Maternity coverage under Obamacare (Patient Protection Affordable Care Act- PPACA) ushers in a new era for couples.
But the Affordable Care Act is new, complicated, and difficult to understand and apply. Pregnancy makes your plan choice critical, and there are many variables to consider such as:
- Essential health benefits covering maternity
- Choosing between five plan designs
- Eligibility for government subsidies
- Buying group plans at work or individual policies
- Pregnancy as a pre-existing condition
- Maternity health benefits are no longer insurance
No longer will it be impossible to find an individual plan that covers normal pregnancy without long waiting periods. Also, women who are already pregnant can get coverage without being rejected for a preexisting condition.
Finding the optimal plan choice can translate into thousands of dollars of savings for families with maternity needs. We hope you find the following guide for choosing the optimal maternity coverage under Obamacare helpful. Scan through the list of considerations to help you make the proper choice.
Essential Maternity Benefits under Obamacare
The Affordable Care Act requires that any plan sold to individuals, or small groups of fifty or fewer employees, must provide ten different essential health benefits. Coverage for maternity and hospitalization are two of the listed benefits.
This means that beginning January 1, of 2014 you can have maternity coverage with no waiting periods.
What if you are already pregnant?
Beginning January 1, 2014 preexisting conditions must automatically be covered with no waiting period before benefits begin. If you are already pregnant and expecting to deliver in 2014 you can get covered beginning January 1. It would make great sense to do so, as hospital delivery is often the most expensive stage of your pregnancy.
Choose Between Five Plan Designs
Under the PPACA there are five standardized plan choices that individuals and employees of small businesses can choose between. They have convenient “metal” labels with corresponding actuarial values, and premium costs.
Actuarial value is the expected amount of in network medical expenses the plan will cover for all the people in the plan. For example an average family selecting the bronze plan would expect to have left over medical bills representing 30% of their utilization.
Expectant parents are not average. Their utilization will be far higher. This radically changes the best plan choice. The ratio of expected cost to expected value is very different.
Eligibility for Government Subsidies
Government subsidies are available to help lower premium costs, and total out of pocket medical costs. The subsidies are based upon your household income relative to the Federal Poverty Level (FPL). Families with incomes below four hundred percent of FPL may qualify for assistance.
If your employer offers a qualified plan, you do not qualify for a subsidy, even if your family income falls into a qualifying range.
Buy at Work or Through Your State Exchange?
Perhaps the most difficult and complex decision to make is whether to buy a maternity plan at work or through your state’s exchange. There is no right answer.
The Affordable Care Act has a huge loophole that strikes growing families directly. Employer plans are considered qualified if the premium cost for employee only coverage is not more than 9.5% of the individual income for full time workers. Employer plans must cover dependents, but not spouses.
This loophole has profound impacts depending upon whose employer offers qualified plans.
Open Enrollment Timeframes
Open enrollment for Obamacare health plans begins on October 1, 2014 and closes March 31, of 2014. You must make your plan choice during this timeframe. Once your coverage begins, you can’t make a change unless there has been a qualifying life event.
Couples purchasing maternity coverage often have a qualifying life event: birth of a child or loss of insurance coverage if mom loses her job while on maternity leave, or chooses to stay home to raise her family.
Open enrollment is a critical concept to understand for women who are already pregnant. Timing is everything.
State Health Insurance Exchanges
State health insurance exchanges provide the detailed information for maternity plans where you live. Some exchanges are either run by the state, the federal government, or in partnership. Each state has different insurance mandates which impact services are covered, and what policies may cost.
Medicaid is a primary provider of maternity health insurance for pregnant women. The Affordable Care Act provided incentives for states to expand their Medicaid programs. Your home state Medicaid expansion status impacts where you may get coverage, and your level of assistance.
Health plans will have a wide variety of in network providers. One key consideration is finding whether the top children’s hospitals in your state participate in the plans network. If your local hospital NICU unit is out of network, you may experience a nasty surprise when you can least afford it.
Essential Maternity Benefits More Social Policy
The essential maternity health benefits baked into Obamacare (The Affordable Care Act) are more social policy than insurance. The implications for parents-to-be can be profound depending upon the outcome of their pregnancy. Those who understand these implications, can forecast their outcome, and then choose the optimal plan based upon the interaction of the two will come out ahead of the game.