Discover Mid-Year Your Health Plan Doesn’t Cover Maternity Services? You May be Out of Luck

My colleagues and I here at CHIR were asked to help a young woman in Florida who had recently been thrilled to discover she is pregnant. But she was not so thrilled to learn that her health insurance policy doesn’t cover maternity services. She wanted to know – can she switch plans to one that covers the care she and her baby need? And, why doesn’t her plan cover maternity services? Under the Affordable Care Act, isn’t maternity a required minimum essential benefit?

Can She Switch Plans?

Unfortunately, the answer is no. The open enrollment period for coverage in 2014 closed on March 31, 2014. There are life events, such as the loss of a job or a move, that would allow her to obtain a special enrollment period, but pregnancy by itself doesn’t do it. Once she has the baby, she’ll qualify for a special enrollment period and can switch plans, but until then she’s stuck in a plan that doesn’t cover critical pre-natal care or her labor and delivery.

We asked whether she might qualify for Medicaid, which has year-round enrollment, but in Florida her income is too high to qualify.

Why Doesn’t Her Plan Cover Maternity Services?

Although this new mom-to-be has a good job, it doesn’t offer a group health plan, so she had to buy coverage on the individual insurance market. She purchased her policy in 2012, before full implementation of the Affordable Care Act, and a time when it was not uncommon for health plans to offer skimpy coverage. In her case, the plan did not cover maternity services, which she didn’t realize at the time she bought it.

The Affordable Care Act requires all individual and small group market health plans to cover a minimum set of essential health benefits, beginning January 1, 2014. It’s now June 2014, so why doesn’t her plan cover maternity services?

She’s not in a “grandfathered” plan. Grandfathered plans are those that were in existence on or before March 23, 2010, the day the Affordable Care Act was signed into law. In this woman’s case, she purchased her plan in 2012, so it’s not grandfathered.

Most likely, her plan was early renewed in 2013, allowing it to escape many of the Affordable Care Act’s consumer protections, such as minimum essential benefits, for much of 2014. As we’ve discussed in previous blog posts, this practice, which became widespread towards the end of 2013 and was allowed to be extended by the Obama Administration through 2017, leaves many Americans in plans that may not meet their needs. In the case of this young woman, it’s leaving her exposed to thousands of dollars in health care costs. If she delays or foregoes pre-natal care because of the expense, it could put her health or the health of her fetus at risk.

I wish we had a better answer for her.

1 Comment

  • Chelsea says:

    Sabrina, my fiancé and I are in the same position as the young lady you described above. My coverage began in January 2013 with United Healthcare and was purchased as an individual plan as my employer doesn’t offer group insurance coverage to his employees. I found out that I was pregnant on February 17th and “Open Enrollment” ended on February 15th. I was advised that pregnancy isn’t a special circumstance to qualify for Special Enrollment so we are in quite the pickle. I am so happy to be expecting but the stress of knowing that I have no control in switching my insurance to another carrier or policy is very overwhelming. We are due in October which is before Open Enrollment begins. The policy only covers my pregnancy if there are “complications.” I am not looking forward to the hospital bill. 🙁

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