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Health Insurance Coverage During Pregnancy: Benefits and Exclusions

How Does Health Insurance For Pregnant Women Work? 

Under current ACA regulations, no major health insurer can deny a person medical coverage due to pregnancy. As long as a pregnant woman meets the conventional eligibility requirements expected of all other policyholders, she can enroll in ACA-compliant healthcare.

ACA plans include prenatal and maternity benefits and automatically cover newborns under their parent’s policy. Furthermore, women do not have to share costs for specific preventative care services related to pregnancy, such as disease screenings and tobacco counseling.

The Importance of Health Coverage During Pregnancy 

Health coverage during prenatal care provides critical financial support for women during a demanding period of life. Doctors usually ask patients to come in for prenatal checkups once every 4-6 weeks during the first 32 weeks of pregnancy, every 2-3 weeks for the 32nd-37th week, then once a week until birth. Without insurance, patients must the entire cost of every necessary appointment and procedure.

The effect of ACA-mandated care for pregnant women has been significant, even in the decade since it was enacted. For example, the ACA provided funds to fortify and expand Medicaid, government subsidized healthcare for low-income individuals who would otherwise lack access to health insurance. States that accepted those federal funds and expanded Medicaid eligibility saw a 50% decline in infant mortality, underscoring the importance of accessible prenatal care.

What Will Health Insurance Cover For Pregnant Women? 

ACA mandate classifies prenatal and postpartum care as an essential benefit, meaning that all ACA-compliant plans must cover pregnancy-related services. Actual protections may vary as the Affordable Care Act does not explicitly spell out every covered health service. Pregnant women or those planning for children should iron out the details with their tentative insurer before committing to a long-term plan.

To receive coverage, those enrolled in ACA policies must still adhere to doctors and hospitals within their insurance provider’s healthcare network. Many preventative procedures, such as birth control and immunizations, qualify for full coverage without cost-sharing (deductibles, copays, or coinsurance) under ACA-compliant plans.

What Is Covered During Pregnancy?

  • Prenatal visits: Regular checkups with doctors, nurses, or midwives throughout pregnancy.
  • Ultrasounds: Sonograms of the baby in utero that help check its health and detect complications.
  • Necessary vitamin supplements: Pregnant women must ensure their bodies receive all essential nutrients. Chief of these, folic acid supplements prevent neural tube defects that can seriously compromise fetal development.
  • Prenatal screenings: Tests performed during pregnancy to monitor your and your baby’s health. 
  • Prenatal bloodwork: A panel performed during early pregnancy to check for diseases and infections in a mother and her unborn child.
  • Tobacco usage counseling: Programs that help pregnant women quit smoking and prevent nicotine-related complications.

What Is Covered For Childbirth? 

  • Labor induction: Medically prompting the uterus to contract during pregnancy to expedite a vaginal birth, typically following concern for the mother’s or the fetus’s well-being.
  • Pain management medication: Most commonly epidurals, anesthesia injections that numb a mother’s belly to her upper legs.
  • Vaginal or cesarean birth: Pregnancies too complicated for vaginal delivery might require a cesarean birth (C-section) to remove the baby from the womb surgically.
  • Hospital stay: Medical staff typically monitor a mother and newborn in the hospital for 24-96 hours before sending them home.
  • Delivery room items: Most other products used in the delivery room, including diapers, wipes, petroleum jelly, and baby formula.
  • Medical professional team: Obstetricians, nurses, or midwives who take part in monitoring the health of the mother and child during and immediately following childbirth.

What Is Covered After Birth? 

  • Lactation counseling for parents: Specialized training to help ease mothers through common breastfeeding issues.
  • Breastfeeding equipment: Nursing bras, nipple cream, pads, pumps, and other accessories that soothe the breastfeeding process.
  • Postpartum screenings for parents: The AAP recommends both parents undergo multiple depression tests during the first six months after childbirth.
  • Doctor checkups for newborns: Doctors must examine newborns six times before their first birthday.
  • Screenings for newborns: Blood, heart, and hearing tests performed 1-2 days after birth to check for abnormalities.
  • Vaccines for newborns: Doctors recommend 1-2 month-old babies receive vaccines for polio, whooping cough, Hepatitis B, tetanus, and more.
  • Birth control for parents: Contraceptive methods that prevent another immediate pregnancy and help parents plan their family.

What Is Not Covered For Pregnant Women? 

Not all pregnancy expenses receive coverage under the Affordable Care Act. Insurance will not cover certain delivery room items, such as disposable underwear or sanitary wipes. Parents who decide to hire doulas, uncertified spiritual guides that help coach mothers through childbirth, should expect to pay for them entirely out-of-pocket.

New parents must purchase their child’s birth certificate through their state’s vital records office for a non-refundable, out-of-pocket fee.

How to Find Health Insurance For Pregnant Women 

Pregnant women seeking health insurance should follow these steps in order:

  1. Explore health insurance options for pregnant women.
  2. Consider factors that affect the cost of pregnancy insurance.
  3. Make your insurance selection.
  4. Get documentation ready.
  5. Apply and enroll in a health insurance policy.
  6. Receive confirmation of coverage.

Each step in this process can vary depending on your situation, as detailed below.

1. Explore Your Health Insurance For Pregnant Women Options 

According to ACA mandate, insurance companies can no longer deny health coverage by categorizing pregnancy as a pre-existing condition. Furthermore, they cannot charge you higher premiums for your pregnancy and must provide prenatal benefits beginning on the first day of your plan. Since you cannot get removed from insurance while pregnant, you can always stay with your current provider. If you have employer-sponsored health insurance, going on maternity leave will not impact your coverage as long as you technically remain employed.

However, as listed below, several more coverage options exist for pregnant women without or wanting to change their insurance.

Add Yourself to Your Spouse’s Health Insurance

If you are married and your spouse has good health insurance through their employer or private individual coverage, consider adding yourself to their plan. While most insurers consider the birth of a child a special life circumstance and allow women to switch plans outside of their open enrollment window, they do not extend the same latitude to expecting mothers. Pregnant women must time the switch between policies with their new insurer’s annual open enrollment period.

Insurance companies typically offer lower rates for married couples and families under one healthcare policy. Unmarried couples can occasionally share plans depending on how their state recognizes domestic partnerships.

Add Yourself to Your Parent’s Health Insurance 

Similarly, pregnant women can only join their parent’s health insurance during the annual open enrollment period or any relevant special enrollment window. Though most policies must cover prenatal care and delivery for dependents, you lose your status as a dependent the day you turn 26. Additionally, parental policies do not extend to newborn grandchildren. Expecting mothers might prove better off looking into Medicaid or marketplace health insurance.

Get Your Own ACA Insurance Plan From the Health Marketplace 

Explore the ACA marketplace if you cannot secure affordable coverage through your employer or family members. ACA plans offer coverage in four tiers: platinum, gold, silver, and bronze. Platinum and gold plans set the lowest deductibles and coinsurance in exchange for higher annual premiums, ideal for the frequent doctor’s and hospital visits required of pregnant women.

Another perk of marketplace plans comes with the tax credits available to lower-income families and individuals. As with all previously mentioned healthcare options, new members must wait until the ACA open enrollment period to switch plans, which begins November 1st each year. Marketplace plans require members to see medical providers within an ACA-compliant network.

Enroll In a Government-backed Health Insurance Option 

Many low-income families and individuals qualify for government-sponsored health insurance, which typically offers comprehensive care for little to no cost. Common programs include:

  • Veterans Affairs (VA) Health Care: VA must offer a maternity insurance plan and routine pregnancy services for all honorably discharged military veterans, including exams, prescriptions, ultrasounds, newborn care, and more. Veterans can use their VA health plan concurrently with other forms of health insurance for expanded coverage.
  • Medicaid: Medicaid for pregnant women must provide all the same benefits of marketplace plans and allows members to enroll at any point during the year. Most women who make less than 138% of the federal poverty level can receive essential pregnancy care with zero out-of-pocket costs under Medicaid.
  • CHIP: The Children’s Health Insurance Program provides health care to children under 19 and pregnant women who earn too much to qualify for Medicaid but cannot afford ACA coverage. Nine states offer full pregnancy benefits without cost-sharing under CHIP, while the rest ask women to pay part of their premium or some coinsurance.

Consider Short-term Health Insurance For Temporary Coverage 

If more traditional methods prove out of reach, pregnant women can enroll in short-term health insurance as a stop-gap until they find permanent coverage. These plans typically only last several months to a year and do not conform to ACA regulations, allowing them to deny prenatal and maternity coverage by disqualifying pregnancies as pre-existing conditions. With this in mind, expecting mothers should only settle on temporary insurance as an interim solution and continue searching for a long-term plan.

2. Consider Insurance Factors That Affect the Cost of Pregnancy

When comparing insurance plans and options, the details below ultimately dictate how much you will pay for healthcare during pregnancy. Cutting costs could prove critical for anyone expecting a high-risk pregnancy requiring ancillary medical care.

  • Type of plan: The most common policies come as HMOs or PPOs. HMOs charge less out-of-pocket and set a lower monthly premium for a smaller network of participating doctors, whereas PPOs cost more and allow greater flexibility.  
  • Deductible: The specific amount each plan requires you to pay out-of-pocket before insurance coverage takes over paying for the rest of that year.  
  • Copay and coinsurance: Copays are small, fixed amounts required with each doctor’s visit; coinsurance is a percentage of the final covered cost. Pregnant women should seek plans with lower upfront expenses since they frequently visit their OBGYN and many other specialists. 
  • Out-of-pocket maximum: The limit to what you may pay for covered services each year before your insurance begins paying 100% of all exceeding costs. Pregnant women should select plans with lower out-of-pocket maximums.
  • Network: The list of medical providers covered under your specific insurance plan. Ensure your preferred OBGYN and hospital fall within your network to guarantee benefits.
  • Out-of-network costs: If you cannot stay within your policy’s network, doctors will charge you full price for the cost of care.

How Much It Costs to Have a Baby

Securing proper healthcare during or before pregnancy can save you tens of thousands of dollars.According to a 2022 study by the KFF, women who give birth incur nearly $19,000 in health costs over three years, factoring in prenatal care, childbirth, and newborn healthcare expenses. On average, insured mothers would pay $2,854 of this out of pocket, leaving their insurance to cover the rest.  

Exact costs vary widely depending on the type of delivery performed, your age, pregnancy complications, and your state. Healthcare expenses related to C-section births average nearly $26,280, whereas incident-free vaginal births fall closer to $14,768. Prenatal and postpartum costs stack up quickly, including hospital bills, routine obstetric care, lab tests, anesthesia, vaccines, and radiology, among other regular fees.  

These numbers do not factor in the sizeable non-pregnancy costs of raising a child. New parents should expect to spend nearly $13,000 every year until a child turns 17 and considerably more during the first year of their life.

3. Make Your Insurance Selection 

After exploring your health insurance options and noting everything that could affect the cost of your pregnancy, ask yourself the following questions:

  • Do you or your spouse already have health insurance? If you do, it may be best to remain on either plan to avoid coverage gaps while waiting for the next open enrollment period.
  • Is the deductible low enough for you to meet it with routine care? This is important because pregnant women must undergo many repeat doctor’s visits. Lower deductibles, copays, and coinsurance ensure less money out of pocket.
  • Does your or your spouse’s employer offer subsidized healthcare? Many employers will pay a percentage of your health insurance premiums, lowering out-of-pocket costs.
  • Do you live in a state that considers pregnancy a special life event? Connecticut, Maine, Maryland, New York, New Jersey, and Washington DC allow special enrollment periods for expecting mothers to lock down an ACA plan.

Your answers to these questions should help you narrow in on the best policy for you.

4. Get Documentation Ready 

Whether you join a pre-existing plan, purchase your own, or sign up for Medicaid or CHIP, you must prove your identity, date of birth, and citizenship status using your passport or naturalization papers. Your insurer may also ask for utility bills and pay stubs to prove your address and income, marriage certificates, and previous insurance paperwork, among many other documents.  

5. Apply and Enroll Into a Health Insurance Policy 

When ready to enroll in a new health insurance policy, communicate with the provider of your choice and ensure you know the full details of your policy before committing. If you need help navigating the healthcare process, consider enlisting a trusted insurance agent to guide you through your options and express your needs to your potential insurer.

When Can You Enroll In Health Insurance When Pregnant? 

Most pregnant women must wait until their open enrollment period to apply for coverage, albeit those in the small number of states that consider pregnancy a qualifying life event (QLE). QLEs may include changes in a person’s marital status or address, family deaths, the loss of health insurance, and any other significant change their insurer considers worthy of a special enrollment period. While most insurance companies see the birth of a child as a QLE, very few view pregnancy as one.

Alternatively, pregnant women who qualify for government assistance can enroll in Medicaid or CHIP any time of year.

6. Receive Confirmation of Coverage 

Your new insurer will send you a certificate of coverage explaining your benefits and a new health insurance card to present at every appointment. Under ACA regulations, prenatal care must begin on the first day of coverage. Your insurer will automatically include your newborn baby on your policy.

Alternative Options If Health Insurance Is Out of Reach 

Expectant parents who cannot afford major medical insurance should look into their state’s Medicaid and CHIP programs. The following organizations also offer free or low-cost pregnancy care:

  • Local Health Programs: Institutions that provide wide-ranging benefits to the most vulnerable members of their community. Examples include religious charities and free pregnancy clinics.
  • Community Health Center: Patient-directed, community-based systems that deliver high-quality healthcare to people in need, including federally funded women’s clinics or student health centers.
  • Planned Parenthood: A national leader in reproductive health and education, Planned Parenthood clinics nationwide offer affordable access to prenatal care, birth control, and much more.
  • Hill-Burton Facilities: Built using construction grants passed in the Hill-Burton law of 1946, these hospitals offer free or low-cost care to underserved communities. While funding ended in 1997, about 140 facilities still operate across the US.
  • Payment Plans: Uninsured families can work out payment plans with their medical providers, allowing them to pay for prenatal services incrementally instead of posting large lump sums. Staggered bills help mothers receive necessary care without immediate financial stress.

Putting It All Together 

Having a baby costs a lot of money. The Affordable Care Act views prenatal and maternity care as essential benefits, meaning no ACA-compliant plan can deny coverage or raise premiums due to pregnancy. Expectant mothers must still meet standard ACA requirements and apply for a new plan during their annual open enrollment period. The same goes for women looking to join their spouse’s or parent’s health insurance policy.

Women who cannot afford insurance can apply for Medicaid or CHIP year-round or explore alternative low-cost options through Planned Parenthood and other community programs. Factor in your health needs and budget, and talk to a trusted insurance agent to find the best healthcare policy for your growing family.

You’re just a few steps away from a personalized health insurance quote.

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You’re just a few steps away from a personalized health insurance quote.

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