FAQ: What benefits leaders need to know about maternity care unbundling

In practice, prenatal visits, labs, ultrasounds, delivery, and postpartum care will each be billed separately instead of bundled together. The AMA is deleting 17 old codes, adding 12 new ones, and revising 6 more — the biggest change to maternity billing in over 30 years.

The bottom line: A final decision on how Medicare pays for the new codes is expected around November 2026.

One thing isn't settled yet: how Medicare will actually pay for the new codes. CMS is also considering keeping a global-code-like option (new "G-codes") for Medicare instead of fully switching over. ACOG opposes this, warning it would create two competing billing systems. A final decision is expected around November 2026.

In practice, employers should expect a transition period running well into 2027 — likely six to eight months or more — during which both billing systems are active simultaneously for different members, depending on when each pregnancy started. This isn't a sign that something's gone wrong with claims processing; it's the expected result of a mid-pregnancy system change.

The bottom line: Expect a transition period running well into 2027 — confirm with your TPA how mixed billing will be flagged.

It's worth confirming with your TPA or carrier how they plan to identify and flag which pregnancies fall under which code set, so mixed billing doesn't look like a data error when you're reviewing claims next year.

The global code was built decades ago, when one obstetrician typically saw a patient through an entire pregnancy; today, care is delivered by teams that include OB-GYNs, midwives, maternal-fetal medicine specialists, and mental health providers, and the flat fee hasn't kept pace with that added complexity.

The bottom line: Unbundling is meant to let clinicians bill for the work they actually do.

Clinical risk has also grown: gestational diabetes affects roughly 8% of U.S. pregnancies and is rising, according to the CDC, and hypertensive disorders complicate 5–10% of pregnancies. Unbundling is meant to let clinicians bill for the work they actually do and give payers clearer visibility into how care is delivered across a population.

Based on CMS's proposed rule, here's what's anticipated to cost more, less, or about the same:

• Likely more: labor and delivery codes — CMS has proposed increasing the value of these codes by roughly 15%, and any pregnancy with added complications, specialist visits, NICU admission, or a C-section will now show up as its own, larger set of line items rather than being absorbed into a flat fee.
• Likely less, per visit: routine prenatal (antepartum) visits — CMS is proposing to shift value away from these individual visits, and ACOG's updated guidance also assumes fewer visits for average-risk pregnancies (8–9 instead of the old 12-visit standard).
• Same code, higher price: the delivery codes themselves aren't being redefined or split into smaller pieces — what's changing is the dollar value assigned to them.

The net effect on total spend still depends on utilization — a low-risk pregnancy could cost about the same or less, while a high-risk pregnancy could cost meaningfully more. It's worth asking your TPA now how claims adjudication systems are being updated for the new codes.

The bottom line: There's no longer a built-in cost ceiling the way a bundled fee provides one.

Labor management, delivery, and postpartum care are also split into their own distinct codes, while the delivery-only codes themselves remain largely intact. In practice, a healthy, lower-risk pregnancy that once generated a single global claim could now generate eight or nine separate billed encounters, reflecting ACOG's updated visit guidance for average-risk pregnancies, or more for higher-risk pregnancies.

The bottom line: A once-single global claim could now generate eight or nine separate billed encounters.

Because these pregnancies already involve more clinical touchpoints, they'll surface as some of the largest, most detailed itemized claims once the global code disappears. This doesn't mean these pregnancies are becoming more expensive to deliver; it means costs that were previously absorbed into one flat number will now be visible in granular detail.

The bottom line: Costs that were previously absorbed into one flat number will now be visible in granular detail.

This matters because cost-sharing changes behavior. There's decades of insurance data showing that when people have to pay out of pocket for care, they're more likely to skip or delay it.

The bottom line: Costs that were previously absorbed into one flat number will now be visible in granular detail.

In pregnancy, nearly every prenatal visit serves a preventive function, so if that distinction isn't handled thoughtfully in plan design, there's a real risk of members skipping visits specifically to avoid the expense — the opposite of what anyone wants heading into 2027. This is worth raising directly with your carrier now, before final CMS guidance lands.

CMS proposes that shift so routine prenatal care is valued lower per visit, and labor/delivery is valued higher. These are proposed figures, not final — public comments close September 14, 2026, and final values are expected around November 2026.

The bottom line: These are proposed figures — final values are expected around November 2026.

First, high-risk pregnancies already drive a disproportionate share of maternity costs, and under the new codes, that cost becomes far more visible and itemized rather than smoothed into one flat number.

The bottom line: For a fertility-heavy or high-risk population, that's a compounding effect, not two separate line items.

Second, IVF-conceived pregnancies carry meaningfully higher clinical risk, and access to that risk pathway is expanding: 25 states and Washington, D.C.already mandate some form of fertility coverage, with a few states, including California and Virginia, adding or broadening mandates around 2027–2028. For employers with a fertility-heavy or high-risk-skewing population, that's a compounding effect, not two separate line items.

That's a significant gap, because most maternal morbidity and mortality actually occurs after delivery, not during pregnancy or birth itself.

The bottom line: Providers now have a direct financial incentive to see patients more than once postpartum.

Once postpartum visits are billed individually rather than folded into one flat fee, providers have a direct financial incentive to see patients more than once during the postpartum period — including for postpartum depression screening. A managed benefit can proactively schedule and coordinate additional postpartum touchpoints; a reimbursement-only model will just pass along more, smaller bills for the same visit pattern as before.

• Fully insured: the cost still shows up over time through premiums. Carriers routinely build expected cost trends into renewals based on projected utilization, not just historical claims, so the first renewal after January 1, 2027 likely won't be a quiet one — pricing is likely to sharpen further in year two and beyond.
• ASO: your ASO carrier's claims processing fees may increase given higher claims volume per pregnancy, and if you carry stop-loss coverage, those premiums could also reprice based on anticipated claims volatility.

The bottom line: Ask your ASO carrier both how administrative fees might change and how stop-loss pricing factors this in.

It's also worth modeling what your last one to two years of maternity claims would look like under the new itemized structure, since that can reveal where your specific exposure sits before it shows up as a surprise.

The bottom line: Employers using Maven have seen up to $9,600 in savings per birth, up to 27% lower NICU admission rates, and up to 15% lower C-section rates.

Review whether your current maternity benefit actively works to reduce complications and high-cost events, like NICU admissions and C-sections, rather than simply administering and paying for them after the fact. NICU stays in particular often run well into six figures for extended stays, so avoiding even a portion of them has an outsized effect on total spend.

A managed benefit takes an active role in identifying risk early and coordinating care to help prevent avoidable complications. That distinction matters more under unbundling, because a reimbursement model will simply show you more, smaller bills for the same underlying utilization pattern. A managed model, by contrast, is built to reduce the clinical events — preterm birth, NICU admission, C-section — that generate the largest new claim lines under the itemized system.

The bottom line: A managed model is built to reduce the clinical events that generate the largest new claim lines.

Ask whether those outcomes are backed by independent, claims-based analyses or peer-reviewed research rather than self-reported figures. It's also worth asking what percentage of members conceive without IVF or IUI, since that's a direct signal of whether a vendor is actively managing the fertility-to-maternity pathway or simply processing claims within it — and whether the vendor's model spans preconception through postpartum or covers only a single stage of the journey.

The bottom line: Ask whether outcomes are backed by independent, claims-based analyses — not self-reported figures.

• How are your claims adjudication systems being updated for the new CPT codes, and when will that work be complete relative to the January 1, 2027 effective date?
• What guidance have you received from CMS or the AMA on modifier use and code mapping, since implementation details are still being finalized?
• Can you provide claims-level reporting broken out by the new codes so we can track our own population's utilization pattern as the transition unfolds?
• Might we see a split model — where some payers use the new itemized codes while others, including Medicare and possibly Medicaid, stick with a global-code-like structure, at least for a while?

The bottom line: There's no longer a built-in cost ceiling the way a bundled fee provides one.

Employers using a clinically managed maternity benefit like Maven can manage fertility and maternity as one connected journey rather than two separate benefits. It's positioned to address claim categories, like IVF-related pregnancies, that tend to generate the most detailed itemized bills under the new codes.

The bottom line: Employers using Maven have seen up to $9,600 in savings per birth, up to 27% lower NICU admission rates, and up to 15% lower C-section rates.

Employers using Maven have seen up to $9,600 in savings per birth, up to 27% lower NICU admission rates, and up to 15% lower C-section rates, validated across 25,000+ pregnancies in independent, claims-based analyses. See how Maven can support your population and reach out to us today.

CMS released its proposed rule in July 2026, public comments are open through September 14, 2026, and CMS is expected to issue its final rule — including final payment values and a decision on the G-code question — around November 2026.

The bottom line: A tight six-to-eight week window sits between the final rule and the January 1 effective date.

That gives roughly six to eight weeks between the final rule and the January 1 effective date for payers, TPAs, and clinics to implement it — a tight window, which is part of why it's worth confirming readiness with your health plan and TPA now.