Changes are on the horizon for maternity care billing in the United States. Starting in January, a new billing system will require medical providers to itemize and charge separately for each pregnancy-related service and visit, instead of applying a single bundled payment covering the entire maternity episode. This adjustment marks a significant departure from the previous approach, which standardized payments regardless of the complexity or number of services provided during pregnancy, childbirth, and postpartum care.

Background on the Billing System

The shift to an à la carte billing model has been advocated by leading professional organizations, including the American College of Obstetricians & Gynecologists (ACOG), which argues that the bundled payment model does not accurately reflect the diverse needs of expectant patients. As more individuals require specialized care or additional visits--often due to advanced maternal age or pre-existing health conditions--the new codes are designed to accommodate these variations, allowing providers to bill for each service rendered, whether delivered in person or remotely.

Implications for Providers and Patients

Healthcare providers, including obstetricians, midwives, hospitalists, and maternal-fetal medicine specialists, will be able to document and receive payment for a broader range of services under the updated codes. This includes more accurate reimbursement based on the complexity and volume of care, as well as the involvement of multiple practitioners throughout the maternity process.

For patients, particularly those with high-deductible insurance plans, the revised billing system could translate into higher out-of-pocket expenses. While the Affordable Care Act mandates coverage for certain preventive maternity services without direct charges to patients--such as prenatal and postpartum visits and select screenings--other aspects of care, including ultrasounds, specialist consultations, and laboratory tests, may not be fully covered under the new system. The ultimate impact on patient costs will depend on how individual insurers implement the new codes and update their reimbursement structures.

Considerations from Stakeholders

Insurers and employer groups have expressed concern about the transition timeline and the potential for increased administrative complexity. Industry representatives point out that implementing the revised codes will require operational adjustments and could affect how maternity services are managed. Additionally, there is apprehension that the fee-for-service structure may incentivize providers to recommend more--and potentially unnecessary--services, potentially driving up overall healthcare spending.

Experts in health policy highlight that the previous move toward bundled payments was intended to control costs and improve care quality, with the hope of reducing high rates of cesarean sections and unnecessary interventions. However, research indicates that the earlier system did not significantly change C-section rates or consistently lower costs.

Impact on Medicaid and Postpartum Care

Approximately 41% of births in the United States are covered by Medicaid, the federal-state program for low-income individuals. These patients generally do not face out-of-pocket costs for maternity care, and the new billing codes are not expected to have a financial impact on this group.

Another notable change involves the extension of postpartum care. Most states and Washington, D.C., now offer a full year of Medicaid coverage after childbirth. Under the new billing system, providers will be able to bill for ongoing postpartum visits beyond the two typically covered under the previous bundled payment model. This could enable better monitoring and management of postpartum issues, such as depression, substance use, diabetes progression, and cardiovascular changes after delivery.

Ongoing Evaluation

The Centers for Medicare & Medicaid Services (CMS) is currently reviewing the proposed updates to the billing codes, with a final decision expected to be released in the upcoming fee schedule. The American Medical Association and ACOG are working to educate providers and insurers about the coming changes. Ultimately, the effects of the new billing structure on care quality, patient expenses, and the broader maternity care landscape will depend on how payers, providers, and policymakers adapt to the revised system.