Want to Have a Baby? Obamacare's Got You Covered

The ACA changed the rules for maternity care - here's what you need to know

Maternity coverage - Obamacare changed everything
Thinking about having a baby? Thanks to Obamacare, maternity coverage is standard on all new policies. Chev Wilkinson/Cultura RM/Getty Images

The bad old days

Prior to 2014, maternity coverage in the individual health insurance market was rare - and prohibitively expensive - in most states, and non-existent in others. By 2013, nine states required maternity benefits to be included on all individual health insurance plans, but even so, just 12 percent of individual market plans nationwide included maternity benefits.

For women who get their health insurance from a large employer, maternity coverage has been mandated for nearly four decades.

 The Pregnancy Discrimination Act of 1978 requires health plans to cover maternity benefits if the business has at least 15 employees. There was no federal regulation requiring maternity coverage on individual plans or for groups with fewer than 15 employees, but 18 states had passed laws in the ensuing decades to require small group plans - and in some cases individual plans - to cover maternity care.

So prior to 2014, for women who were covered under very small group plans or who had to buy their own health insurance, the availability of maternity benefits depended largely on where they lived. And in nearly every state, pregnancy itself was a pre-existing condition that precluded an applicant from enrolling in any individual health plan.

Great news for moms to be

But thanks to the ACA, that’s no longer the case. Pre-existing conditions are no longer an eligibility factor, and in every state, maternity coverage is one of the essential health benefits that’s covered on all new individual and small group plans.

That means maternity care is covered just like any other claim, and there’s a cap on out-of-pocket spending. In 2015, out-of-pocket spending on essential health benefits cannot exceed $6,600 for an individual, although many plans are designed with much lower out-of-pocket exposure. Premiums are generally higher on plans with lower out-of-pocket costs, but it you’re planning a pregnancy, it will probably make sense to consider more robust health plans, despite the higher premiums.

While labor and delivery will typically come with a substantial copay or a deductible, prenatal checkups are considered well-woman care, which means they’re covered with no copays. Some prenatal testing - screening for gestational diabetes, Hepatitis B, some STDs, and Rh factor incompatibility - is also covered with no out-of-pocket cost. In addition, breastfeeding support and supplies (including breast pumps) are also covered at no charge as a result of the ACA. And for women who don’t want to become pregnant, the ACA also mandates contraceptive coverage with no cost-sharing.

What plans don't cover maternity?

There are still health plans in force that don’t include any maternity care. These include grandfathered plans and transitional (grandmothered) plans, although transitional plans are required to cover preventive care with no cost-sharing, including prenatal checkups.

And although the ACA included a provision to allow young adults to remain on a parent’s health plan until age 26, maternity coverage is not mandated for dependents.

So young women who remain on a parent’s health plan could find themselves without maternity coverage and unable to obtain coverage that does include maternity unless it happens to be open enrollment time. Health 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.

Don't go uninsured

Half of all pregnancies in the US are unplanned, and pregnancy in and of itself does not allow a woman the opportunity to enroll in a health plan outside of open enrollment. So the possibility of a pregnancy is yet another reason that it’s important to maintain continuous health insurance coverage.

Lawmakers in New York passed Senate Bill 5972 in June 2015 although it has not yet been signed into law. The bill would make pregnancy a qualifying event in New York, allowing a pregnant woman the option to enroll in a new health plan or switch to a different one at any point after the commencement of her pregnancy.

Advocates have pushed for similar regulations on a federal level, but although HHS considered that possibility, they clarified in February 2015 that they decided not to include pregnancy among the list of qualifying events that apply nationwide. That could change in future years, but for the time being, pregnant women do not have an opportunity to enroll in a health plan or change plans (outside of open enrollment) unless they simultaneously experience a qualifying event.


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