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- Pregnancy, maternity care, and childbirth are considered essential health benefits under the Affordable Care Act and all qualifying health plans are required to cover your pregnancy
- Only grandfathered insurance plans are not subject to the Affordable Care regulations and do not have to cover pregnancy
- If your grandfathered plan is ending or you just had your child, you may be eligible for a special enrollment period and can enroll in a marketplace plan that will cover maternity care
- Other private plans and employer-based plans should still cover pregnancy
- If you cannot afford another plan, you should consider applying for Medicaid or the Children’s Health Insurance Program
What are the essential health benefits under the Affordable Care Act and is pregnancy included?
Under the Affordable Care Act, all marketplace insurance plans, small group plans, plans not sold on the marketplace, such as employer-based coverage, and most Medicaid and Medicare options must cover services from each of the 10 essential health benefits categories.
One of these categories is maternity and newborn care. This means that your insurance plan must cover you for labor, delivery, and the time period immediately following the delivery for both you and your baby.
Other essential health benefits include hospitalization, mental health services, prescription drugs, rehab and lab services, preventive care including wellness visits and chronic disease management, and pediatric services.
Insurance plans must cover services within these categories but the exact benefits will differ from plan to plan.
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What is a grandfathered health insurance plan?
One reason that your health insurance plan might not be covering your pregnancy is because it is a grandfathered health plan. These plans already existed before March 23, 2010, and have not significantly cut their benefits or increased their costs since then. They do not necessarily have to comply with the Affordable Care Act regulations.
Grandfathered plans are not sold on the Marketplace. You would have already had to purchase one through a private insurance company.
Grandfathered plans are still required to cover dependents up until the age of 26, have restrictions on lifetime monetary limits, and spend the majority of the premium you pay for your healthcare needs not business costs.
However, grandfathered healthcare plans are not required to cover preventive care free of cost or allow you to appeal a decision about your healthcare.
Individual grandfathered plans can deny you coverage if you have a pre-existing condition. In some cases, pregnancy can count as a pre-existing condition.
If you have a grandfathered plan and wish to get a new one, you can apply for marketplace coverage during the open enrollment period between November and January. If your grandfathered plan ends before the open enrollment period starts, you may be eligible for a special enrollment period.
Can I change my insurance plan with a special enrollment period?
When you lose your health insurance coverage, such as when your grandfathered plan ends, you should be eligible to purchase a marketplace plan that covers pregnancy with a special enrollment period.
If you lost your coverage in the past 60 days or you expect to lose it in the next 60 days, you should apply for a special enrollment period. However, you will not be eligible for a special enrollment period if you chose to cancel your plan on your own.
When you have your baby, you can qualify for a special enrollment period to enroll in a plan that covers your child or add them to your existing plan. You will have up to 60 days after the day of birth to apply for a plan through your special enrollment period.
The coverage will start the day of birth even if you do not enroll for 60 days afterward.
What are my health insurance options on the healthcare Marketplace or with my employer if I am pregnant?
If you already have a Marketplace plan, you should be covered for pregnancy, labor, and delivery. When the baby is born, you can add your child to your current plan or get a new plan with more benefits for the baby.
With a Marketplace plan, you are entitled to coverage even if you were pregnant before you enrolled in the plan. Under the Affordable Care Act, you cannot be denied coverage for being pregnant or any other pre-existing condition.
Most employer-based insurance plans will allow you to add your child to the plan after they are born.
You should speak directly to your human resources representative about your options but most employer-based coverage is required to cover dependents until the age of 26.
What is Medicaid and the Children’s Health Insurance Program?
If you need a health insurance plan that covers your pregnancy but you are worried you cannot afford one, you should consider applying for Medicaid or the Children’s Health Insurance Program. In states that expanded Medicaid, you will qualify if your income is less than 138 percent of the federal poverty level.
If your state did not expand their Medicaid program, you may still qualify based on your income and other determining factors.
In some states, the Children’s Health Insurance Program also covers pregnant women. If it does not, you should still apply for your child if they do not have health insurance. Some states require a monthly premium for the Children’s Health Insurance Program, but it will never cost more than 5 percent of your total household income.
You can apply for both programs through the Marketplace or by going to your state Medicaid agency.
Health Insurance Not Covering Pregnancy
Unless you have a grandfathered health insurance plan or a plan that is not compliant with the Affordable Care Act guidelines, your plan is required to cover your pregnancy, labor, and delivery. If it does not, you should apply for a Marketplace plan, Medicaid, or the Children’s Health Insurance Program.
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