What steps do I take to get coverage for mandated maternity and newborn care under my California health plan?

Under California law, most health plans must cover maternity and newborn care as essential health benefits. To get coverage, you must understand your plan's rules, get necessary pre-authorizations, and be prepared to appeal any improper denials. Here are the steps to ensure you receive your mandated coverage: Step 1: Confirm Your Specific Benefits Call the member services number on your health insurance card and ask for a copy of your "Summary of Benefits and Coverage." Specifically ask about prenatal care, delivery, hospitalization, and newborn care. Confirm your deductible, co-pays, and which doctors and hospitals are in your network. Step 2: Get Pre-Authorization for Services Your plan will likely require pre-authorization (or prior approval) for your hospital stay and certain medical procedures. Your doctor’s office typically manages this process, but you must confirm with them that the approval was received before you are admitted. Failure to do so can result in a denial of payment. Step 3: Review Your Explanation of Benefits (EOB) After you receive care, your insurer will send an EOB. This is not a bill. It shows what your provider charged, what your plan paid, and what you are responsible for. Carefully review it to ensure all services were processed correctly and identify any denied claims. Step 4: File an Internal Appeal If a Claim Is Denied If your plan denies coverage for care you believe is medically necessary, you must file a formal appeal directly with the health plan. You generally have 180 days from the date of the denial notice to file. Submit a written request, including a letter from your doctor explaining the medical necessity of the treatment. Step 5: Request an Independent Medical Review (IMR) If your health plan still denies coverage after your appeal, you can escalate the issue to the state. You must file a request for an IMR within 6 months of receiving the plan's final denial. You can submit an IMR application online through the California Department of Managed Health Care (for HMO plans) or the California Department of Insurance (for PPO plans). Important considerations: California Health and Safety Code Section 1367.65 mandates coverage for a minimum hospital stay of 48 hours after a vaginal delivery and 96 hours after a C-section, unless you and your doctor agree to a shorter stay. Always use in-network providers to keep your out-of-pocket costs down. Note: Some older, "grandfathered" health plans may not be required to provide the full scope of essential health benefits. Deadlines for appeals are strict; missing one may prevent you from challenging a denial. This is general information and does not constitute legal advice. For complex situations, consult with a qualified California attorney.