Do all health insurance plans cover maternity?
- Louise Norris
- Individual health insurance and health reform authority; broker
- November 17, 2017
Q: Now that the ACA has been implemented, do all health insurance plans cover maternity?
A: Nearly all plan cover maternity. Since January 2014, the ACA has required all newly issued and renewing individual and small group health insurance policies to provide maternity coverage.
Large-group plans have long been required to include maternity coverage, thanks to the Pregnancy Discrimination Act of 1978, which applies to employers with 15 or more employees. In addition, 18 states had passed laws over the years that required smaller groups and/or individual policies to cover maternity benefits.
Some states had tighter requirements even before the ACA, but the ACA closed the remaining gaps. The ACA requires large employers (50 or more employees) to offer coverage to their full-time employees, and the longstanding Pregnancy Discrimination Act ensures that maternity care is part of the coverage. The ACA also requires all individual and small group plans to include maternity care as one of the law’s essential health benefits. Small employers (up to 49 employees) are not required to offer coverage, but if they do, it has to include maternity care.
And anyone who doesn’t have access to coverage from an employer can purchase an individual market plan instead, with coverage for maternity care included in all plans in every state. Maternity coverage must be covered on all non-grandfathered/grandmothered individual and small group plans issued or renewed after January 1, 2014. So all of the policies being sold in the exchanges — and off-exchange — include maternity coverage. The ACA also prohibits gender-based premium determination, so women cannot be charged more for their policies than men.
Prior to 2014, the majority of individual health insurance policies did not cover maternity as a standard benefit. In some states, it was available as an optional rider, but the cost was often prohibitively high, since the coverage was usually only purchased by people who were planning to use it, and was priced accordingly.
The ACA also prohibits health plans from turning away applicants because of preexisting conditions, including pregnancy. Prior to 2014, pregnant women (and expectant fathers) in most states could not obtain coverage in the individual market, even if the plan didn’t include any maternity benefits.
Exceptions: There are still plans that don’t cover maternity
There are a few exceptions to keep in mind — some plans still don’t cover maternity care. If you’ve retained your grandmothered individual policy (possible until the end of 2018 in many states) or if you’re staying on a grandfathered plan, your plan may not include maternity care.
In addition, large group plans are not required to provide maternity coverage for dependent children, which has become more significant now that adult children can remain on their parents’ plans through age 26. The National Women’s Law Center filed a discrimination complaint about this in June 2013. In May 2015, HHS announced that plans must cover preventive care — including prenatal care — for dependents, but there is still no requirement that dependents be covered for labor and delivery costs.
And coverage that’s not regulated by the ACA (ie, “excepted benefits“) does not have to conform to any of the new rules. So if you purchase a short-term insurance policy, a fixed indemnity plan, or other supplemental coverage, it’s not likely to provide any maternity benefits. Healthcare sharing ministries are also not regulated by the ACA (or state insurance departments, as they’re not technically considered insurance), so there’s no requirement that they provide maternity benefits.
If you’re buying a plan that’s not regulated with the ACA, there’s a good chance that it won’t cover maternity, and it’s also likely that your application will be rejected if you’re already pregnant when you apply for coverage (note that individual major medical plans that are grandfathered or grandmothered can no longer be sold to new applicants, but excepted benefits can still be sold to new applicants, and can reject applicants based on medical history). Pay attention to the fine print, and know that there are plans available in every state that do cover maternity care, although enrollment is limited to open enrollment periods and special enrollment periods, just the way it is for employer-sponsored plans.
Maternity Insurance for Pregnant Women
Home / Planning and Preparing / Maternity Insurance for Pregnant Women
You may feel confused with all the changes in the healthcare system and wonder how to get pregnancy insurance. The good news is that pregnancy insurance is much more accessible now. Previously, only a handful of insurance plans offered maternity and childbirth benefits.
However, now all qualified health plans under the Affordable Care Act offer this coverage. For information on finding a health insurance plan through the Marketplace, visit www.healthcare.gov.
If you already have an insurance plan that you purchased yourself, you will want to determine if the plan is grandfathered. Grandfathered plans are insurance plans that were in place on March 23, 2010, and have not been significantly changed.
Not all grandfathered plans are required to offer maternity and childbirth benefits, so if you have a grandfathered plan, make sure to contact your insurance company to find out your benefits.
If you do not have insurance through the Marketplace or an employer, you may consider applying for Medicaid or CHIP (Children’s Health Insurance Program). These programs offer maternity and childbirth benefits. Income qualifications vary by state.
Click here for more information on Medicaid and to see if you qualify.
Health Care Discount Programs for Maternity Coverage
There are alternatives to traditional health insurance and Medicaid, such as finding ways to negotiate discounts on your health care. Be sure to contact your healthcare provider to find out how much of a discount you would receive if you paid cash for their services. In deciding your course of action, consider any monthly fees, deductibles, and premiums that may be involved.
One discount service is AmeriPlan. This discount plan is currently available in every state except Alaska, Montana, North Dakota, South Dakota, Vermont, and Wyoming. AmeriPlan can reduce the cost of healthcare services by up to 50% or even more in some cases.
Benefits include physician, hospital, and ancillary services (i.e., lab work, tests, x-rays). Because AmeriPlan is not an insurance plan, all pre-existing conditions are covered (except orthodontic treatment in progress). There are no deductibles, no waiting periods, no claim forms, and no annual limits. For more information, you can go to AmeriPlanUSA or call them toll-free at (800) 647-8421.
Options for Managing costs with no maternity insurance
Some additional ways to help you manage costs related to prenatal care and labor include:
- If you are delivering at a hospital, you can contact their accounting office to see if you can set up a payment plan or to find out if they offer a sliding scale. Though many hospitals offer these options, they are often overlooked by those who would benefit from knowing about them.
- If you do not have a high-risk pregnancy, consider giving birth at a birthing center. The estimated cost of delivery and prenatal care at a birthing center is about $3,000 – $4,000, which is half of what it would cost at a hospital. Many birthing centers also provide sliding scales, payment plans, and are willing to accept Medicaid.
- If you are a single parent, you can go to Single Parenting: Making It Work and Doing It Alone for additional ways to save money.
Remember to try to enjoy your pregnancy without allowing financial concerns to rob you of your excitement.
Last updated: December 12, 2017 at 9:34 am
Compiled using information from the following sources:
Why get pregnancy Insurance?
Pregnancy insurance is one of the best ways to minimize the expenses that will come with your prenatal care and the hospital stay when you give birth. If you don’t have maternity insurance, you can anticipate spending around $10,000-$12,000. In 2011, the average cost of labor and vaginal delivery in a hospital was $10,657. This can increase by 50% or more if you have a scheduled or emergency C-section. The cost for either can increase dramatically if there are any complications.
Having bills pile up is stressful, which is not good for you or your baby. Thus, it is important to take care of your health and prepare for the baby without adding to financial pressures. Getting maternity insurance is one way to alleviate stress.
Money which originally would have been spent on prenatal care and birth expenses can now be directed towards the other needs you and your baby have.
How to Get Maternity Insurance?
Under the Affordable Care Act, there have been many changes regarding health insurance, including pregnancy insurance. All qualified health plans (both within and outside of the Marketplace) are now required to provide maternity care and childbirth health benefits.
Prior to the Affordable Care Act, only a handful of insurance plans automatically provided maternity coverage. For some plans, such coverage had to be requested as an addition. Also, if a woman tried to apply for maternity coverage after she became pregnant, coverage was oftentimes either unavailable or more expensive.
Fortunately, now pregnancy coverage is much more accessible. If you do not have medical coverage through an employer, Medicaid, or CHIP (Children’s Health Insurance Program), you can find an insurance plan through the Marketplace. For more information on getting health coverage through the Marketplace, visit www.healthcare.gov.
If you already have health insurance, it is important to know if your plan is grandfathered or not. Grandfathered insurance plans are those that were in place on March 23, 2010, and have not been significantly altered to affect consumer benefits or the cost of insurance to consumers.
Individual grandfathered plans that you purchase yourself (not job-based grandfathered plans) are not obligated to provide maternity and childbirth benefits. If your plan is grandfathered, contact your insurance company to determine what coverage you have.
If you do not have coverage through the Marketplace or an employer, another option would be to apply for Medicaid and/or CHIP to cover maternity and childbirth health benefits. Eligibility is based on income requirements, which vary by state and are different for Medicaid and CHIP.
Also, several states have broadened their income requirements. As such, even if you did not qualify previously, you may now be eligible. You can also apply for these programs at any point during the year.
Whether or not you get pregnancy insurance, you may also want to consider lower-cost options such as using a midwife or giving birth at a birth center. This can significantly reduce labor and delivery costs. Birth centers oftentimes offer payment plans, sliding scales, and accept Medicaid. Another option would be to look into a healthcare discount program for pregnancy coverage.
Last updated: December 12, 2017 at 11:50 am
Compiled using information from the following sources:
How Obamacare changed maternity coverage
Prior to 2014, most individual plans excluded maternity coverage. Today, all new policies include maternity benefits.
- Louise Norris
- Individual health insurance and health reform authority; broker
- August 16, 2016
Prior to 2014, women who purchased their own health insurance were often completely out of luck if they wanted to have coverage for maternity . In 2013, the National Women’s Law Center reported that just 12 percent of individual market plans included maternity benefits. And that was despite the fact that nine states required maternity benefits to be included on all individual plans.
In the rest of the states, maternity coverage in the individual market was extremely rare, and if it did exist, it was generally in the form of an expensive rider that could be added to a plan, usually with a waiting period. Yet even on plans that excluded maternity coverage, women were charged premiums that were at least 30 percent higher than those charged to men for the same coverage.
Before Obamacare made coverage guaranteed issue, pregnancy itself was also considered a pre-existing condition that would prevent an expectant parent — male or female — from obtaining coverage in all but five states. And many individual health insurance carriers considered a previous cesarean section to be a reason to decline an application or charge a higher initial premium. (in Maine, Massachusetts, New Jersey, New York, and Vermont, state regulations prevented carriers from using medical underwriting to determine eligibility for coverage, long before this became the norm under the ACA).
Obamacare changes everything
The ACA has been a game-changer for individual health insurance, and maternity coverage is one of the areas where the changes are most pronounced. Maternity care is one of the ten essential health benefits that must be included on all new individual and small group policies. An expectant parent can now obtain coverage in every state during open enrollment or during a special enrollment period triggered by a qualifying event. And women are no longer charged higher premiums than men, despite the fact that every new policy – both in and out of the exchanges – includes maternity coverage.
Even before the ACA, maternity coverage was available on most group plans, thanks to the 1978 Pregnancy Discrimination Act. The Act mandates that if an employer with 15 of more employees opts to provide health insurance, the coverage must include maternity benefits. And in nearly 40 percent of the states, there were regulations that required small group plans to include maternity benefits, even if the employer had fewer than 15 employees.
But the ACA has filled in the gaps; in every state, new small-group plans must include maternity benefits. (Small employers with fewer than 50 employees are not required to offer coverage at all under the ACA, but if they do, it must include maternity benefits.)
Taken by surprise
Before the ACA reformed the individual insurance landscape, some people with individual health insurance weren’t aware that their plans didn’t cover maternity – until they became pregnant. And there were often misconceptions about the ability to purchase additional coverage, with some insureds believing that as long as they maintained continuous coverage, they would be able to purchase coverage that included maternity if and when they needed it. But that was not the case
According to WebMD, in 2012, the average cost of an uncomplicated hospital delivery was over $10,000, and climbed to almost $18,000 for an uncomplicated cesarean delivery – plus the cost of pre-natal care. That meant that parents with individual health insurance often went home from the hospital with a significant bill in addition to their new bundle of joy.
There are still individual and small-group plans that don’t include maternity care, because grandmothered and grandfathered plans are still in existence. All grandmothered plans will end by December 31, 2017 (and were never allowed at all in some states). And the number of grandfathered plans is steadily declining, since those are plans that were in force as of March 2010 and have remained largely unchanged ever since. But maternity coverage is included in all individual and small-group plans with original effective dates of January 1, 2014 or later.
It’s true that some new plans have relatively high out-of-pocket costs, but even the lowest-cost Bronze plans have a maximum individual out-of-pocket limit of $6,850 in 2015 ($7,150 in 2017). And som e prenatal care, including gestational diabetes testing, is specifically included in the preventive care that’s covered with no out-of-pocket cost under the ACA.
Preventive care is covered with no cost-sharing on plans that were sold or renewed after September 23, 2010, and additional woman-specific preventive care was added to plans that were sold or renewed after August 1, 2012. So at this point, all grandmothered plans include free preventive care, as well as all new plans that are fully ACA-compliant.
But you still have to plan ahead
In order to have maternity coverage, you must have an in-force health insurance policy that’s ACA-compliant (or one that pre-dates 2014 and happens to have maternity coverage included – but those are rare). And while medical underwriting is no longer used to determine eligibility for coverage – which means that being pregnant won’t cause an application to be declined – there’s only a short window each year during which you can enroll in a health plan. For 2017 coverage, it starts November 1, 2016 and runs until January 31, 2017.
In New York, a law took effect in 2016 making pregnancy a qualifying event that triggers a special enrollment period (special enrollment periods allow people to obtain coverage outside the normal enrollment period). So women in New York who become pregnant outside of open enrollment have the opportunity to enroll in coverage for the first time or to switch plans, with an effective date of the first of the month in which the pregnancy is confirmed by a health care provider.
Advocates have been pushing to make pregnancy a qualifying event in every state. And HHS has considered it, but clarified in early 2015 that they had decided against making pregnancy a qualifying event. They could still change their mind in the future, and it’s certainly possible that some of the state-run exchanges could implement a special enrollment period for pregnant women in future years.
But for now, it’s important to keep in mind that while all ACA-compliant plans cover maternity, you cannot go uninsured and simply plan to enroll in a policy if and when you get pregnant. And if you have a grandmothered or grandfathered plan that doesn’t include maternity coverage, you cannot switch to a plan with maternity if you get pregnant – you’d have to wait until the next open enrollment, which only comes around once a year, unless you experience a qualifying event.
Insurance When You’re Pregnant: FAQ
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The Affordable Care Act makes it easier for pregnant women to get insurance to help pay for the medical care they need.
Can a health plan refuse to let me enroll because I’m pregnant?
No. In the past, insurance companies could turn you down if you applied for coverage while you were pregnant. At that time, many health plans considered pregnancy a pre-existing condition.
Health plans can no longer deny you coverage if you are pregnant. That’s true whether you get insurance through your employer or buy it on your own.
What’s more, health plans cannot charge you more to have a policy because you are pregnant. An insurance company can’t increase your premium based on your sex or health condition. A premium is the amount you pay each month to have insurance.
How can I get health insurance while I’m pregnant?
First, see if your employer — or your partner’s employer — offers health insurance. You will probably get the most coverage at the best price from a health plan offered by an employer. That’s partly because most employers share the cost of insurance premiums with employees.
You can also shop for coverage in the health insurance Marketplace, which is also called an exchange. You may also qualify for Medicaid in your state if your income is low.
In the marketplace, you can:
- Compare health plans side by side
- See if your income is in the range to qualify you for financial help from the government, which will lower the cost of your insurance premiums; you may also qualify for lower out-of-pocket costs, such as deductibles, copays, and coinsurance.
You must enroll in a health plan during the open enrollment period, set by either the employer for employer coverage or the federal government for Marketplace coverage. You may qualify for a special open enrollment period if you have a “life event” such as losing other health coverage or moving to a new state. Unfortunately, pregnancy is not one of the life events which qualify you for a special open enrollment period. However, having a baby (or adopting a child) is. So once you give birth, you can shop for insurance and enroll in a plan even if you missed the open enrollment period. If your income qualifies you for Medicaid, you can enroll at any time during the year.
You can also shop for coverage outside the government-run Marketplaces, but you must buy a Marketplace plan in order to qualify for financial help to lower the cost of premiums or out-of-pocket costs.
Will I get the same coverage no matter which state I live in or which plan I choose?
Not necessarily. The law requires most private health plans to help pay for a basic set of 10 essential health benefits, including maternity and newborn care. But the details of what each plan will cover depends on two things:
- Where you live. Your health plan choices will vary from one state to another, and even within the same state in different zip codes.
- Which health plan you choose. Although all plans must cover the 10 essential health benefits, the details of how services are covered can vary; for example, all plans must help pay for prescription drugs, but one plan may cover the brand of medication you use while another does not.
Make sure you carefully review your health plan’s summary of benefits, especially to see the specific set of prenatal and maternity services it covers.
What prenatal care can I expect to be covered by my health plan during my pregnancy?
All health plans must cover certain preventive care with no out-of-pocket cost to you at the time of the visit. The exception is grandfathered health plans — those that were in existence before March 23, 2010, and that haven’t made significant changes to their benefits and costs. They do not have to comply with this part of the law. Contact your insurance company or your employer to find out whether your plan is grandfathered.
These services are listed roughly in the order you would need them over the course of your pregnancy.
- Testing and counseling for sexually transmitted diseases, including HIV
- Testing for a blood condition known as Rh incompatibility
- Folic acid supplements, which help protect your baby from certain birth defects (with a prescription)
- A wide range of prenatal tests, including anemia screening and screening for urinary tract infections
- Testing for gestational diabetes
- Screening and help to quit tobacco use
- Labor and delivery costs, including your hospital stay
- Breastfeeding counseling and equipment
- Birth control after you’ve had your baby
What’s covered for maternity care can vary from plan to plan. That’s true if you get insurance through your work or buy it yourself. So for any plan you are considering, review the details of the plan’s summary of benefits or call the insurance company for more information.
What delivery costs and after-delivery costs will be covered by health insurance?
Most health plans will cover much of the costs of delivery and aftercare, but, as with any other stay in a hospital or other health care facility, you may need to pay part of the bill. Your costs may include having to meet your health plan’s deductible as well as copays or coinsurance or, in some cases, both copays and coinsurance.
Your deductible is the money you have to spend before your insurance helps pay for your care.
Copays are a flat fee you pay when you see a doctor, such as $20 per visit.
With coinsurance, you pay a percentage of the cost of your medical care.
You can find out what services are covered by your plan and what your costs are likely to be by looking at your health plan’s summary of benefits or by calling your insurance company.
Here are some things you might want to look for to confirm whether your plan covers these services, and if so, how much of the bill you’ll be expected to pay:
- Labor and delivery services in the setting you choose, such as a birthing center, home, or hospital
- Alternative birthing options, like water birth
- Midwife services
- Enhanced coverage for high-risk pregnancy or pregnancy complications
- Delivery/C-section costs after infertility treatment
- Medically prescribed C-section, including recovery
- Neonatal care
Am I eligible for Medicaid while I’m pregnant?
All states offer Medicaid coverage to pregnant women whose income makes them eligible. The amount of money you can earn and still qualify varies by state.
States have the option to extend Medicaid coverage to pregnant women with incomes up to or over 185% of the federal poverty level (and most states have done so). In 2016, that’s roughly $21,978 for an individual. Coverage continues through pregnancy, labor, delivery, and the first 60 days after birth.
Some states may cover your maternity care under the Children’s Health Insurance Program.
After your Medicaid pregnancy coverage ends, you may still have other insurance options through your state or a private company.
The Affordable Care Act gives states new opportunities to expand their Medicaid programs to cover individuals who earn up to 138% of the federal poverty level ($16,394 per year for an individual in 2016). Not all states have done this. If your state has expanded the program and you meet the income and other eligibility criteria (for example, you are a resident of the state in which you are applying), you will still be covered under Medicaid.
If you no longer qualify for Medicaid after you give birth, you may be eligible for government assistance to buy a health plan through your state’s marketplace. Even if the open enrollment period – the time during which anyone can buy a health plan – is closed, there is a special enrollment period for people who qualify. If your Medicaid coverage ends, you will qualify for this enrollment period.
What questions should I ask before choosing a health plan to cover my pregnancy?
Ask how much your deductible will be. In general, your deductible goes down as your monthly premium payments go up. Also, take the time to understand other out-of-pocket costs that come with your plan, such as copays and coinsurance.
Ask which providers are in your plan’s network. You’ll want to know which obstetricians, hospitals, and pediatricians participate in the plan. Your plan will likely only cover preventive services in full and at no cost to you if you receive your care from in-network providers.
Review the plan’s full summary of benefits and look it over closely. Pay close attention to any specific services you want or need to make sure they are covered by your health plan.
Once your baby is born, you qualify for a special enrollment period through the Marketplace during which you can add your baby onto your policy.
What happens after my baby is born?
You need to get in touch with your employer, insurance company, or state Marketplace to add a child to your health plan shortly after you give birth. Many employers require you to add your baby to your policy within 30 days. Having a baby qualifies you for a special open enrollment period in your state’s marketplace and allows you 60 days to choose a plan for your baby or make changes to your existing plan. Depending on your income, your child may qualify for Medicaid or CHIP even if you have a policy through your employer or state Marketplace.
The American Congress of Obstetricians and Gynecologists: “Committee Opinion: Benefits to Women of Medicaid Expansion Through the Affordable Care Act,” January 2013.