Maternity Coverage in Colorado
The Affordable Care Act (ACA), also known as Obamacare, mandated that all health insurance plans include coverage for medical expenses incurred as a result of pregnancy and delivery, as well as care of newborns. Prior to this, few individual health insurance plans included maternity coverage, and those that did were often prohibitively expensive. Others required waiting periods for covering pregnancy medical costs, or very high deductibles that often rivaled the cost of pregnancy itself.
However, if you want a low-cost coverage option that covers maternity benefits, healthshare plans is a great option. We've provided the details on our healthshare maternity coverage page.
Paying for the Cost of Having a Baby: How Plans Basically Work
Now you can be assured that any health insurance plan you choose in Colorado will cover pregnancy and delivery, just like any other medical expense. All health insurance companies offer five basic levels of coverage. The plans differ with respect to how much of the costs of your health care you cover, and how much the insurance company picks up. They are rated based on an “actuarial value” that calculates how much of a typical policyholders medical expenses will be covered in one year.
- Catastrophic plan: This level of coverage has an actuarial value of less than 60%, leaving the average policyholder paying over 40% of their healthcare costs. Catastrophic plans are only available to people under 30, or those with what the government calls a “hardship exemption.” There are several situations that qualify you for this exemption, and there’s a complete list on our Hardship Exemption page. This coverage is extremely minimal but very low in cost.
- Bronze plan: 60% actuarial value
- Silver plan: 70% actuarial value
- Gold plan: 80% actuarial value
- Platinum plan: 90% actuarial value
If you know you want to become pregnant during the upcoming year, it probably makes sense to choose a plan that covers a greater percentage of your costs, like a gold or platinum plan. This way more of the costs of prenatal care and labor and delivery will be covered by your insurance plan. These plans are more expensive, but you can always change to a less expensive plan the following year.
Being Pregnant is No Longer a “Pre-Existing Condition”
In the past insurance plans did not cover the cost of maternity if the insured was not covered prior to becoming pregnant. This is no longer the case. Coverage cannot be denied due to pregnancy, nor can the payment of claims associated with it be denied.
All health insurance plans must provide coverage for breastfeeding support, counseling, and equipment during the duration of breastfeeding. Your health insurance company will consult with your doctor about what is specifically needed in your case, and the plan will likely have guidelines as to whether you may purchase a new pump, rent a pump, and whether it will pay for a manual or electric pump. Your individual plan will spell this out.
Special Enrollment Period After Giving Birth
Most people can only enroll in coverage or change to a new plan during the federal government’s Open Enrollment Period (OEP), which is typically between November 1 through January 31. When you give birth, you qualify for a Special Enrollment Period (SEP). You can enroll up to 60 days after the baby is born and still have coverage effective from the baby’s birthdate. The SEP allows you to either 1) keep your current Marketplace plan and add your baby to your plan, or 2) enroll in a different Marketplace plan.
When Pregnancy Might Not Be Covered By Your Plan
There are still a few “grandfathered” plans in force. These plans are not ACA-compliant, and may not cover the costs of maternity. If you have one of these plans, consult your insurance carrier about how these claims are handled. These policies are no longer for sale, so it’s not possible to purchase a plan at this point that does not offer coverage for maternity.
Deductibles, Coinsurance and Copayments
All Marketplace plans have coinsurance, deductibles and copayments. These charges represent the amount of money you will pay out of your own pocket for your pregnancy and delivery. Those plans in the “catastrophic” category have the largest total amount of outlay in terms of these, while those in the “platinum” category have the smallest. The vast majority of the costs associated with pregnancy and delivery are subject to these.
A deductible is the lump-sum amount of medical costs you will have to incur before your plan begins to pay anything. For example, if your plan carries a deductible of $1000, the total costs associated with doctor’s visits, drugs, testing, etc, for a given calendar year must reach $1000 before your insurance company will pay. So that initial $1000 is one of your out-of-pocket costs.
Coinsurance refers to the percentage of the cost of a covered service that you are required to pay. Not all services require the payment of coinsurance by the insured, but many do. The amount of coinsurance you pay varies depending on whether your plan is catastrophic, bronze, silver, gold, or platinum. If your coinsurance is 20% for doctor’s visits, for example, and the visit charge is $100, you’ll pay $20 for the visit, and the insurance company will pay $80. Coinsurance is typically paid at the time of the visit.
A copayment is a fixed amount you pay for a particular covered service, usually at the time the service is provided. The insurance company pays the remainder of the allowed amount of the cost of the service.
Some Services Are Not Subject to Deductibles, Coinsurance or Copayments
Some of the common costs of pregnancy are not subject to deductibles, coinsurance or copayments. One-hundred percent of the cost of these items is covered by your insurance company. These include:
- Anemia testing
- Testing for gestational diabetes between 24 and 28 weeks (and at other times during the pregnancy for those considered at high-risk for development of this metabolic disorder)
- The cost of folic acid supplements (for those who are or may become pregnant)
- Hepatitis B screening when you first become pregnant
- Rh incompatibility screening
- Urinary tract or other infection screening
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