Surrogacy and Health Insurance
A Practical Guide for Intended Parents and Gestational Carriers

A gestational carrier may already have health insurance, but that does not mean the policy can automatically be used for a surrogacy pregnancy.

Some policies cover ordinary maternity care but exclude surrogacy. Others are silent or unclear. Some contain lien, reimbursement, or subrogation language that could create financial exposure for the intended parents. Employer plans can change during the journey, and some policies may initially pay claims and later reverse or deny them.

For that reason, health insurance should be reviewed before contracts are signed and before medications begin. Understanding the insurance situation while considering a match with a surrogate candidate is wise, particularly when cost concerns are at issue. Depending on the situation, insurance plans can cost upwards of $32,000.

The review aims to answer practical questions: Does the surrogate have current health insurance? Does the policy cover maternity care? Does it exclude surrogacy? Is it fully insured, self-funded, ACA, Medicaid, military, private, short-term, or employer-sponsored? Are there lien or reimbursement provisions? What are the deductible and out-of-pocket maximum? Is separate maternity coverage needed? Is backup or contingent coverage recommended? Does the transfer timing create a coverage gap?

The first question is whether the gestational carrier already has health insurance.

If she does, the policy should be reviewed by someone experienced in surrogacy insurance. It is not enough to look at the insurance card or confirm that the policy includes maternity benefits. The actual policy language matters.

A review should look for: surrogacy exclusions; maternity exclusions; pre-existing condition language; lien or reimbursement provisions; subrogation provisions; coordination of benefits issues; whether the plan is fully insured or self-funded; whether the policy is employer-sponsored, ACA, Medicaid, military, private, or short-term; and whether claims could be denied or reversed after pregnancy begins.

Many major medical policies are required to cover pregnancy-related care, but that does not end the analysis in surrogacy.

Some — often very few — Affordable Care Act Marketplace plans cover pregnancy and childbirth. Open Enrollment for Marketplace coverage typically runs from November 1 through January 15, with January 1 coverage available when enrollment is completed by the applicable December deadline and the first premium is paid. Some state marketplaces use different or extended deadlines, so the gestational carrier's state must be checked.

A legal requirement to cover pregnancy does not always mean a policy will safely cover a surrogacy pregnancy. A policy may cover pregnancy generally but exclude surrogacy. A self-funded employer plan may not be subject to state insurance mandates. A policy may contain lien or reimbursement language. A plan may pay claims initially and later deny or reprocess them. The newborn's coverage is separate from the surrogate's maternity coverage. Short-term/catastrophic policies do not have the same protections as ACA-compliant major medical plans.

After the review, the surrogate's health insurance usually falls into one of several categories.

The policy appears usable. This is the best-case scenario. The policy does not appear to exclude surrogacy, and maternity claims may be submitted through the gestational carrier's existing plan. Even then, intended parents should expect to pay deductibles, copays, coinsurance, out-of-pocket maximums, and any uncovered expenses related to the pregnancy.

The policy has a surrogacy exclusion. If the policy excludes surrogacy, intended parents generally should not rely on it for the surrogate pregnancy. The insurance strategy should move to one of the other specific options addressed in this guide: an ACA policy (during Open Enrollment or with a Special Enrollment Period); Short Term Insurance as a bridge to ACA (when transfer timing allows); IVF Recipient Complications Insurance; a surrogacy-specific maternity policy, including a Lloyd's of London-underwritten policy; or backup or contingent maternity insurance.

The policy is unclear or ambiguous. This is common. The policy may not clearly say whether surrogacy is covered or excluded. Intended parents need to decide whether the risk is acceptable or whether backup coverage or another policy should be considered.

The surrogate has no usable insurance. Intended parents may need to explore ACA coverage, a surrogacy-specific maternity policy, Short Term Insurance as a bridge to ACA, IVF Recipient Complications Insurance, or other options depending on the timing and risk profile of the journey.

ACA policies can be useful in surrogacy, but timing is critical.

For most states using the federal Marketplace, Open Enrollment runs from November 1 through January 15. Enrollment by the applicable December deadline generally allows coverage to begin January 1, while enrollment by January 15 generally allows coverage to begin February 1. State-based marketplaces may have different deadlines.

Intended parents usually cannot simply purchase an ACA policy for the gestational carrier at any time of year. If the surrogate's current insurance cannot be used and Open Enrollment has passed, the parties must determine whether she qualifies for a Special Enrollment Period or whether another insurance strategy is needed.

A Special Enrollment Period allows someone to enroll in or change Marketplace coverage outside the yearly Open Enrollment Period because of certain qualifying life events.

Qualifying life events may include losing health coverage, getting married, having a baby, adopting a child, moving, or other significant household or residence changes. Depending on the type of Special Enrollment Period, the person usually has a limited window to enroll, and documentation may be required before coverage can begin.

For surrogacy, the key point is this: becoming a gestational carrier, preparing for embryo transfer, or needing maternity coverage does not automatically create a Special Enrollment Period. There is also a deadline of 60 days from the time of the qualifying event to enroll in an ACA policy.

Insurance planning is calendar-driven.

A January or February transfer may be easier to coordinate with ACA coverage because the policy can already be active at the beginning of the year. A late-summer or fall transfer can create a more complicated situation.

For example, if the gestational carrier starts medications in August or September, but the intended strategy is ACA coverage effective January 1, there may be a gap between the transfer cycle and the ACA effective date. The gestational carrier may already be receiving medications, undergoing transfer, becoming pregnant, and beginning prenatal care before ACA coverage begins.

Donor/recipient complication insurance addresses a different risk than maternity insurance.

In a surrogacy journey, the “recipient” refers to the person receiving medications and undergoing embryo transfer — the gestational carrier. This type of insurance may cover certain complications related to the IVF process, including the medication and transfer period.

IVF Recipient Complications Insurance covers complications due to IVF from the medication start date until heartbeat confirmation of pregnancy. Depending on timing, this may make more sense than Short Term Insurance, because Short Term Insurance covers complications after confirmed pregnancy and does not cover IVF-related complications.

The distinction matters: IVF Recipient Complications Insurance may cover IVF-related complications before heartbeat confirmation. Short Term Insurance may cover catastrophic pregnancy-related complications after pregnancy is confirmed. ACA coverage may be the preferred policy for routine prenatal care and delivery once effective.

Short Term Insurance may sometimes be used as temporary bridge coverage before an ACA policy becomes effective. It should not be confused with full maternity coverage.

Short Term Insurance is a temporary policy until ACA Open Enrollment, with availability and duration depending on the gestational carrier's state and ZIP code. It must be applied for before medications begin, or pregnancy could be listed as an exclusion. Short Term Insurance will only cover catastrophic events and does not cover routine maternity care or pre-existing conditions. It is not used for delivery.

Short-term insurance rules changed in 2024. Federal rules amended the definition of short-term limited-duration insurance to limit the initial contract term to no more than three months, with a maximum coverage period of no more than four months, including renewals or extensions.

This change matters in surrogacy. Although the federal rule may allow a fourth month through renewal, renewal may not be available once the gestational carrier has started medications or is pregnant. Short-term insurance strategy should therefore plan for a maximum three-month coverage period, treating the policy as practically providing about three months of usable coverage.

If the goal is ACA coverage effective January 1, the medication start date becomes a key insurance planning date.

If the medication start date is in October and Short Term Insurance is placed in October, there may be no gap before the ACA effective date. But if medications start before October, the Short Term Insurance would need to begin earlier and may expire before ACA coverage begins.

This is not a universal rule because state availability, carrier rules, and policy terms can change. But it is a useful planning concept.

Short Term Insurance does not generally cover routine prenatal care.

If the gestational carrier becomes pregnant before the ACA policy becomes effective, intended parents may need to pay routine OB/GYN visits directly until ACA coverage begins.

Cash-pay OB/GYN visits and premiums could range roughly from $1,000 to $8,000, depending on how long the policy needs to remain active and the type of care received.

Short Term Insurance is not available in every state.

At this time, Short Term Insurance coverage is not available for California, Colorado, Connecticut, D.C., Massachusetts, Maine, New Jersey, New Mexico, New York, Rhode Island, or Vermont.

Because state rules and carrier availability can change, no state list should be treated as permanent. Availability should be confirmed during the matching phase of the surrogacy arrangement.

When the surrogate's existing insurance cannot be used, and ACA coverage is unavailable or not suitable, intended parents may need to consider a surrogacy-specific maternity policy.

These policies are designed for surrogacy maternity risk and may be available through specialized ART insurance brokers. Some policies in this category are underwritten through Lloyd's of London programs or other specialized markets.

This option may be considered when the surrogate has no health insurance; her policy excludes surrogacy; her policy language is too risky or unclear; ACA coverage cannot be obtained in time; Short Term Insurance is unavailable or insufficient; or the intended parents want a policy designed specifically for surrogacy maternity care.

These policies can be very expensive (approximately $32,000). They may also include deductibles, self-funded retentions, network requirements, coinsurance, exclusions, or policy limits.

Backup or contingent insurance is different from primary maternity insurance.

It may be used when the gestational carrier has a primary health insurance policy that appears usable, but intended parents want additional protection in case the primary insurer later denies maternity claims.

This can happen even when a policy initially appears surrogacy-friendly. A carrier may later deny claims, reverse claims, assert a reimbursement right, or take the position that the pregnancy was not covered.

This product should not be confused with bridge coverage: backup or contingent coverage addresses the risk that a primary policy denies claims; Short Term Insurance addresses a temporary gap before ACA begins; IVF Recipient Complication Insurance addresses IVF-related complications during medications and transfer; and surrogacy-specific maternity insurance may serve as the primary maternity policy when other coverage is unavailable.

Each option in a surrogacy insurance plan solves a different problem. The table below summarizes what each option may help with and what it does not solve.

Has the surrogate's actual policy been reviewed? Does the policy contain a surrogacy exclusion? Is the policy fully insured or self-funded? Are there lien, reimbursement, or subrogation provisions? What are the deductible and out-of-pocket maximum?

Can ACA coverage be obtained? Is the surrogate inside Open Enrollment or eligible for a Special Enrollment Period? When would ACA coverage begin? When will medications start? When is embryo transfer expected? Will there be a gap before ACA coverage begins?

Is IVF Recipient Complications Insurance recommended? Is Short Term Insurance available in the surrogate's state? Would Short Term Insurance last until ACA begins? Will routine prenatal care need to be paid in cash before ACA begins? Is a surrogacy-specific maternity policy necessary? Should backup or contingent coverage be considered? Who will monitor premiums and claims? What happens if claims are denied or reversed?

A gestational carrier should understand whether her existing policy will be used; whether her policy has been reviewed; whether intended parents will pay all pregnancy-related medical expenses; whether she will need to apply for ACA or another policy; whether premiums will be paid by intended parents; whether she should send all bills and insurance notices to the agency or broker; whether routine care before ACA begins will be handled as cash pay; who to contact if she receives a bill; and whether any coverage could affect her benefits, subsidies, or household coverage.

The insurance strategy should be reviewed before the match is finalized, the legal agreement is signed, the surrogate starts medications, embryo transfer is scheduled, ACA Open Enrollment deadlines pass, or any temporary or short-term policy deadline passes.

The contract should identify who is responsible for premiums, deductibles, copays, coinsurance, uncovered medical bills, cash-pay prenatal care, additional policies, and expenses caused by claim denials.

Health insurance in surrogacy is not one-size-fits-all.

A surrogate's existing policy may be usable, but it must be reviewed. ACA coverage may be a strong option, but it depends on enrollment timing. Special Enrollment Periods are limited and require qualifying life events. Late-year transfers may require bridge planning. IVF Recipient Complications Insurance may be needed for the medication and transfer period. Short Term Insurance may provide limited protection for catastrophic pregnancy-related complications before ACA begins, but it does not cover routine prenatal care or delivery. Surrogacy-specific maternity policies may be available, but they can be expensive. Backup insurance may be useful if the primary policy appears usable but still carries denial risk.

The best time to address these issues is before contracts are signed and before medications begin.