Can a health plan refuse to let me enroll because I'm pregnant?
Health plans can no longer deny you coverage if you are pregnant. That's true whether you get insurance through your employer or buy it on your own.
What's more, health plans cannot charge you more to have a policy because you are pregnant. An insurance company can't increase your premium based on your sex or health condition. A premium is the amount you pay each month to have insurance.
How can I get health insurance while I'm pregnant?
First, see if your employer -- or your partner’s employer -- offers health insurance. You will probably get the most coverage at the best price from a health plan offered by an employer. That's partly because most employers share the cost of insurance premiums with employees.
You can also shop for coverage in the health insurance Marketplace, which is also called an exchange. You may also qualify for Medicaid in your state if your income is low.
In the marketplace, you can:
- Compare health plans side by side
- See if your income is in the range to qualify you for financial help from the government, which will lower the cost of your insurance premiums; you may also qualify for lower out-of-pocket costs, such as deductibles, copays, and coinsurance.
You must enroll in a health plan during the open enrollment period, set by either the employer for employer coverage or the federal government for Marketplace coverage. You may qualify for a special open enrollment period if you have a “life event” such as losing other health coverage or moving to a new state. Unfortunately, pregnancy is not one of the life events which qualify you for a special open enrollment period. However, having a baby (or adopting a child) is. So once you give birth, you can shop for insurance and enroll in a plan even if you missed the open enrollment period. If your income qualifies you for Medicaid, you can enroll at any time during the year.
You can also shop for coverage outside the government-run Marketplaces, but you must buy a Marketplace plan in order to qualify for financial help to lower the cost of premiums or out-of-pocket costs.
Will I get the same coverage no matter which state I live in or which plan I choose?
Not necessarily. The law requires most private health plans to help pay for a basic set of 10 essential health benefits, including maternity and newborn care. But the details of what each plan will cover depends on two things:
- Where you live. Your health plan choices will vary from one state to another, and even within the same state in different zip codes.
- Which health plan you choose. Although all plans must cover the 10 essential health benefits, the details of how services are covered can vary; for example, all plans must help pay for prescription drugs, but one plan may cover the brand of medication you use while another does not.
Make sure you carefully review your health plan’s summary of benefits, especially to see the specific set of prenatal and maternity services it covers.
What prenatal care can I expect to be covered by my health plan during my pregnancy?
All health plans* must cover certain preventive care with no out-of-pocket cost to you at the time of the visit. The exception is grandfathered health plans -- those that were in existence before March 23, 2010, and that haven’t made significant changes to their benefits and costs. They do not have to comply with this part of the law. Contact your insurance company or your employer to find out whether your plan is grandfathered.
These services are listed roughly in the order you would need them over the course of your pregnancy.
- Testing and counseling for sexually transmitted diseases, including HIV
- Testing for a blood condition known as Rh incompatibility
- Folic acid supplements, which help protect your baby from certain birth defects (with a prescription)
- A wide range of prenatal tests, including anemia screening and screening for urinary tract infections
- Testing for gestational diabetes
- Screening and help to quit tobacco use
- Labor and delivery costs, including your hospital stay
- Breastfeeding counseling and equipment
- Birth control after you've had your baby
What's covered for maternity care can vary from plan to plan. That's true if you get insurance through your work or buy it yourself. So for any plan you are considering, review the details of the plan’s summary of benefits or call the insurance company for more information.
What delivery costs and after-delivery costs will be covered by health insurance?
Most health plans will cover much of the costs of delivery and aftercare, but, as with any other stay in a hospital or other health care facility, you may need to pay part of the bill. Your costs may include having to meet your health plan’s deductible as well as copays or coinsurance.
Your deductible is the money you have to spend before your insurance helps pay for your care.
Copays are a flat fee you pay when you see a doctor, such as $20 per visit.
With coinsurance, you pay a percentage of the cost of your medical care.
You can find out what services are covered by your plan and what your costs are likely to be by looking at your health plan's summary of benefits or by calling your insurance company.
Here are some things you might want to look for to confirm whether your plan covers these services, and if so, how much of the bill you’ll be expected to pay:
- Labor and delivery services in the setting you choose, such as a birthing center, home, or hospital
- Alternative birthing options, like water birth
- Midwife services
- Enhanced coverage for high-risk pregnancy or pregnancy complications
- Delivery/C-section costs after infertility treatment
- Medically prescribed C-section, including recovery
- Neonatal care
Am I eligible for Medicaid while I'm pregnant?
All states offer Medicaid coverage to pregnant women whose income makes them eligible. The amount of money you can earn and still qualify varies by state.
States have the option to extend Medicaid coverage to pregnant women with incomes up to or over 185% of the federal poverty level (and most states have done so). In 2020, that’s roughly $23,606 for an individual. Coverage continues through pregnancy, labor, delivery, and the first 60 days after birth.
Some states may cover your maternity care under the Children's Health Insurance Program.
After your Medicaid pregnancy coverage ends, you may still have other insurance options through your state or a private company.
The Affordable Care Act gives states new opportunities to expand their Medicaid programs to cover individuals who earn up to 138% of the federal poverty level ($17,609 per year for an individual in 2020). Not all states have done this. If your state has expanded the program and you meet the income and other eligibility criteria (for example, you are a resident of the state in which you are applying), you will still be covered under Medicaid.
If you no longer qualify for Medicaid after you give birth, you may be eligible for government assistance to buy a health plan through your state’s marketplace. Even if the open enrollment period – the time during which anyone can buy a health plan – is closed, there is a special enrollment period for people who qualify. If your Medicaid coverage ends, you will qualify for this enrollment period.
What questions should I ask before choosing a health plan to cover my pregnancy?
Ask how much your deductible will be. In general, your deductible goes down as your monthly premium payments go up. Also, take the time to understand other out-of-pocket costs that come with your plan, such as copays and coinsurance.
Ask which providers are in your plan’s network. You'll want to know which obstetricians, hospitals, and pediatricians participate in the plan. Your plan will likely only cover preventive services in full and at no cost to you if you receive your care from in-network providers.
Review the plan’s full summary of benefits and look it over closely. Pay close attention to any specific services you want or need to make sure they are covered by your health plan.
Once your baby is born, you qualify for a special enrollment period through the Marketplace during which you can add your baby onto your policy.
What happens after my baby is born?
You need to get in touch with your employer, insurance company, or state Marketplace to add a child to your health plan shortly after you give birth. Many employers require you to add your baby to your policy within 30 days. Having a baby qualifies you for a special open enrollment period in your state’s marketplace and allows you 60 days to choose a plan for your baby or make changes to your existing plan. Depending on your income, your child may qualify for Medicaid or CHIP even if you have a policy through your employer or state Marketplace.
* Short-term health plans, those providing less than 12 months of coverage, are not required to offer you insurance and do not have to include maternity care in their benefits.