Insurance When You're Pregnant: FAQ
The Affordable Care Act makes it easier for pregnant women to get insurance to help pay for the medical care they need.
Can a health plan refuse to let me enroll because I'm pregnant?
No. In the past, insurance companies could turn you down if you applied for coverage while you were pregnant. At that time, many health plans considered pregnancy a pre-existing condition.
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 from 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 based on your income.
- Compare health plans side by side.
- See if your income is in the range for financial help from the government. If it is and you otherwise qualify, you can use that money to lower the cost of your premiums. You may also qualify for lower out-of-pocket costs, such as deductibles, copays, and coinsurance.
You can also shop for coverage outside your state's Marketplace, but you will not qualify for financial help to lower the cost of premiums or out-of-pocket costs unless you are eligible and purchase coverage through the Marketplace.
You can enroll in a Marketplace plan only during the annual open enrollment period unless you meet special circumstances. The open enrollment period is from November 15 through February 15 each year. Your employer may also require you to sign up for insurance during an annual open enrollment period. If you qualify for Medicaid. you can enroll at any time during the year.
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 maternity and newborn care benefits. An insurance plan calls these covered benefits. But the details of what each plan will cover depend on two things:
- Where you live. Each state has rules about which insurance can be sold in that state, and each Marketplace chooses which plans will be sold through it.
- Which health plan you choose, because each plan varies in terms of what is covered.
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 new 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 changed in certain significant ways. They do not have to comply with this part of the law. Contact your insurance company to find out whether your plan is grandfathered.
Some of these services have been available at no cost since 2012. They're listed roughly in the order you would need them over the course of your pregnancy.
- Certain prenatal care
- Testing and counseling for sexually transmitted diseases. including HIV
- Testing for a blood condition known as Rh incompatibility
- Folic acid supplements (with a prescription), which help protect your baby from certain birth defects
- 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
- 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, look at the details in its summary of benefits or call the insurance company for more information.
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 or, in some cases, both copays and 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:
- 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 2015, that’s roughly $21,590 for an individual. Coverage continues through pregnancy, labor, delivery, and the first 60 days after birth. If you qualify for Medicaid because of pregnancy, you may still be eligible to buy extra coverage through your state’s Marketplace. In some states, women who qualify for Medicaid because of pregnancy only get the pregnancy benefits. So you may not be covered for other types of health care.
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. If your Medicaid coverage ends, you can qualify for a special enrollment period to shop and buy a health plan through your state’s Marketplace, even if it is outside the annual open enrollment period.
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 (just over $16,000 per year for an individual in 2014). Not all states have done this. See the Source Box for a link to check your state’s status. 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.
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 may only cover preventive services received from in-network providers.
Ask to see the 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 the special enrollment period through the Marketplace. You may be eligible for more coverage for new parents.
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.