Is Pregnancy a Pre-Existing Condition for Obamacare?
- Affordable Care Act (Obamacare) requires pregnancy to no longer be considered a pre-existing condition. Under Obamacare rules, insurance companies can't deny coverage or charge higher rates to a woman who is currently pregnant or who had prior pregnancies.
Prior to the passing of the Affordable Care Act (ACA, or “Obamacare”), it was commonplace for health insurance companies to charge higher rates or deny someone coverage entirely for pre-existing conditions.
Pregnancy was often considered a pre-existing condition, and women who were expecting were often unable to obtain affordable coverage as a result. Some health insurance companies considered a prior cesarean delivery a pre-existing condition and some carriers even considered a previous pregnancy to be a pre-existing condition. Many health insurance plans didn’t even cover prenatal, maternity or newborn care.
But the Affordable Care Act changed all that. Most insurance plans sold today are bound by ACA regulations, which means:
- Insurance companies can no longer deny coverage or charge higher rates because someone has a pre-existing condition.
- Pregnancy may no longer be classified as a pre-existing condition under an ACA-compliant plan.
This includes women who are currently pregnant or who have had prior pregnancies. ACA-compliant health insurance plans are also now required to provide prenatal, maternity and newborn benefits.
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How Do ACA and Non-ACA Plans Differ on Pregnancy?
Health insurance plans that are ACA-compliant are required to provide coverage for prenatal, maternity, newborn care and breastfeeding care and must do so without any cost-sharing (copays, coinsurance, etc.), as they are considered preventive services.
Most health insurance plans today are ACA-compliant, which includes all plans sold on the federal marketplace and most off-marketplace and employer-sponsored plans. Some of the health insurance plans that are not bound by ACA regulations include:
- Grandfathered or grandmothered plans, which were in effect prior to the passing of certain ACA regulations
- Temporary or short-term health insurance plans
- Workers’ compensation
- Indemnity plan
- Medical discount plan
- Supplemental accidental coverage
- Association Health Plans
- Agriculture/Farm Bureau Plans
- Sharing ministries
If you are enrolled in one of the above types of plans, you are not protected by ACA regulations and might not have access to the same pregnancy benefits. In such cases, pregnancy can be considered a pre-existing condition and you may be denied coverage or charged higher rates because of your pregnancy.
Can I Get Health Insurance While I’m Pregnant?
The Affordable Care Act ensures that pregnant women can sign up for health insurance and not be denied coverage or charged a higher premium because of their pregnancy under an ACA-compliant plan. However, there’s no guarantee that the entire duration of your pregnancy will be covered, because there is often a waiting period for benefits to take effect.
Below is a summary of how each type of ACA-compliant health insurance works as it relates to pregnancy.
Employer-Sponsored Health Insurance
Employer-sponsored plans are allowed to impose waiting periods of up to 90 days. If you are hired for a new job while pregnant, or become pregnant soon after being hired, you may have a lapse in coverage during your waiting period until your benefits take effect.
Marketplace (Obamacare) Plans
For plans purchased on the marketplace (Obamacare plans), there is an open enrollment period that begins Nov. 1 and lasts until Jan. 15 in most states. A few states allow enrollment as late as Jan. 31.
Most plans purchased on the federal or state marketplace before Dec. 15 become effective on Jan. 1. Plans purchased after Dec. 15 may have a Feb. 1 effective date, and a few states with later enrollment deadlines have benefits that take effect as late as March 1 for those who sign up late.
While most marketplace plans don’t technically have a waiting period, there is still a lapse in coverage between the time you sign up for coverage and the day the coverage begins, since no plans take effect before Jan. 1.
If you enroll on Dec. 14, you might only have to wait a couple of weeks for your benefits to begin on Jan. 1. But if you sign up on the first day of open enrollment on Nov. 1, you will have to wait at least two months for your coverage to kick in. If you are pregnant during the open enrollment season, you may have to endure a lapse in coverage before your benefits take effect.
Off-Exchange Plans
Plans sold by private insurance companies outside of the marketplace are referred to as “off-exchange” or “off-marketplace” plans. These plans are ACA-compliant and follow the same open enrollment period as marketplace plans.
Like marketplace plans, off-exchange plans generally do not have a waiting period but may result in a coverage gap between the time you sign up during open enrollment and the time the plan takes effect in the new year.
Is Becoming Pregnant a Qualifying Life Event?
Outside of the open enrollment period that takes place each fall, your only other opportunity to sign up for health insurance is during a special enrollment period.
To qualify for a special enrollment period, you must experience a qualifying life event including, but not limited to:
- Moving to a new area
- Involuntarily losing your health insurance coverage
- Experiencing a death in the family
- Becoming a U.S. citizen
Becoming pregnant does not count as a qualifying life event and will not make you eligible for a special enrollment period. However, having a baby or adopting a child is a qualifying life event and will make you eligible for a special enrollment period. If you are pregnant, you must wait until the birth of your child before beginning your special enrollment period.
Can I Buy Short-Term Health Insurance While Pregnant?
Yes. Short-term health insurance plans provide temporary coverage of less than one year and are designed to fill gaps created by changing jobs, waiting for Medicare eligibility or other scenarios.
However, short-term (or temporary) health insurance plans are not required to follow ACA regulations and may deny you coverage or charge you higher rates if you are pregnant.
Can I Stay on COBRA Coverage if I’m Pregnant?
Yes, you can stay on COBRA coverage if you’re pregnant.
Being pregnant does not disqualify you from remaining on your former employer’s insurance plan through COBRA. If the plan provides maternity benefits, you will receive the same coverage during your pregnancy and childbirth as you would if you were still employed.
Can I Get Medicaid While Pregnant?
Yes. Medicaid eligibility differs by state, but proof of pregnancy and proof of income that is below a certain threshold will qualify you for Medicaid in all states.
Specific maternity coverage under Medicaid can differ by state, but labor and delivery services are always covered with no out-of-pocket costs.
