The Affordable Care Act (sometimes referred to colloquially as “Obamacare”) requires health care plans to cover pregnancy costs. The best health insurance for this typically will provide coverage for nearly all pregnancy costs, including physician visits, prenatal testing, blood work and other lab tests, ultrasounds and sonograms, as well as the cost of actual delivery of the baby.
These medical bills can add up fast, with the average cost of pregnancy ranging from as low as $5,000 to as high as $230,000 without insurance. More affordable plans are sometimes also available, such as limited benefit policies, but they don't usually include as many complete benefits as other more comprehensive maternity health insurance coverage options.
Pregnancy is generally considered a pre-existing condition, but recent laws have been enacted that require all marketplace, employer-provided and Medicaid plans to cover maternity and newborn care. Before this legislation, you could be denied coverage due to your pregnancy as a pre-existing condition.
Today, pregnancy is considered an essential health benefit that all ACA health insurance plans must cover. Some pregnancy expenses typically include:
1. Doctor visits
2. Gynecologist (OBGYN) and obstetrician visits
3. Ultrasounds and sonograms
4. Lab tests
5. Birthing classes
The ACA also says that insurance plans have to cover these listed services for everyone, including pregnant women:
1. Regular health checkups
2. Sickness visits
3. Hospital care
4. Emergency room services
The ACA mandates that an insurance plan cannot:
1. Drop your health insurance if you get sick
2. Charge you more for health care services because you’re a woman
3. Charge you more for health care services if you’ve had a medical condition in the past
4. Set a lifetime or annual cap (limit) on coverage. This means that an insurance company can’t stop covering your medical expenses once they reach a certain limit.
5. Make you pay unlimited costs out of pocket. Insurance plans have to set yearly limits on what you pay on your own for health care. Once you reach the limit, the company has to pay your expenses through the rest of the year.
Many of the medical bills for pregnancy can be very costly if you do not have health insurance, which makes finding an affordable policy critical.
The most optimal health insurance for you will depend on whether you’re currently pregnant or plan to conceive in the future. For most situations, you will be able to get the best health insurance for maternity possible if you plan ahead, as you will have more options for maternity coverage. For example, if you currently do not have health insurance from an employer, you should plan to purchase a policy during the open enrollment period, which typically occurs from the start of November to the end of December (and sometimes may go into January, depending on what state you reside in.)
Even when pregnancy comes as a surprise, there are still good health insurance options if you do not have coverage when you become pregnant. These can include options like Medicaid or non-ACA comprehensive health insurance policies, and some other alternatives to traditional health insurance coverage, which can be purchased at any time during the year. There also may be some good medical cost-sharing plans that may share some or all pregnancy costs as well.
Is A Midwife Covered?
If you want to use a certified nurse midwife or deliver your baby in a birth center or at home, find out what coverage your plan provides in these situations. Most plans cover a certified nurse midwife, and some will pay for a delivery at selected pre-approved birthing centers , but very few insurance plans cover home births.
Changing insurance or jobs during pregnancy
If you are pregnant and enrolled through an employer’s health insurance plan, but then you switch jobs, you may have to wait before joining the new health insurance plan. This may not be an issue if you are early in your pregnancy, but it could be more serious if you are further along. To bridge this gap, you can enroll in your former employer’s COBRA plan, in which you would receive all of the same pregnancy benefits as your previous health insurance. COBRA insurance is costly, but it would provide the necessary coverage for all medical bills.
It is usually not advisable to change insurance plans while pregnant, as coverage options may be quite limited. Typically, it is much more difficult to find a full coverage pregnancy insurance plan while you are pregnant as opposed to simply planning ahead and purchasing a plan before conception since pregnancy is considered a pre-existing condition. And if you have a pre-ACA grandmothered or grandfathered plan that doesn’t include maternity coverage, you generally cannot simply switch over to a plan which does have maternity coverage when you get pregnant – you would have to wait until the next open enrollment period, which only happens once a year, unless you experience a special qualifying event. And keep in mind that conception/ pregnancy is NOT considered a qualifying event for Affordable Care Act plans, but the birth of the baby is. So once again, it is much better to have coverage in place before conception if possible.
Short Term Health Plans For Maternity?
Short-term health insurance plans do not typically provide maternity coverage, since they do not cover major pre-existing conditions. If you currently have a short-term plan and are considering having a child, it would be advisable to switch to another health insurance policy which does provide coverage for pregnancy/ maternity.
Subsidized health insurance for pregnancy (ACA)
Subsidized health insurance for pregnancy from government sources will be determined by your income and whether your or your spouse’s employer provides health insurance. There are three types of health insurance plans that provide the best affordable options for pregnancy: employer-provided coverage, Affordable Care Act (ACA) plans and Medicaid. Affordable Care Act plans will give you premium assistance towards a Blue Cross / Blue Shield plan for example.
Employer-Sponsored Insurance / Group Health Care Coverage
One of the best health insurance options for pregnant women is going to be employer-provided coverage, either through the mother or her spouse. It is important to note that some employer health care plans will have a waiting period, typically three months from the date your coverage begins, during which benefits would not be provided. This is to prevent sick individuals from applying for health insurance only after they have become ill.
Adult children who are classified as dependents under an employer group health care plan are usually not eligible to receive coverage for pregnancies or their child. This could become an issue because you are allowed to stay on a parent’s plan until the age of 26. In this case, the best health insurance option would be to look into Medicaid or marketplace health insurance or possibly other affordable alternatives to traditional health insurance coverage which cover births.
Marketplace (Affordable Care Act/ ACA) health insurance
Marketplace health insurance coverage always provides maternity care and must cover all of the essential health benefits listed under the ACA. Furthermore, the insurer can’t deny coverage for a pre-existing condition, so you won’t need to endure any waiting periods at all.
A marketplace policy can only be purchased during the open enrollment period for your state, which requires you to plan ahead. ACA (Affordable Care Act) plans can also be purchased if you experience a qualifying life event, which then activates a Special Enrollment Period (Special Qualifying Event Election Period. ) This can include events such as getting married or losing your job. However, becoming pregnant is not a qualifying life event and thus would not open a special enrollment period.
On the other hand, giving birth is a qualifying life event. Once you give birth, your newborn will be eligible for coverage from your health insurance provider. Additionally, under the Health Insurance Portability and Accountability Act (HIPAA), the birth of your child will open a special enrollment period in which you can purchase newborn insurance. This is a 30-day period which allows you to enroll your new baby in your family’s plan on the state marketplace.
Medicaid and CHIP (Child Health Insurance Program)
Most states have expanded their Medicaid coverage to pregnant women within certain income limits, but you should check whether yours does. If it does, determine the eligibility requirements since they can vary by state.
If you do not receive coverage from an employer, and cannot afford to purchase a marketplace policy or miss open enrollment, you can probably get coverage through Medicaid. Since Medicaid is regulated by the ACA and federal government, it must provide the same maternity, prenatal and newborn insurance coverage as marketplace and employer policies. Additionally, Medicaid does not have designated waiting or enrollment periods, which means you can apply for coverage at any time during the year.
The Medicaid program allows low-income individuals to enroll in the plan and receive health care benefits if their household income falls below certain limits.
The Child Health Insurance Program (CHIP) is a separate health insurance policy that provides coverage for children under 19 years old and pregnant woman. It is similar to Medicaid in that it is a low-income insurance plan designed for individuals and families.
CHIP health coverage can provide a safe haven for women who earn too much for Medicaid coverage but still cannot afford an ACA plan. The following states provide full pregnancy benefits without premiums and coinsurance under the CHIP program:
3. District of Columbia
6. New Jersey
7. Rhode Island
Other states that have adopted this legislation may require a pregnant woman to pay some of the premium and use coinsurance for pregnancy coverage. For this reason, you should check your state’s CHIP-provided services before relying on this plan for pregnancy health insurance.
Alternative Medical Insurance Options for Pregnancy
Supplemental Health Insurance Policies
Supplemental maternity insurance coverage is a medical insurance policy that makes cash payments directly to you rather than paying the doctor or hospital. There are two main forms of additional insurance that you can purchase for pregnancy: short-term disability and hospital indemnity. However, both of these policies must be purchased before conception, as they do not include coverage for pre-existing conditions.
Medical Cost-Sharing Plans
There may be some faith-based or community-based medical cost-sharing plans that may offer coverage for maternities. Some may share the cost of pregancy up to a certain maximum limit, or require you to pay an Initial Unshareable Amount (IUA) before sharing the costs more completely.
Disability Insurance For Pregnancies and Maternity Leave Coverage
A short-term disability or maternity-leave insurance plan is designed to replace the mother’s income during maternity leave and if she is ordered for bed rest by her doctor. Some employers will pay full salary when a woman goes on maternity leave, but not every company does. For this reason, you should consult your employer to find out its maternity leave policy. If it does not support maternity leave or only provides a few weeks’ worth of full salary, then purchasing a short-term disability maternity plan might be the best solution.
Hospital Indemnity Plans
Another pregnancy policy that may be useful for your situation could be a hospital indemnity plan. This insurance is not a complete coverage policy like other health insurance plans. Instead, it is considered as a substitute health care plan if you cannot afford a typical health insurance policy, and is probably much better than having no coverage at all.
A hospital indemnity plan as an alternative to comprehensive health insurance solution may cover expenses for admission to the hospital and the delivery of your baby but would not provide prenatal coverage or therapy. Additionally, the indemnity plan can provide extra benefits if your infant is born prematurely and needs to be admitted to the neonatal intensive care unit (NICU).
Having coverage for complications of birth may be even more crucial than having coverage just for the birth itself, especially since those costs can be astronomically high.