Now that the healthcare law is being finalized and the largest aspects are nearly implemented, we are getting closer to understanding what coverage will be like when Obamacare is in full effect. After 2014, maternity coverage will finally make its way onto the menu for individual and family health plans. If you are planning to have a child at any time in the future, these major adjustments to health insurance will likely work in your favor. A victory for women in America, this provision ends the discrimination against pregnancy to which private individual and small group (100 or fewer employees) health plans have been so attached.
Previously, a perfectly healthy woman without coverage should have known better than to not have a health plan before getting knocked up, and therefore, it wasn’t a problem to turn down an applicant with child, suggesting they apply for Medicaid or CHIP. Many women do not meet the low income guidelines for such programs, thus having to work out a payment plan with a hospital (if available) or simply stomaching a large bill paid in cash. Since Obamacare has put the spotlight on female health issues, and maternity is certainly one of the most frequently occurring and costly ones, coverage will be much different in the coming months under any health plan.
So, who gets which benefits based on their plan type? The individual and small group market has received the widest publicity for getting revamped, but what about employer-sponsored plans? It may be assumed that most group plans will pay for pregnancy, labor, delivery, and infant care, but is it a requirement by federal law, or are employers free to choose the benefits they wish to provide? And will every single individual plan cover such services, or only policies offered through the new exchanges?
Free Preventive Prenatal & Postnatal Care: Every Plan
Since August 2012, the Affordable Care Act has provided free women’s health services, including prenatal exams for gestational diabetes while pregnant, in addition to training, supplies, and counseling for breastfeeding. While these freebies may be few, they are included in every health insurance plan, whether Medicaid, employer-sponsored, or individual.
Essential Maternity Benefits: The Individual Market
As one of the ten essential health benefits under the Affordable Care Act, maternity and newborn care will be mandatory for the majority of individual and small business plans available. Both private health plans and the exchanges will be required to cover these services, unless they are grandfathered or the state decides their private plans will not cover maternity. Individual and small group policies, Medicaid benchmark and benchmark-equivalent plans, and Basic Health Programs are required to cover essential health benefits, including maternity and newborn care.
This entails office visits with a primary care doctor or OB/GYN throughout pregnancy, with ultrasounds and other diagnostic exams and lab work, vitamins and prescription medications under pharmacy benefits, as well as the hospital stay, cost of labor and delivery, midwife or nursing services, and newborn care. However, each state is required to choose their own set of EHBs to apply to each individual and small group plan statewide, which may exclude maternity coverage if they choose.
Until the states release their lists of approved benefits, the only secure source of maternity coverage on the individual market is an exchange. It is likely that many states will approve maternity benefits and insurers will offer them in order to compete with the government-run health plans. Another bonus of joining the exchange for maternity care is, of course, the potential to get tax credits to lower your premium cost. Pregnant women who earn up to $62,040 per year, and families of four with income up to $94,200 may be eligible for subsidies which can discount your monthly bills and provide immediate coverage for pregnancy.
If individual health plans in a certain state are not required to add maternity as an essential health benefit, they are free to provide the service or not, with any limitations they choose. Yet, the difference between now and January 1 is that if you apply for a private health plan and you’re already pregnant, you will not be declined coverage, and not issued any pre-existing condition exclusions. The risk pool days are gone, and private insurers must accept anyone.
Employer-Sponsored Maternity Coverage
Pregnancy has not been considered a pre-existing condition for many large group health plans, and therefore was not subject to any waiting periods or exclusions, unlike the individual market. Yet, the ACA ensures workers and their families will get the coverage they need by prohibiting small or large group plans from denying anyone or adding exclusions to their plan after 2014. Under the majority of employer-sponsored health plans, maternity care has been regarded similarly to treatment for other conditions in terms of payment. The whole process of pregnancy and giving birth would be covered, from prenatal visits and vitamins, to your delivery and inpatient stay. As such, the federal government modeled their rules for individual and small group plans after what large group plans tend to offer.
After 2014, group plans purchased on a state insurance exchange will include guaranteed maternity and newborn coverage. Employer-sponsored plans effective in 2014 will be required to cover these benefits only if they are a company of 100 or less. Grandfathered plans, or those which were purchased prior to March 23, 2010, the date when the Affordable Care Act became law, do not have to comply with any new laws or benefit requirements, though they are unlikely to be preserved for long. If a grandfathered plan eliminates coverage for any certain condition (such as pregnancy), among other alterations such as increasing coinsurance, deductibles, or out-of-pocket limits by a certain amount, it is subject to nullification. So, if your grandfathered plan refuses to cover maternity services, you can inform the feds, and the plan will have to cover what you need.
Self-insured plans are not required to cover the minimum level of services under the Affordable Care Act, which includes primary and preventive care, maternity and newborn services, emergency, hospital, and others included in the essential benefits group.
2. Healthcare.gov. Pregnant Women and The Affordable Care Act.
3. 16 December 2011. Center for Consumer Information and Insurance Oversight. Essential Health Benefits Bulletin.
4. UC Berkeley Labor Center. Affordable Care Act: Summary of Provisions Employer-Sponsored Insurance.
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