CurrentUnitedHealthcarePolicy BIP091.P

Maternity and Newborn Care: CA – UnitedHealthcare West Benefit Interpretation Policy

Defines UnitedHealthcare West coverage positions and regulatory requirements for maternity and newborn services in California, including prenatal/postnatal care, inpatient maternity care, newborn care, maternal mental health screening/treatment, and related statutory mandates (NMHPA, CA HSC provisions).

Policy Summary

PayerUnitedHealthcare

PolicyMaternity and Newborn Care: CA – UnitedHealthcare West Benefit Interpretation Policy

Policy CodePolicy BIP091.P

Change TypeRevised / Added

Effective DateApril 1, 2026

Next Review Date

Key ActionConduct and document at least one maternal mental health screening during pregnancy and one within six weeks postpartum; document follow-up and referrals per program guidelines.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to the California Prenatal Screening (PNS) Program and California HSC Section 1367.625.

Added language to indicate the services of a doula are covered when performed within the scope of their training as a doula.

Revised language to indicate maternal mental health conditions include screening, treatment, and referral and provided examples of screening timing.

Added definition of 'Postpartum' and updated definition of 'Prenatal'.

Updated References section to reflect the most current information.

48Minimum vaginal delivery inpatient stay (hours)

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Minimum C-section inpatient stay (hours)

6Postnatal office visit coverage period (weeks)

12Months maternal mental health coverage limit

Coverage Summary

Defines UnitedHealthcare West coverage positions and California regulatory requirements for maternity and newborn services, covering prenatal and postnatal care, inpatient maternity care (including NMHPA minimum stays), newborn immediate coverage, and maternal mental health screening/treatment and referral programs. Applies to UnitedHealthcare West members in California and aligns plan benefits with federal NMHPA protections and multiple California Health & Safety Code provisions.

High-level notes: payer = UnitedHealthcare West; jurisdiction = California; policy focus = maternity & newborn services and maternal mental health, including mandated screenings and program requirements per California HSC Section 1367.625.

Covered Benefits — Prenatal & Postnatal Care

Covered Benefits / Prenatal and Postnatal Care

Covered when provided by a plan provider or network/participating licensed/Certified Nurse-Midwife when available and authorized by member's network/participating medical group:

ALL of the following

Prenatal office visits
Postnatal (after delivery) office visits up to 6 weeks post-deliveryup to 6 weeks (42 days) post-delivery
Outpatient (office visit) physician services
Screening and diagnostic laboratory and radiological procedures (including California Prenatal Screening Program)
See Federal/State Mandated Regulations for PNS details
Prenatal diagnosis of fetal genetic disorders including tests for specific genetic disorders for which genetic counseling is available
Educational materials for individual needs provided in physician's office
Maternal mental health services (examples)
- At least one maternal mental health screening conducted during pregnancy
- At least one additional maternal mental health screening within the first six weeks postpartumwithin first six weeks postpartum
- Additional postpartum screenings when determined medically necessary and clinically appropriate by treating physician
- Screening, treatment, and referral for maternal mental health services
Maternal mental health condition coverage limited to 12 months from diagnosis or from end of pregnancy, whichever is latershall not exceed 12 months from diagnosis or from end of pregnancy, whichever occurs later
operational coverage limit
Services of a doula when performed within the scope of their training as a doula

Inpatient Maternity Care — Minimum Stay & Related Services

Inpatient Maternity Care

Covered inpatient services and minimum stay requirements per federal NMHPA unless attending physician and mother decide earlier:

ALL of the following

Inpatient hospital care for maternity (including labor, delivery and recovery room care, treatment, services)
Minimum 48-hour inpatient stay for normal vaginal delivery48 hours
may discharge earlier if attending physician in consultation with mother decides
Minimum 96-hour inpatient stay following cesarean section96 hours
may discharge earlier if attending physician in consultation with mother decides

Newborn Care

Covered when medically necessary and provided by plan/network providers:

ALL of the following

Postnatal hospital services for newborns, including special care nursery
covered when medically necessary
Immediate accident and sickness coverage from moment of birth for newborn infant of covered subscriber/spouse per CA HSC Section 1373(c) (subject to plan terms)immediate from moment of birth
See HSC 1373(c) for adoption placement provisions

Not Covered / Exclusions

The following services are expressly not covered unless otherwise required by federal/state mandated regulations or member EOC/SOB:

ANY of the following

Childbirth classes (e.g., Lamaze)
excluded
Educational courses on childcare
excluded
Elective home delivery unless covered under Federal/State Mandated Regulations section
excluded
Maternity services for non-UnitedHealthcare member acting as surrogate to UnitedHealthcare member

Statutory / Programmatic Coverage Requirements

Statutory / Programmatic Coverage Requirements (Federal/State Mandated Regulations)

Coverage and program participation required by cited federal/state statutes and programs:

ALL of the following

NMHPA: Cannot restrict hospital stays to less than 48 hours for vaginal delivery and 96 hours for C-section; earlier discharge allowed if attending physician in consultation with mother decides48 hours (vaginal), 96 hours (C-section)
See Newborns' and Mothers' Health Protection Act of 1996
California Prenatal Screening (PNS) Program participation must be covered; such coverage not subject to cost sharing per HSC 1367.54
Refer to HSC 1367.54 and PNS program materials
Direct access to OB-GYN (HSC 1367.695):

Provider Actions & Billing Rules

Documentation Required

Physician decision and documentation for early discharge

If mother/newborn are discharged prior to the 48- or 96-hour minimum, the attending physician must make the decision in consultation with the mother and document that decision. When appropriate, the attending physician must prescribe and document a post-discharge follow-up visit for mother and newborn to occur within 48 hours of discharge.

Prior Authorization

Circumcision medical necessity review

Circumcision requests that fall outside the specified covered conditions (e.g., not performed prior to hospital discharge or outside the defined neonatal time frames) must be reviewed for medical necessity by the network medical group or by the UnitedHealthcare medical director or designee.

Documentation Required

Coverage determination for newborns (grandchildren/adopted)

Coding

No specific procedure/care codes listedmixed

No codes listed

Definitions

Certified Nurse-Midwife (CNM) / Certified Midwife (CM): Graduate-level educated midwives who pass national certification and provide care during pregnancy, childbirth, postpartum, and care for healthy newborns during the first 28 days.

NMHPA (Newborns' and Mothers' Health Protection Act of 1996): Federal law that generally prohibits restricting hospital stays to less than 48 hours following vaginal delivery or 96 hours following cesarean delivery, with earlier discharge permitted when the attending physician, in consultation with the mother, decides.

Postpartum: Period of 12 weeks after a woman gives birth.

Postnatal: Begins immediately after birth and extends up to six weeks (42 days) after birth.

Prenatal: The period during pregnancy before birth occurs.

Revision History

04/01/2026revisedLatest

Revised language pertaining to the California Prenatal Screening (PNS) Program and California HSC Section 1367.625 (maternal mental health program) reflecting program and statutory changes.

04/01/2026addedLatest

Added language to indicate the services of a doula are covered when performed within the scope of their training as a doula.

Policy Summary

PayerUnitedHealthcare

PolicyMaternity and Newborn Care: CA – UnitedHealthcare West Benefit Interpretation Policy

Policy CodePolicy BIP091.P

Change TypeRevised / Added

Effective DateApril 1, 2026

Next Review Date

Key ActionConduct and document at least one maternal mental health screening during pregnancy and one within six weeks postpartum; document follow-up and referrals per program guidelines.

SourceLink

On This Page

If discharged prior to minimum hours, post-discharge follow-up visit for mother and newborn within 48 hours when prescribed by treating physicianwithin 48 hours of discharge

Alternative birthing center services when provided or arranged by a network hospital affiliated with member's network medical group

Delivery by vaginal or cesarean section

Treatment of miscarriage and complications of pregnancy or childbirth

Physician services related to medically necessary inpatient maternity care

All medically necessary ancillary services related to inpatient maternity care (including diagnostic lab and radiologic procedures)

Services of a licensed/Certified Nurse-Midwife only when available within member's network/participating medical group

Circumcision coverage conditions (male newborn)

Circumcision performed at hospital prior to hospital discharge is covered
Circumcision after hospital discharge covered when delayed by network provider during first hospitalization (unless delay was for medical reasons), only through the 28-day neonatal periodwithin 28 days neonatal period if delay by provider and not for medical reasons
Circumcision after discharge covered when medically inappropriate during first hospitalization due to medical reasons; covered when network provider determines medically safe and performed within 90 days from that determinationwithin 90 days from determination of medical safety
All other requests for circumcision must be reviewed for medical necessity by network medical group or UnitedHealthcare medical director or designee

Newborn coverage of a grandchild unless employer provides coverage or subscriber/spouse/domestic partner has guardianship as filed in court or provides proof of placement for adoption

exclusion with specified exceptions

Non-medically indicated testing excluded

Any procedure intended solely for sex determination (e.g., ultrasound)
excluded
Blood testing to determine paternity
excluded

Non-medically necessary screening of newborns to determine carrier status for inheritance disorders when there would not be an immediate medical benefit or when results would not be used to begin medical interventions/treatment while a newborn

excluded

Take home medications and/or supplies, unless member has a supplemental pharmacy benefit

excluded unless supplemental benefit present

CA HSC 1367.695: Direct access to OB-GYN services without prior approval; plan may set reasonable requirements for participating OB/GYN to communicate with PCP

Donor human milk (HSC 1367.624): CA HSC 1367.624 (effective Jan 1, 2025): Coverage for medically necessary pasteurized donor human milk from licensed tissue banks as basic health care serviceeffective Jan 1, 2025

Maternal mental health program (HSC 1367.625): CA HSC 1367.625 (effective Jan 1, 2025): Mandated maternal mental health program including at least one screening during pregnancy and at least one screening within first six weeks postpartum; program to include quality measures, screening, diagnosis, treatment and referral; applies to health care service plans (with specified exceptions)

Immediate newborn coverage (HSC 1373(c)): CA HSC 1373(c): Immediate coverage for newborn from moment of birth; coverage for newborns placed for adoption from date of documented placement or evidence of right to control healthcareimmediate from moment of birth

PKU testing and treatment (HSC 1374.56): HSC 1374.56: Coverage for testing and treatment of PKU including medically necessary formulas and special food products per statutory conditions

Implements federal NMHPA requirements that prevent plans from restricting hospital stays to less than 48 hours after vaginal delivery and 96 hours after cesarean delivery, while allowing earlier discharge if the attending physician, in consultation with the mother, makes that decision.

Implements California Health & Safety Code provisions including mandatory participation in the California Prenatal Screening (PNS) Program with no cost sharing (HSC §1367.54), and the mandated maternal mental health program (HSC §1367.625) requiring at least one screening during pregnancy and at least one screening within the first six weeks postpartum, plus program components for screening, diagnosis, treatment, referral, and quality measures.

Notes statutory additions effective January 1, 2025, such as coverage of medically necessary pasteurized donor human milk from licensed tissue banks (HSC §1367.624) and the amended maternal mental health program requirements (HSC §1367.625).

The policy explicitly adds coverage for the services of a doula when performed within the scope of their training as a doula.

To establish coverage for a newborn grandchild or an adopted newborn, the provider must verify and document the applicable authority: employer-provided coverage for the child, valid guardianship filed in court, or proof of placement for adoption (such as a health facility minor release report, medical authorization form, relinquishment form, or other evidence of the subscriber's/spouse's right to control the child's health care).

Documentation Required

Maternal mental health screening and follow-up

Providers should conduct and document at least one maternal mental health screening during pregnancy and at least one additional screening within the first six weeks postpartum. Additional postpartum screenings, referrals, and treatment should be documented and provided when determined to be medically necessary and clinically appropriate by the treating provider, consistent with the maternal mental health program requirements.

Billing Rule

Supplemental pharmacy benefit requirement for take-home meds

Take-home medications and supplies are not covered under this policy unless the member has a supplemental pharmacy benefit. Providers should bill accordingly and confirm the member's supplemental pharmacy benefit before dispensing take-home meds or supplies.

Revised maternal mental health provisions to require at least one screening during pregnancy and at least one additional screening within the first six weeks postpartum; coverage for maternal mental health conditions limited to 12 months from diagnosis or end of pregnancy, whichever is later.

04/01/2026addedLatest

Added definition of 'Postpartum' and updated definition of 'Prenatal'.

04/01/2026updatedLatest

Updated References / Bibliography to reflect current information.

01/01/2025statutory_effective

California HSC Section 1367.625 (maternal mental health program) becomes effective Jan 1, 2025, requiring at least one screening during pregnancy and one within first six weeks postpartum, program elements including screening, diagnosis, treatment and referral, and encouragement to include doula coverage.

01/01/2025statutory_effective

California HSC Section 1367.624 (coverage for medically necessary pasteurized donor human milk from licensed tissue banks) becomes effective Jan 1, 2025.