Maternity insurance under ObamaCare (Affordable Care Act) allows parents to purchase individual coverage but holes remain: paid leave, left-over costs, dependent pregnancies, and more.
Parents can find an individual plan that covers normal pregnancy without long waiting periods. Women who are already pregnant can get coverage without being rejected for a preexisting condition. But the law is new, complicated, and difficult to understand and apply.
- ObamaCare maternity coverage holes
- ObamaCare maternity requirements
- Essential benefits
- Waiting periods for preexisting pregnancies
ObamaCare Maternity Coverage Holes
Finding the optimal plan choice can translate into thousands of dollars of savings for families with maternity needs. Start the process by understanding where the holes exist. Remember that pregnancy is a major health event, and complications arise 1/3 of the time. By understanding the holes you can be prepared with the correct plan choices.
Get a quote from an expert insurance agent when ready to enroll in a plan.
ObamaCare Maternity Leave
The first major hole that many families often miss is paid maternity leave. ObamaCare maternity leave does not exist anywhere in the law. Supplemental maternity insurance does fill this hole provided that coverage is purchased prior to conception, and the policies are bought at work via voluntary employee benefits.
Left-over Medical Expenses
Left-over medical expenses is the second hole with maternity insurance under ObamaCare. Families having children utilize significantly more healthcare services than the average consumer. In many respects the Affordable Care Act is more social policy than insurance. More people get better coverage, but certain populations may pay far more – those having children often end up with unexpected bills.
Five Different Cost Sharing Options
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.
One provision of the Affordable Care Act is to require employer group plans to include coverage for adults up to age 26. It is estimated that 70% of these plans do not cover dependent pregnancies. The new law does not close this loophole. Young adults on their parents’ plans may not have maternity insurance coverage under ObamaCare.
Spouse Policies at Work
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.
New ObamaCare Maternity Requirements
ObamaCare maternity requirements do many things to expand options for families planning to have children. Maternity riders have gone away! No more long waiting periods or large deductibles. Women who are already expecting can purchase plans (with timing limits). There may also be premium and costs sharing assistance based upon income.
Essential Maternity Benefits
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.
Open Enrollment Time frames
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.
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.
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.