Can a pregnant woman get health insurance?
June 2, 2011 10:52 AM Subscribe
My wife is pregnant. Does that basically make it impossible for us to get health insurance?
I have a job that provides health insurance that covers both me and my wife. I've received a grant that will allow me to leave my job for a couple of years to do some exciting work in my field. Taking that grant means leaving my job and, thus, insurance. If pregnancy is a preexisting condition—which, except for under HIPAA, which doesn't apply here, I believe it is—then is it going to be impossible to get coverage elsewhere? I would ask my insurance agent, but she's a family friend, and we haven't told anybody we're expecting yet.
I'm in the United States. (Obviously...)
I have a job that provides health insurance that covers both me and my wife. I've received a grant that will allow me to leave my job for a couple of years to do some exciting work in my field. Taking that grant means leaving my job and, thus, insurance. If pregnancy is a preexisting condition—which, except for under HIPAA, which doesn't apply here, I believe it is—then is it going to be impossible to get coverage elsewhere? I would ask my insurance agent, but she's a family friend, and we haven't told anybody we're expecting yet.
I'm in the United States. (Obviously...)
I would do some research about pregnancy being designated as preexisting. I could have sworn that insurance companies cannot deny you for pregnancy (seeing the health of another, your wife, etc). Not saying you wouldn't pay a boatload perhaps and/or get crappy coverage beyond basic care but I don't think they can flat out deny you for that.
Call around.
posted by stormpooper at 10:55 AM on June 2, 2011
Call around.
posted by stormpooper at 10:55 AM on June 2, 2011
That is to say, if the size of your current company is large enough.
posted by Zophi at 10:55 AM on June 2, 2011
posted by Zophi at 10:55 AM on June 2, 2011
I went through this last year in California, and pregnancy is a pre-existing condition for her AND for you! The only way we could get covered was with a HIPAA plan, since there was no COBRA. Fortunately, the HIPAA rate is actually cheaper than most COBRA rates.
Maybe newly-effective provisions from healthcare reform have changed this since last year...
posted by hammurderer at 11:00 AM on June 2, 2011 [1 favorite]
Maybe newly-effective provisions from healthcare reform have changed this since last year...
posted by hammurderer at 11:00 AM on June 2, 2011 [1 favorite]
Yeah, read up on COBRA. That said, your COBRA premium will probably be insanely expensive. But preexisting conditions are not that big a deal if you currently have insurance - just don't interrupt your coverage.
The trouble is a lot of individual insurances don't just consider pregnancy to be a preexisting condition, they don't cover pregnancy expenses at all, or they charge an extra pregnancy insurance rider that is approximately the cost of a normal pregnancy.
All of this is going to vary wildly depending on what state you live in, though. Might be a good time to move to Vermont or Massachusetts :)
posted by mskyle at 11:03 AM on June 2, 2011
The trouble is a lot of individual insurances don't just consider pregnancy to be a preexisting condition, they don't cover pregnancy expenses at all, or they charge an extra pregnancy insurance rider that is approximately the cost of a normal pregnancy.
All of this is going to vary wildly depending on what state you live in, though. Might be a good time to move to Vermont or Massachusetts :)
posted by mskyle at 11:03 AM on June 2, 2011
Is it not possible to continue with your existing insurance provider?
posted by Gomez_in_the_South at 11:43 AM on June 2, 2011
posted by Gomez_in_the_South at 11:43 AM on June 2, 2011
Pre-existing exclusions do not generally apply to people who already have health insurance.
Previously.
You'll need to get what's called a "certificate of credible coverage" from your current carrier, which you can present to other carriers to avoid this exclusion.
Now it may be the case that your new carrier will decline to write you at all, but that's different than being subject to a pre-existing condition exclusion.
Call a couple of brokers and see what you can find. Avoid COBRA, as it's stupidly expensive.
posted by valkyryn at 11:45 AM on June 2, 2011
Previously.
You'll need to get what's called a "certificate of credible coverage" from your current carrier, which you can present to other carriers to avoid this exclusion.
Now it may be the case that your new carrier will decline to write you at all, but that's different than being subject to a pre-existing condition exclusion.
Call a couple of brokers and see what you can find. Avoid COBRA, as it's stupidly expensive.
posted by valkyryn at 11:45 AM on June 2, 2011
I'm not sure if it's relevant to your exact situation or not, but the Affordable Care Act (or "Obamacare," as it is sometimes known) set up insurance plans for people who have been denied insurance coverage due to a pre-existing condition. The downside is that it's pricey (depending on where you live) and that you have to go six months without insurance coverage, which I'm sure would be nearly impossible in yours/your wife's case. But I thought I'd throw it out there, just in case. It's called "PCIP," and you can find out more here. Good luck!
posted by lagreen at 11:47 AM on June 2, 2011
posted by lagreen at 11:47 AM on June 2, 2011
In many states, women who are pregnant and without other insurance can receive Medicaid, and pregnancy is not a preexisting condition for purposes of Medicaid.
In some cases, someone can be retroactively added to a Medicaid plan from the start date of the pregnancy or first prenatal appointment so as to cover most or all of the pregnancy expenses. If you've paid out of pocket until then, you'd be reimbursed.
Medicaid will limit options for care provider, but it is more than likely an option for your wife. If other options fail, consider Medicaid.
posted by zizzle at 11:55 AM on June 2, 2011
In some cases, someone can be retroactively added to a Medicaid plan from the start date of the pregnancy or first prenatal appointment so as to cover most or all of the pregnancy expenses. If you've paid out of pocket until then, you'd be reimbursed.
Medicaid will limit options for care provider, but it is more than likely an option for your wife. If other options fail, consider Medicaid.
posted by zizzle at 11:55 AM on June 2, 2011
You'll need to get what's called a "certificate of credible coverage" from your current carrier, which you can present to other carriers to avoid this exclusion.
The rules may have changed on this recently, but my experience with this in the past decade was that the certificate of credible coverage only acts as a shield for pre-existing conditions if you are moving from a group plan (e.g., employer's coverage) to another group plan, but not from a group plan to an individual/family plan. Has this changed? (God, I hope so.)
posted by scody at 12:00 PM on June 2, 2011 [1 favorite]
The rules may have changed on this recently, but my experience with this in the past decade was that the certificate of credible coverage only acts as a shield for pre-existing conditions if you are moving from a group plan (e.g., employer's coverage) to another group plan, but not from a group plan to an individual/family plan. Has this changed? (God, I hope so.)
posted by scody at 12:00 PM on June 2, 2011 [1 favorite]
I would ask my insurance agent, but she's a family friend, and we haven't told anybody we're expecting yet.
That isn't really a good reason to avoid talking to your insurance agent about something like this. Unless she's seriously unprofessional, she will treat your disclosure appropriately.
posted by madmethods at 12:07 PM on June 2, 2011 [1 favorite]
That isn't really a good reason to avoid talking to your insurance agent about something like this. Unless she's seriously unprofessional, she will treat your disclosure appropriately.
posted by madmethods at 12:07 PM on June 2, 2011 [1 favorite]
my experience with this in the past decade was that the certificate of credible coverage only acts as a shield for pre-existing conditions if you are moving from a group plan (e.g., employer's coverage) to another group plan
I used one when I transferred from my parents' group plan to an individual plan, then from that individual plan to my last group plan, and finally from that group plan to my current group plan.
posted by valkyryn at 12:31 PM on June 2, 2011
I used one when I transferred from my parents' group plan to an individual plan, then from that individual plan to my last group plan, and finally from that group plan to my current group plan.
posted by valkyryn at 12:31 PM on June 2, 2011
I didn't have any conditions, so it didn't matter much, but the certificates were available and accepted in every case.
posted by valkyryn at 12:32 PM on June 2, 2011
posted by valkyryn at 12:32 PM on June 2, 2011
Mod note: comments need to be primarily answers not platforms for universal health care, sorry
posted by jessamyn (staff) at 2:32 PM on June 2, 2011
posted by jessamyn (staff) at 2:32 PM on June 2, 2011
If you don't end up with insurance, negotiate a cash rate with the hospital before the birth. They will often drop the price considerably if you set it up then.
posted by dawkins_7 at 4:40 PM on June 2, 2011
posted by dawkins_7 at 4:40 PM on June 2, 2011
What state are you in and would you be taking a significant pay cut? You might check to see if you're eligible for medicaid-type programs (examples here and here). We had to go there when I was in between jobs awhile back and were basically able to keep everything in place w/r/t to her OB and so on.
posted by jquinby at 6:40 PM on June 2, 2011
posted by jquinby at 6:40 PM on June 2, 2011
I've seen a couple references to COBRA being very expensive, but I think it only costs exactly as much as the plan your employer signed up for (likely taking advantage of their HR research and group rates). The thing I'd check on is whether you can take COBRA if you voluntarily leave a position as opposed to being laid off or fired.
posted by meinvt at 6:41 PM on June 2, 2011
posted by meinvt at 6:41 PM on June 2, 2011
I've seen a couple references to COBRA being very expensive, but I think it only costs exactly as much as the plan your employer signed up for (likely taking advantage of their HR research and group rates).
Which is why it's still likely to be pretty expensive, as group rates have also risen pretty significantly in the past 5-10 years as well. But it's certainly true that it depends entirely on the employer's plan; it's not like there's a flat "COBRA rate" out there.
posted by scody at 7:07 PM on June 2, 2011
Which is why it's still likely to be pretty expensive, as group rates have also risen pretty significantly in the past 5-10 years as well. But it's certainly true that it depends entirely on the employer's plan; it's not like there's a flat "COBRA rate" out there.
posted by scody at 7:07 PM on June 2, 2011
Here's some good information from the US Department of Labor to clear up some of the back-and-forth on HIPAA, COBRA, and creditable coverage.
http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html
You'll see that HIPAA and certificates of creditable coverage do have a role in a person's transition from group plan to group plan, as some answerers have indicated. But that's not what's relevant to you now.
Read the section way to the bottom to see the answer to the question "How does HIPAA apply when changing from group health coverage to an individual insurance policy?" That is the section relevant to your situation, and you will note that if COBRA is available to you, you must use it and exhaust it before you can take advantage of HIPAA protections.
Keep in mind that there are two important issues when it comes to pregnancy as a preexisting condition: the first is whether the pregnant person can get coverage at all, given the pregnancy; and the other is whether the policy the woman is able to enroll in includes coverage for services related to pregnancy (many individual plans do not, whether you're pregnant when you enroll or not).
It seems clear from the DOL info (see link) that under qualifying circumstances HIPAA protects the right to GET a plan, but whether it requires the plan to cover pregnancy-related medical services is a question that would require more research.
posted by celilo at 10:37 PM on June 2, 2011
http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html
You'll see that HIPAA and certificates of creditable coverage do have a role in a person's transition from group plan to group plan, as some answerers have indicated. But that's not what's relevant to you now.
Read the section way to the bottom to see the answer to the question "How does HIPAA apply when changing from group health coverage to an individual insurance policy?" That is the section relevant to your situation, and you will note that if COBRA is available to you, you must use it and exhaust it before you can take advantage of HIPAA protections.
Keep in mind that there are two important issues when it comes to pregnancy as a preexisting condition: the first is whether the pregnant person can get coverage at all, given the pregnancy; and the other is whether the policy the woman is able to enroll in includes coverage for services related to pregnancy (many individual plans do not, whether you're pregnant when you enroll or not).
It seems clear from the DOL info (see link) that under qualifying circumstances HIPAA protects the right to GET a plan, but whether it requires the plan to cover pregnancy-related medical services is a question that would require more research.
posted by celilo at 10:37 PM on June 2, 2011
More fun with HIPAA: I did a little more digging to see whether the insurance policy available to a HIPAA-eligible individual must cover maternity care. And while I did not find an answer to that specific question, I did learn that the composition of the plan you buy as a HIPAA-eligible person can vary from state to state.
Families USA*, a health care consumer group, has this to say: "Some states designate particular health plans that must serve HIPAA-eligible individuals, while in other states, HIPAA-eligible individuals are guaranteed the right to enroll in any health plan that sells policies to individuals (45 CFR § 148.103). Contact your state insurance department for more information. You can find contact information at http://www.naic.org/state_web_map.htm."
Here's another fantastic way to find out your state-specific rights: choose your state from the map here to read a Georgetown University Health Policy Institute "Guide to Getting and Keeping Health Insurance." Once in your state guide, go to the section on Individual Health Plans, and look for info on "conversion" or "portability" plans.
(Note: Don't get confused if the eligibility guidelines don't square with what you read on the DOL site. The DOL description sets out the federally mandated minimum protections; your state law may be more generous.)
(Welcome to federalism, everybody!)
*disclosure: I worked for them 6 years ago, but not on this issue, and I landed on this info through robust Googling, not cherry-picking my former employers.
posted by celilo at 9:09 AM on June 3, 2011
Families USA*, a health care consumer group, has this to say: "Some states designate particular health plans that must serve HIPAA-eligible individuals, while in other states, HIPAA-eligible individuals are guaranteed the right to enroll in any health plan that sells policies to individuals (45 CFR § 148.103). Contact your state insurance department for more information. You can find contact information at http://www.naic.org/state_web_map.htm."
Here's another fantastic way to find out your state-specific rights: choose your state from the map here to read a Georgetown University Health Policy Institute "Guide to Getting and Keeping Health Insurance." Once in your state guide, go to the section on Individual Health Plans, and look for info on "conversion" or "portability" plans.
(Note: Don't get confused if the eligibility guidelines don't square with what you read on the DOL site. The DOL description sets out the federally mandated minimum protections; your state law may be more generous.)
(Welcome to federalism, everybody!)
*disclosure: I worked for them 6 years ago, but not on this issue, and I landed on this info through robust Googling, not cherry-picking my former employers.
posted by celilo at 9:09 AM on June 3, 2011
This thread is closed to new comments.
posted by Zophi at 10:53 AM on June 2, 2011 [2 favorites]