Is Pregnancy a 'Qualifying Event' for Health Coverage?

There's no ACA-mandated special enrollment period for pregnant women

Happy pregnant woman
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If you have a baby or adopt a child, your family is eligible for a special enrollment period for health insurance, regardless of whether you get your health plan through your employer or in the individual market (on or off-exchange).

But what if you get pregnant? This has been a controversial subject lately, with consumer advocates pushing for pregnancy to trigger a special enrollment period in the health insurance exchanges.

So far, the federal government has said no, and only one state—New York—has enacted regulations to make pregnancy a qualifying event that allows the mom-to-be to enroll in a plan through the exchange. 

The History of Qualifying Events

The Health Insurance Portability and Accountability Act (HIPAA) has been in place since the mid-90s, and includes a range of qualifying events that trigger special enrollment periods for employer-sponsored health insurance plans. 

In the individual market (i.e., plans you buy yourself, rather than obtaining from an employer), qualifying events and special enrollment periods weren't part of the picture prior to 2014, but they are now that health insurance carriers cannot decline applications based on medical history. Coverage is guaranteed-issue, but only during open enrollment or special enrollment periods. In other words, the individual market now much more closely resembles the employer-sponsored insurance market.

The Affordable Care Act (ACA) and subsequent regulations published by the Department of Health and Human Services (HHS) laid out guidelines in terms of what counts as a qualifying event in the individual market. In most cases, they apply both inside and outside the exchanges, although some qualifying events only apply in the exchanges.


In both cases—HIPAA for employer-sponsored plans, and the ACA for individual market plans—the rules apply nationwide. But states can add additional qualifying events and consumer protections as they see fit.

New York: Pregnancy Is a Qualifying Event

In January 2016, the new rules for pregnancy-triggered special enrollment periods took effect in New York. State lawmakers passed Senate Bill 5972 in June 2015, and Governor Andrew Cuomo signed it into law in December 2015. 

The New York law requires health insurance carriers to allow a pregnant woman to enroll in a health plan through the exchange (New York State of Health) at any time after the pregnancy is confirmed by a health care provider. The coverage effective date is the first of the month during which the pregnancy is confirmed.

New York State of Health is a fully state-run exchange, which means they do not use, and have considerable flexibility in setting their own rules. The exchange confirmed by phone that the special enrollment period for pregnant women only applies for individual market plans, and not for small group plans offered through the exchange (in other words, a woman who becomes pregnant has an opportunity to buy her own plan through the exchange, but not to enroll in a plan offered by her employer if she's outside the open enrollment period for the employer-sponsored plan).

The New York law also allows women to change plans during the special enrollment period triggered by pregnancy. So a woman who becomes pregnant in New York can go from being uninsured to having coverage, or she can opt to switch from one plan to a different one when she becomes pregnant.

Other States Don't Count Pregnancy

New York is the only state in the country that has made pregnancy a qualifying event that allows a mom-to-be to enroll in a health plan. California lawmakers considered similar legislation in 2015, but it did not pass.

Advocates have urged HHS to make pregnancy a qualifying event nationwide, but in early 2015, the agency clarified that they were not adding any additional qualifying events for the time being (and indeed, they've worked since then to tighten up the existing regulations regarding qualifying events, rather than relaxing them). They reiterated the fact that states have the freedom to add additional qualifying events if they choose to do so, but thus far, only New York has moved forward with making pregnancy a qualifying event.

Coverage with Year-Round Enrollment

Private health insurance (on-exchange, off-exchange, and provided by employers) limits enrollment to annual open enrollment periods and special enrollment periods triggered by qualifying events. But public health plans for low- and modest-income households have year-round enrollment.

This includes Medicaid, Children's Health Insurance Program (CHIP), and Basic Health Programs (BHPs). The ACA provided federal funding to expand Medicaid, and gave states the option to create BHPs. Thus far, only New York and Minnesota have established BHPs.

Although 19 states have not yet accepted federal funding to expand Medicaid, every state offers Medicaid coverage to low-income pregnant women. Pregnant women are eligible for Medicaid in every state with incomes at or below 133 percent of the poverty level, and in some states, eligibility extends well above 200 percent of the poverty level. 

And a pregnant woman is counted as two people when determining Medicaid eligibility. So a single pregnant woman could have income as high as $21,307 in 2016 and be eligible for Medicaid in every state. In many states, her income could be well above that level and she'd still qualify for Medicaid.

Medicaid enrollment continues year-round, so if a woman is uninsured and becomes pregnant, she can enroll in Medicaid at any time, assuming she's eligible based on the income guidelines. If CHIP is available to pregnant women (this is the case in a few states), enrollment is also available year-round.

BHPs have year-round enrollment too, and offer coverage to anyone with an income up to 200 percent of the poverty level. New York's BHP is called The Essential Plan, but it's specifically not available for pregnant women, as pregnant women with income under 200 percent the poverty level are eligible instead for Medicaid in New York. Minnesota's BHP is called MinnesotaCare. Pregnant women may be eligible for MinnesotaCare, depending on their circumstances.

In short, if you're pregnant and have a relatively low income, you may find that you're eligible for coverage under a public health program, and enrollment in those plans is available as soon as you're eligible, regardless of the time of year.

You may not have qualified for Medicaid prior to becoming pregnant, but the income thresholds are higher for pregnant women. And since a fetus counts as a person in terms of determining the number of people in the household, you can have a higher income and still be within the applicable percentage of the poverty level if you're two people instead of one.

The Controversy Over Pregnancy and Insurance

The question of whether or not pregnancy should be a qualifying event in states besides New York is highly controversial. On the one hand, consumer advocates note that prenatal care is linked to better outcomes for moms and babies, and that preventing pregnant women from accessing health insurance sometimes means that the mother and baby receive little or no prenatal care. That in turn can result in higher healthcare costs once the baby is born—and there's already a qualifying event that allows families to enroll in a plan when the baby is born, with coverage retroactive to the birth date.

On the other hand, opponents of making pregnancy a qualifying event explain that it makes little sense to essentially give people the opportunity to enroll in health insurance after they know that they're in need of healthcare, since that can lead to higher premiums for everyone. Health insurance only works - and remains stable - if there are enough healthy people paying premiums and not using healthcare to offset the claims of the insureds who are in need of healthcare. 

This issue is likely far from settled. US lawmakers introduced two bills in 2015—H.R.2866 and S.2220—in an effort to make pregnancy a qualifying event nationwide. But neither bill advanced out of committee, and HHS has not taken any steps to make pregnancy a qualifying event. 

For the time being, consumers should assume that their ability to get health insurance will remain limited outside of open enrollment, regardless of whether they're in need of maternity care or not.

The good news however, is that during open enrollment—either in the individual market, or for your employer's plan—there's no discrimination against pregnant women. Prior to 2014, pregnant women and expectant fathers in most states couldn't purchase health insurance at all in the individual market. That's no longer the case, thanks to the ACA. So if you find yourself pregnant and uninsured, you'll still have a change to enroll in a health plan during the upcoming open enrollment period, even if you're still pregnant at that point.


Centers for Medicare and Medicaid Services, State Medicaid and CHIP Income Eligibility Standards, October 2014. Accessed 6/1/16.

Cornell University Law School, Legal Information Institute, 29 CFR 2590.701-6 - Special enrollment periods. Accessed 6/1/16.

Department of Health and Human Services, Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2016. Accessed 6/1/16.

State of New York, Senate Bill 5972, June 14, 2015. Accessed 6/1/16.

United States Department of Labor, FAQs on the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Accessed 6/1/16.

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