many uninsured pregnant women have few options for getting insurance unless they meet strict income guidelines for state and federal assistance, California offers a program for those who would otherwise fall through the cracks.

The program, called AIM — Access for Infants and Mothers — was started in 1991 to provide prenatal care for women whose incomes are too high to qualify for other state assistance programs but too low to afford private health insurance. Funding for the program comes from taxes on tobacco.

"It helps a lot of people who would fall through the cracks," says Ernesto A. Sanchez, contract and marketing manager for the Managed Risk Medical Insurance Board (MRMIB), a state agency that runs the AIM program. "The feeling in California is that this money is well-spent up front because of the high cost later of low-birth weight babies and premature babies. California is trying to take the lead on that. I don't think there are too many programs like ours."

The AIM Program covers uninsured pregnant women during pregnancy and for 60 days of health care after pregnancy. It also provides health care to the infant for the first two full years.

The program is especially suited for women whose employers don't offer health insurance or whose health plan has a high maternity deductible, as well as women who lack insurance because they're self-employed, recently laid off, or between jobs, says Sarah Soto-Taylor, an associate analyst with MRMIB.

The coverage is comprehensive, including prenatal visits and hospitalization, even for complications, without extra costs to the women.

Women in the program do have to contribute a portion of their income toward premiums — just 2 percent — plus $100 for the baby's care. The cost to participants runs from about $430 for an unmarried pregnant woman making $21,700 to $819 a year for a married woman with a family income of $40,950, and it increases with family size. To qualify, families can earn between 200 percent and 300 percent of the federal poverty level, or up to $41,640 for a family of three.

"It's fairly inexpensive if you consider that an insurance company won't insure women once they're pregnant, so they usually have to get services through a private clinic or a cash-pay program at the doctor's office, which can run into the thousands of dollars," Soto-Taylor notes.

The program is effective, she and Sanchez say. In 1991, before the program began, there were 29,522 uninsured births in California. By 1997, the number of uninsured births had dropped to 15,161.

For more details, visit AIM on the Web. Now, you could get COBRA to cover any interim period between health plans, but employers aren't required by law to offer COBRA unless they have at least 20 employees. And you'll also wind up paying a bit more in premiums: 102 percent of the premium because of administrative fees. Some states have so-called "mini-COBRA" laws that apply to small employers, Sebelius says, but you'll have to check with your state insurance department to find out the rules in your state.

The Individual Insurance OptionIf you can't get COBRA and if you've had at least 18 straight months of group coverage, you might be entitled to buy an individual policy at "guarantee issue," which means the insurance company cannot turn you down. But states have leeway in these laws, and some might force you into a high-risk pool, where the exorbitant premiums could be more than you'd pay on a couple of prenatal visits anyway. And even then, according to the National Association of Insurance Commissioners, your pregnancy could be denied as pre-existing on an individual policy.

You could try to buy individual health coverage on your own, but chances are slim you'll be offered a policy if you're pregnant — if you can even find one that will offer a policy for only a few months, says Richard Coorsh, a spokesman for the Health Insurance Association of America. And again, you'll be facing high premiums.

"The coverage possibilities for an already-pregnant woman are very slim," Sebelius agrees. "Very few plans want to take you, and they'd be very expensive because health plans are taking the risk. They know you have a condition that's going to require treatment and care. In the worst-case scenario, something happens along the way — a difficult birth, or a premature baby — and the baby ends up in the neonatal unit. So any time you're trying to buy insurance for a condition which is already in place, the costs are going to be very steep."

Government AssistanceMedicaid is another option, but only if you meet the low-income requirements. To find out, call your state insurance department. "Simply being pregnant doesn't entitle someone to Medicaid," says a spokeswoman from the Health Care Financing Administration, which administers Medicaid.

Some women might also qualify for WIC — the Special Supplemental Nutrition Program for Women, Infants, and Children run by the federal government. It provides nutrition counseling and access to health care services to low-income women who are pregnant, breastfeeding, and nonbreastfeeding postpartum, and to infants and children up to age 5 who are at nutritional risk. To qualify, women must meet income guidelines (you must be below 185 percent of the federal poverty rate, which is about $30,433 for a family of four), a state residency requirement, be individually assessed as a "nutritional risk" by a health professional, or already qualify for certain other low-income programs, such as Medicaid. For more information, visit WIC online or call your state insurance department.

Employers Have Little Responsibility to Pregnant WomenBear in mind that many employers are not required by law to offer pregnancy coverage at all, Sebelius says. "It's not a legal requirement, and employers who want to save money might opt for a plan that doesn't have pregnancy coverage," she says.

In fact, there's no legal requirement that an employer offer a health plan at all. However, if they opt to do so, the health plan must comply with federal ERISA laws as well as state requirements. And those state requirements often mandate maternity and prenatal care, notes Louis Saccoccio, general counsel of the American Association of Health Plans. "Usually when a health plan is licensed in a state, it's required to offer a comprehensive set of benefits, and invariably prenatal care is part of that," he says.

But when a company is "self-insured," it's not required to meet any of those state mandates, and thus it could exclude coverages such as prenatal care and childbirth. Self-insured companies, which are usually large businesses, pay for their own health care and generally have it administered by a third party. They are not governed by state laws, but by a federal law called the Employee Retirement Income Security Act (ERISA).

Planning is Vital to Ensure CoverageSo what can you do to ensure coverage for your pregnancy? In a word, plan.

"You have to assume individual responsibility," Coorsh says.

If you are planning to become pregnant, make sure you have health insurance first. If you're pregnant and thinking about switching jobs, be aware that you might have to go a month or two without insurance, and make sure your next health plan covers pregnancy. Check with the company's employee benefits administrator to find out.

It's illegal for a potential employer to ask a woman in a job interview about her family plans, but obviously if you ask pointed questions about maternity coverage you'll give yourself away.

"People need to be very cautious about job changes when they're pregnant," Sebelius says. "Getting some very specific information about how the job change will affect your coverage is not something to be taken lightly because people could wind up with no insurance coverage for the pregnancy."

And unmarried pregnant women take note: Despite the movement afoot in some communities and businesses to offer coverage to "domestic partners," chances are you won't be added to your boyfriend's or fiance's group health plan simply because you're having his baby; there's no legal requirement to do so, and it's at the whim of the health plan. "Some plans might offer that, but it would be the exception rather than the rule," Saccoccio says. "It's pushing the envelope."

Once the baby is born, however, the unmarried father should be able to easily add the baby to his group health plan, though he might have to own up to the paternity in writing first, Saccoccio says. And a woman with individual health coverage should have little problem adding her baby to her plan — though the premiums will no doubt spike.

By Jennifer M. Gangloff