Q. Now that the ACA has been implemented, do all health insurance plans cover maternity care?
A. Nearly all plan cover maternity. Since January 2014, the ACA has required all newly issued and renewing individual and small group health insurance policies to provide maternity coverage.
Large-group plans have long been required to include maternity coverage, thanks to the Pregnancy Discrimination Act of 1978, which applies to employers with 15 or more employees. In addition, 18 states had passed laws over the years that required smaller groups and/or individual policies to cover maternity benefits. Some states had tighter requirements even before the ACA, but the ACA closed the remaining gaps.
The ACA requires large employers (50 or more employees) to offer coverage to their full-time employees, and the longstanding Pregnancy Discrimination Act ensures that maternity care is part of the coverage.
The ACA also requires all individual and small group plans to include maternity care as one of the law’s essential health benefits. Small employers (up to 49 employees) are not required to offer coverage, but if they do, it has to include maternity care (small employers can self-insure instead of purchasing small group coverage, but they would still be subject to the Pregnancy Discrimination Act of 1978, assuming they have 15 or more employees).
And anyone who doesn’t have access to coverage from an employer can purchase an individual market plan instead, with coverage for maternity care included in all plans in every state. Maternity coverage must be covered on all non-grandfathered/grandmothered individual and small group plans issued on or after January 1, 2014. So all of the policies being sold in the exchanges — and off-exchange — include maternity coverage. The ACA also prohibits gender-based premium determination, so women cannot be charged more for their policies than men.
Prior to 2014, the majority of individual health insurance policies did not cover maternity as a standard benefit. In some states, it was available as an optional rider, but the cost was often prohibitively high, since the coverage was usually only purchased by people who were planning to use it, and was priced accordingly.
The ACA also prohibits health plans from turning away applicants because of preexisting conditions, including pregnancy. Prior to 2014, pregnant women (and expectant fathers) in most states could not obtain coverage in the individual market, even if the plan didn’t include any maternity benefits (the reason expectant fathers were denied coverage was that insurers were generally required to allow either parent to add a newborn baby to the parent’s existing health policy without any medical underwriting; allowing either parent to enroll during the pregnancy would open the insurer up to potentially having to cover a baby with serious health conditions from the first day of its life).
Exceptions: There are still plans that don’t cover maternity
There are a few exceptions to keep in mind – some plans still don’t cover maternity care.
In addition, large group plans are not required to provide maternity coverage for dependent children, which has become more significant now that adult children can remain on their parents’ plans through age 26. The National Women’s Law Center filed a discrimination complaint about this in June 2013. In May 2015, HHS announced that plans must cover preventive care – including prenatal care – for dependents, but there is still no requirement that dependents be covered for labor and delivery costs.
And coverage that’s not regulated by the ACA (ie, “excepted benefits“) does not have to conform to any of the new rules. So if you purchase a short-term insurance policy, a fixed indemnity plan, travel insurance, or other supplemental coverage, it’s not likely to provide any maternity benefits.
Healthcare sharing ministries are also not regulated by the ACA (or state insurance departments, as they’re not technically considered insurance), so there’s no requirement that they provide maternity benefits. Some of these plans will allow members to share maternity costs, but there is often an exclusion for out-of-wedlock births, or for pregnancies that begin before the person joins the sharing ministry plan.
If you’re buying a plan that’s not regulated with the ACA, there’s a good chance that it won’t cover maternity, and it’s also likely that your application will be rejected if you’re already pregnant when you apply for coverage. Note that individual major medical plans that are grandfathered or grandmothered can no longer be sold to new applicants, but excepted benefits can still be sold to new applicants, and can reject applicants based on medical history. Pay attention to the fine print, and know that there are plans available in every state that do cover maternity care, although enrollment is limited to open enrollment periods and special enrollment periods, just the way it is for employer-sponsored plans.
(Some states, including New York, Connecticut, Maine, New Jersey, and DC, provide a special enrollment period that begins when a pregnancy is confirmed by a medical provider. This is unusual, however, as most states allow a special enrollment period that begins when the baby is born, but not at the start of the pregnancy).
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.