Access to affordable, high-quality, comprehensive health care services during pregnancy has long depended on the type of health insurance one is eligible for and enrolled in. While that remains true, the Affordable Care Act (ACA) has also changed and expanded. health care options available to pregnant women. this question and answer addresses the coverage and services available to women who are uninsured, enrolled in traditional or expansion medicaid, enrolled in a marketplace health plan, or covered by private or employer-sponsored insurance.
medicaid and chip for uninsured women
1. Can an uninsured woman enroll in a public health insurance plan when she becomes pregnant?
Yes, women who meet the eligibility criteria for Medicaid or the Children’s Health Insurance Program (CHIP) can enroll in one of these public programs at any time during their pregnancy:
A pregnant woman is eligible for full Medicaid coverage at any time during her pregnancy if she is eligible under state requirements. eligibility factors include household size, income, residency in application state, and immigration status. an uninsured woman who is already pregnant at the time of application is not eligible to enroll in expanded medicaid.
medicaid related to pregnancy
if household income exceeds the income limits for full coverage medicaid, but is at or below the state income limit for pregnancy-related medicaid, a woman is entitled to medicaid in the coverage category for “pregnancy-related services” and “conditions that could complicate pregnancy.” Income limits for pregnancy-related Medicaid vary, but states cannot reduce eligibility for this coverage for below a minimum legal limit ranging from an income of 133% to 185% of the fpl (federal poverty level). level), depending on the state. states may set a higher income limit.
children’s health insurance program (chip)
States also have the option to provide coverage to pregnant women under the state chip plan. This option is particularly important for women who are not eligible for other programs, such as Medicaid, based on income or immigration status. states may provide health care coverage to a pregnant woman directly or to a pregnant woman by covering her fetus. each state has the discretion to set maximum financial eligibility thresholds above a specific floor, but most states set their limits well above 200% fpl.
2. can a pregnant woman receive medicaid or chip services prior to an eligibility decision?
maybe. States may choose, but are not required, to provide some categories of Medicaid enrollees, including pregnant women, with “presumptive eligibility.” where they submit a presumptive eligibility application for Medicaid. currently 30 states provide presumptive eligibility to pregnant women.
3. Are you an uninsured woman who has access to a family member’s employer-sponsored health insurance, but has not enrolled in that plan, eligible for Medicaid or Chip?
yes, medicaid and chip eligibility is not affected by access to employer-sponsored or other types of private health insurance coverage.
4. Do Medicaid and Chip provide pregnant women with comprehensive health coverage?
yes, in most states, but not all. Full coverage Medicaid in all states provides comprehensive coverage, including prenatal care, labor and delivery, and any other medically necessary services.
Pregnancy-related Medicaid covers services “necessary for the health of a pregnant woman and her fetus, or made necessary as a result of the woman’s having been pregnant.” federal guidelines from the department of health and human services (hhs) clarified that the scope of covered services must be comprehensive because the health of the woman is intertwined with the health of the fetus, making it difficult to determine which services are pregnancy-related .[eleven] federal statute mandates coverage for prenatal care, delivery, postpartum care, and family planning, as well as services for conditions that may threaten delivery of the fetus at term or safe delivery of the fetus. the state ultimately decides what broad set of services are covered. Forty-seven states provide pregnancy-related health care that meets Minimum Essential Coverage (MEC) and is therefore considered comprehensive. pregnancy-related medicaid in arkansas, idaho, and south dakota is non-mec compliant and not comprehensive.
Chip coverage for pregnant women is also usually comprehensive. however, in states where services are provided to the pregnant woman covering the fetus, the services may not be comprehensive with respect to the health needs of the pregnant woman.
5. what is the obligation to share costs under medicaid or chip?
none. Medicaid law prohibits states from charging deductibles, copays, or similar charges for services related to pregnancy or conditions that may complicate pregnancy, regardless of Medicaid enrollment category. hhs assumes that “pregnancy-related services” include all services covered by the state plan, unless the state has justified the classification of a specific service as non-pregnancy-related in its state plan. however, states may impose monthly premiums on pregnant women with incomes above 150% fpl and charge for non-preferred drugs.
Most states that cover pregnant women in their chip program have no cost sharing or any other fees associated with participating in the program.
6. how long does medicaid or chip coverage last for pregnancy?
Medicaid or chip coverage based on pregnancy lasts through the postpartum period and ends on the last day of the month in which the 60-day postpartum period ends, regardless of changes in income during that time. once the postpartum period is over, the state must assess the woman’s eligibility for any other category of medicaid coverage.
7. is abortion covered by medicaid or chip?
the hyde amendment, an annual requirement added by congress to a federal appropriations bill, prohibits the use of federal funds to cover abortions, except when the pregnancy is the result of rape or incest, or when the continuation of pregnancy endangers the woman’s life. however, states can use their own funds to cover abortions, and 17 states currently do.
8. can uninsured immigrant women receive medicaid or chip services?
maybe. Immigrants with qualified non-citizen status are eligible to enroll in Medicaid if they meet state Medicaid eligibility requirements, but are subject to a five-year waiting period from the time they receive their qualified immigration status before becoming eligible. .[twenty] some categories of qualified noncitizens are exempt from the five-year bar because they are considered lawfully residing immigrants. For legally residing immigrants, the five-year waiting period was eliminated in 2010, giving states the option to provide legally residing immigrant women with pregnancy-related medical assistance, regardless of how long they have been in the United States. . u. Twenty-three states provide pregnancy-related medical assistance to legally residing immigrants without waiting periods. For DACA-eligible undocumented immigrants, states can provide undocumented immigrant women with federally funded prenatal services via chip. some states may also provide prenatal care entirely with state funds.
market options for uninsured women
1. Can uninsured women enroll in Marketplace coverage when they become pregnant?
only if you are within the established open enrollment period or a woman qualifies for a special enrollment period (sep), does not have a mec-compliant plan through medicaid or an employer, and meets income criteria and immigration. note that except in the states of new york and vermont, pregnancy does not trigger a sep.
Under the aca, individuals who do not qualify for mec-compliant medicaid coverage, and have income between 100% and 400% fpl, qualify for advance premium tax credits (aptcs) and cost-sharing reductions ( csrs), which you can use to lower the cost of health insurance purchased through a marketplace. those with pregnancy-related medicaid in the three non-mec states (arkansas, idaho, and south dakota) are eligible for marketplace subsidies. certain lawfully present immigrants with incomes below 100% fpl subject to their state’s five-year medicaid ban are also eligible for aptcs. undocumented immigrants are not eligible for aptcs, csrs, or marketplace insurance.
2. what is the cost-sharing obligation under a marketplace plan?
Marketplace plans may include premiums, copays, and deductibles. The ACA requires new group health plans and insurance issuers to cover women’s health screenings and preventive care in accordance with Health Resources and Services Administration guidelines. health plans must cover well-woman visits and some preventive services, including some key prenatal care services, without cost sharing. however, pregnant women in the marketplace may have cost shares for some prenatal visits and pregnancy services, such as labor, delivery, and postpartum care. The amount of cost sharing required will depend on many factors, including household size, income, plan choice, and APTC or CSR eligibility.
3. Is a woman who has access to a family member’s employer-sponsored health insurance, but has not enrolled in that plan, eligible to receive subsidies in the marketplace?
possibly. if employer-sponsored insurance is unaffordable or non-mec, the woman is eligible for aptcs. affordability is determined by irs standards for the percentage of income a person is expected to spend on insurance. this calculation applies to the cost of the employee’s insurance, not the cost of the family plan. That means if the employee’s insurance premiums are “affordable,” no family member is eligible for an apt. if the individual’s premium is not affordable, the family will be eligible for aptcs for an amount determined by their income and the cost of the premium.
4. Can an uninsured woman sign up for Marketplace coverage when giving birth?
maybe. if the baby is eligible for Marketplace coverage, then the baby qualifies for a “new dependent” separation. ” until birth.
women who are already enrolled in full or expansion medicaid
1. What changes when a woman who is already enrolled in Medicaid becomes pregnant?
usually nothing. a previously eligible woman enrolled in full coverage medicaid who becomes pregnant remains eligible and will be able to access pregnancy services. a woman who becomes pregnant while enrolled in expanded medicaid can remain on that coverage, at least until redetermination. the state must inform the woman about benefits provided to pregnant women under other coverage categories, such as pregnancy-related medicaid, and provide the option to change category if the woman is eligible.
2. Will Medicaid also cover a newborn?
yes. a child born to a woman enrolled in medicaid or chip at the time of birth is eligible for newborn coverage. this coverage begins at birth and lasts for one year, regardless of any change in household income during that period.
3. what is the cost sharing obligation under medicaid?
See the answer to question #5 in the “Uninsured Women: Public Options for Uninsured Women” section above.
4. Does comprehensive and expansion Medicaid provide pregnant women with comprehensive health insurance?
yes. Medicaid coverage includes prenatal care, labor and delivery, and all medically necessary services, regardless of whether they are directly related to the pregnancy.
women who are already enrolled in market health plans
1. Do market health plans provide women with comprehensive coverage, including maternity care?
yes. all plans in the marketplace must include the ten essential health benefits (ehbs), one of which is maternity and newborn care. hhs has not specified what should be covered under this category, delegating that authority to the states. therefore, the specific benefits covered for maternity care vary by state.
2. What changes when a woman enrolled in a marketplace plan becomes pregnant?
nothing, unless she wants to. the woman can choose to stay in a marketplace plan or, if she is eligible, enroll in medicaid or chip. the woman will not lose eligibility for aptcs as a result of accessing mec through full medicaid or pregnancy-related, but she cannot enroll in both simultaneously and therefore must choose. when deciding which coverage to select, overall cost, access to preferred providers, the impact of transitioning between plans, and the effect on family coverage influence preference.
3. Can a woman who transitioned from marketplace insurance to medicaid or chip re-enroll in a marketplace plan, if she is eligible, when giving birth?
maybe. having a baby may qualify a woman to re-enroll in Marketplace coverage if the newborn is eligible for Marketplace coverage and a Sep.
4. Will a health plan in the marketplace also cover a newborn?
yes. the aca’s ehb requirement calls for coverage of maternity and newborn care. Newborn care covers delivery and immediate care of the baby after birth. Details of this coverage will vary by state and by individual plan, but all women on Marketplace coverage must also enroll their baby in coverage shortly after birth.
If the newborn is eligible for Marketplace coverage, then the parents can choose to add the baby to the family’s existing Marketplace plan or choose a new Marketplace plan for the baby. if they opt for the latter, they can enroll the baby in a new Marketplace plan at any metal level. however, when a newborn is enrolled in Marketplace coverage, other household members are generally not allowed to change their existing Marketplace coverage.
5. Is abortion covered by the market plans?
in some states, depending on the plan. Twenty-five states restrict the availability of abortion coverage in Marketplace health plans. two states restrict it entirely, and 23 restrict it to variations of the hyde exceptions. the other states have no restrictions.
women who are already enrolled in employer-sponsored or non-market private insurance
1. Do employer-sponsored or other non-market private insurance plans provide women with comprehensive coverage, including maternity care?
it depends. Employer-sponsored small group plans must include EHBs, including maternity and newborn care, but employer-sponsored large group and self-insured plans are exempt from this requirement.
2. Can a woman stay on private insurance while she uses Medicaid benefits?
yes. a woman who meets the income and eligibility requirements for medicaid can use it in conjunction with an off-market private insurance plan.
3. Does private insurance also cover a newborn?
it depends. Small group employer-sponsored plans must include EHBs, including maternity and newborn care, but large group and self-insured employer-sponsored plans are exempt from this requirement. While the newborn care requirement covers delivery and immediate postnatal care, women must enroll their babies in coverage soon after birth.
4. Does private insurance cover abortion?
in some states, depending on the plan. ten states restrict the availability of abortion coverage in private health plans, and the remainder have no such restrictions.
Navigating the different types of health care coverage available to pregnant women can be difficult. Fortunately, with the advent of ACA, pregnant women have more options for health care coverage. low-income women who are uninsured when they become pregnant can enroll in medicaid and receive comprehensive health care services during and immediately after pregnancy. Women who already have health insurance at the time they become pregnant can usually keep that coverage or, if they qualify, transition to Medicaid. upon giving birth, a woman’s health coverage options may change again, allowing her to transition to new care or return to a previous source of health care coverage.
 When determining Medicaid eligibility, the number of children the pregnant woman is expected to give birth to counts as part of the household size. thus, for example, if a woman is pregnant with triplets, it counts as a household of four. states can decide whether to count the pregnant woman as one or two people in determining the eligibility of other people in the household. therefore, if a woman is pregnant with triplets, when determining the eligibility of other household members, she will only count as one or two people. 42 c.f.r. §435.603(b). household income cannot exceed the limit established by the state cash assistance program (afdc) that was in effect on may 1, 1996. 42 u.s.c. §§ 1396a(a)(10)(a)(i)(iii), 1396d(n)(1); Changes in eligibility for the Medicaid program under the Affordable Care Act of 2010, 77 Fed. record 17144, 17205 (March 23, 2012). states must accept self-certification of pregnancy unless the state has information that is not reasonably compatible with such certification. 42 c.f.r. § 457.380 (e).
 42 u.s.c. § 1396a(a)(10)(a)(i)(viii); 42 c.f.r. § 435.119(b) (defining eligibility for Medicaid expansion). see pages 7-8 below for information about women who are already enrolled in expanded medicaid.
 42 u.s.c. §§ 1396a(a)(10)(a)(i)(iv), (vi); 42 usc §§ 1396a(l)(1)(a)-(c), 2(a)-(b). Pregnancy-related Medicaid that meets Minimum Essential Coverage (MEC) requirements is comprehensive coverage because it covers all medically necessary services. See Amy Chen, Pregnancy-Related Medicaid and Minimum Essential Coverage, National Health Law Program (January 25, 2017), http://www.healthlaw.org/issues/health-care-reform/pregnancy-related- medicaid-and-minimum-essential-coverage.
 42 c.f.r. §435.116; 77 fed. record 17144 in 17205.
 chip eligibility for pregnant women must be set to at least 185% fpl or the level it was in 2008, but can be set higher. 42 usc § 1397ll(a).
 42 u.s.c. § 1397ll(a). child means a person under the age of 19, including the period from conception to birth, so a state may choose to cover pregnant women as a means of covering “unborn children.” 42 c.f.r. § 457.10. For CMS guidance on how to cover pregnant women via chip, see also CMS, Dear State Health Officer (May 11, 2009), https://downloads.cms.gov/cmsgov/archived-downloads/ smdl/downloads/sho051109.pdf; cms, dear state health officer (September 2, 2009), https://www.medicaid.gov/federal-policy-guidance/downloads/sho090309.pdf.
 see tricia brooks et al, where are the states today? Medicaid and chip eligibility, enrollment, renewal, and cost-sharing policies as of January 2018: Findings from a table of 50-state surveys 4, the kaiser family found. (March 2018), http://files.kff.org/attachment/report-medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018.
 cms, dear state health official (September 2, 2009), supra note 8.
 For a list of states that provide presumptive eligibility for pregnant women, see presumptive eligibility in medicaid and chip, the kaiser family found. (January 1, 2017), http://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip.
 42 cf. § 440.210(a)(2)(i).
 medicaid program; Eligibility changes under the Affordable Care Act of 2010, 77 Fed. record 17143, 17149 (March 23, 2012).
 42 cf. § 440.210(a)(2)(i)-(ii).
 chen, supra note 5, at 4.
 42 u.s.c. §§ 1396o(a)(2)(b), 1396o(b)(2)(b) (prohibiting deductions, cost sharing, or similar charges for pregnancy-related services for pregnant women); 42 c.f.r. §§ 447.53(d), 447.56(a)(vii) (allowing non-preferred but non-preferred prescription drug cost-sharing for pregnant women on Medicaid); Medicaid and children’s health insurance programs: essential health benefits in alternative benefit plans, eligibility notices, appeal and fair hearing processes, and premiums and cost sharing; exchanges; eligibility and enrollment; 78 fed. registration 42160, 42,281 (July 15, 2013) (clarifying that family planning supplies and services, including contraceptives, are exempt from cost sharing).
 42 u.s.c. § 1396o(c).
 fact sheet: state children’s health insurance program (s-chip) coverage during pregnancy, association of state and territory health officials (2016), http://www.astho.org/maternal -and-child- health/state-childrens-health-insurance-program-s-chip-coverage-during-pregnancy.
 42 u.s.c. § 1396a(e)(6).
 For more information on the Hyde Amendment, see Alina Salenicoff et al., The Hyde Amendment and Coverage of Abortion Services, The Kaiser Family found. (September 30, 2016), http://www.kff.org/womens-health-policy/perspective/the-hyde-amendment-and-coverage-for-abortion-services.
 state funding of abortion under medicaid, guttmacher inst. (June 1, 2017), https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid; Alina Salenicoff et al., Coverage for Abortion Services in Medicaid, Marketplace Plans, and Private Plans, Kaiser Family Found. (January 20, 2016), http://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans.
 coverage for lawfully present immigrants, healthcare.gov, https://www.healthcare.gov/immigrants/lawfully-present-immigrants.
 cms, dear state health official (July 1, 2010), https://www.medicaid.gov/federal-policy-guidance/downloads/sho10006.pdf.
 medicaid/chip coverage for legally residing immigrant children and pregnant women, the kaiser family discovered. (January 1, 2017), http://www.kff.org/health-reform/state-indicator/medicaid-chip-coverage-of-lawfully-residing-immigrant-children-and-pregnant-women.
samantha artiga & anthony damico, immigrant health and care coverage, kaiser family found. (June 11, 2017), http://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants.
 Tanya Broder et al., Overview of Immigrant Eligibility for Federal Programs, National Immigration Law Ctr. (December 2015), https://www.nilc.org/wp-content/uploads/2015/12/overview-immeligfedprograms-2015-12-09.pdf; Frequently Asked Questions: Exclusion of Youth Granted “Deferred Action for Childhood Arrivals” from Affordable Health Care, National Immigration Law CTR. (September 2013), https://www.nilc.org/issues/health-care/acadacafaq/.
 Amy Chen & Mimi Spalding, State Creation of Special Enrollment Periods for Pregnancy, National Health Law Program 6-7 (January 26, 2017), http://www.healthlaw.org/issues/reproductive-health/pregnancy/state -creation -of-sep-by-pregnancy.
 26 u.s.c. § 36b(c)(1)(a). a “qualified individual” can get coverage through the Marketplace. 42 USC § 18031(d)(2)(a). a “qualifying individual” excludes people who are incarcerated and people with certain immigration statuses. quick guide to the health insurance marketplace: are you eligible to use the marketplace? healthcare.gov, https://www.healthcare.gov/quick-guide/eligibility.
 cms, Estimated State Health Officer #14-002, Minimum Essential Coverage 10 (November 7, 2014), https://www.medicaid.gov/federal-policy-guidance/downloads/ sho-14-002.pdf. cms, minimum essential coverage approved by the secretary of medicaid, department of health & amp; human services 2, 5-6 (February 16, 2012), https://www.medicaid.gov/medicaid/benefits/downloads/state-mec-designations.pdf. In addition to some pregnancy-related Medicaid, the following types of Medicaid coverage are not considered MEC: Expansion of family planning under a state plan amendment; optional coverage of tuberculosis-related services; and coverage for emergency medical services only. 78 fed. record 53646 at 53,658 (Aug 30, 2013).
 26 u.s.c. § 36b(c)(1)(b).
 42 u.s.c. §18071(e)(1).
 Women’s Preventive Services Guidelines, res. of health. & serves administration. (December 20, 2016), https://www.hrsa.gov/womensguidelines2016/index.html. To learn more about which pregnancy-related preventive services are covered at no cost-share, check out the Preventive Services Tracker, found by the kaiser family. (September 2015), http://www.kff.org/report-section/preventive-service-tracker-pregnancy-related.
 42 u.s.c. § 18082 (a)(2)(b).
 26 c.f.r. § 1.36b-3(g)(2).
 45 c.f.r. § 155.420(d)(2)(i).
 77 fed. registration at 17,149 (providing that the state does not have to transfer a woman who becomes pregnant already enrolled in the expansion category of medicaid to coverage in the pregnancy-related services category since states are not required to monitor the pregnancy status). however, it is unclear whether a woman will have to change to the pregnancy-related category if she presents for redetermination while she is enrolled in the new low-income adult medicaid category.
 id. see also cms, questions and answers: medicaid and the affordable care act at a11-a12 (february 2013), http://www.medicaid.gov/state-resource-center/faq-medicaid-and-chip-affordable – care-actimplementation/downloads/aca-faq-bhp.pdf.
 cms, dear state health official (Aug 31, 2009), https://www.medicaid.gov/federal-policy-guidance/downloads/sho-08-31-09b.pdf.
 but note that women who are already pregnant at the time of application are not eligible to enroll in expanded medicaid. Women who are already enrolled in expanded Medicaid at the time they become pregnant can keep their current coverage until their next renewal or transition to pregnancy-related coverage.
 42 u.s.c. § 18022(b)(1)(d). See also Michelle Lilienfeld, The Importance of Essential Health Benefits in the Private Market, National Health Law Program (January 12, 2017), http://www.healthlaw.org/issues/health-care-reform/ importance-of-essential-health-benefits-in-the-private-market. recent legislation that attempts to repeal and replace aca would give states the option to waive ehbs. For more on the harm this would do to women and children, see Adam Sonfield, Nobody Benefits If Women Lose Maternity Care Coverage, Guttmacher Inst. (June 14, 2017), https://www.guttmacher.org/gpr/2017/06/no-one-benefits-if-women-lose-coverage-maternity-care.
 essential health benefits bulletin, ctr. for consumer information. & in s. oversight (December 16, 2011), https://www.cms.gov/cciio/resources/files/downloads/essential_health_benefits_bulletin.pdf.
 Internal Revenue Service, Notice 2014-71, Eligibility for Minimum Essential Coverage under Pregnancy-Based Medicaid Programs (2014), https://www.irs.gov/pub/irs -drop/n-14-71.pdf (“an individual enrolled in a qualified health plan who becomes eligible for Medicaid coverage for pregnancy-related services that is minimum essential coverage, or for chip coverage based on in pregnancy, is considered eligible for minimum essential coverage under the or chip coverage for purposes of the premium tax credit only if the individual enrolls in the coverage).
 45 c.f.r. § 155.420(d)(2)(i). if a woman continues to be eligible for medicaid, e.g. as a caregiver for a minor child, she will not be eligible for aptcs as a result of qualifying for other mecs. 26 usc § 36b(c)(2)(b).
 82 fed. registration 18346, 18360-18361 (April 18, 2017).
 45 c.f.r. § 155.420(d)(2)(i); 45 c.f.r. § 155.420(a)(4)(i).
 restricting insurance coverage of abortion, guttmacher inst. (June 1, 2017), https://www.guttmacher.org/state-policy/explore/restricting-insurance-coverage-abortion; Salenicoff et al., supra note 20.
 Michelle Lilienfeld, Health Advocate: Essential Health Benefits Overview, National Health Law Program (Aug. 17, 2015), http://www.healthlaw.org/issues/health -care-reform/health -abogado-ehb.
 medicaid coverage for pregnant women remains critical to women’s health, national women’s law ctr. (May 2015), https://nwlc.org/wp-content/uploads/2015/08/medicaid_coverage_for_pregnant_woman3.pdf.
 michelle lilienfeld, supra note 52.
 restriction of abortion insurance coverage, supra note 51; Salenicoff et al., supra note 20.