Claire Benson, of Kansas City, was shocked when her health insurance was canceled when she updated her information with her newly pregnant status. Benson’s situation has sparked a conversation about the implications of terminated insurance for pregnant women. This article explores health insurance related to pregnant women, what protections are available under the law, and provides tips on what to do if their insurance is terminated while pregnant.
The Affordable Care Act (ACA) prohibits insurance companies from barring individuals from coverage based on pre-existing conditions, which include pregnancy.
Knowing the coverage, limitations, and exclusions related to prenatal care, labor, and delivery is essential when selecting a health plan. Some insurance plans have deductibles that must be met before coverage can kick in, while others have out-of-pocket expenses that may be higher than other health plans.
Most termination clauses permit the health insurance company to terminate coverage when monthly premiums are unpaid.
When an individual misses a monthly premium, insurance providers must grant a 90-day grace period before issuing a termination of coverage. Coverage can only be terminated after a sufficient written notification has been mailed to the policyholder.
Health insurance is often challenging to understand because the terms and conditions of each policy differ. However, specific healthcare laws ensure health insurance companies operate under consistent standards to make healthcare accessible to their members. Health insurance companies also categorize their plans by type based on the scope of coverage offered.
Types of insurance policies for pregnant women
An individual has four insurance policies to choose from when initially shopping for healthcare coverage. The general types of insurance policies include:
- Health Maintenance Organization (HMO). HMO health plans are typically the least expensive. They require individuals to choose a primary care physician (PCP) who will issue referrals for specialists when needed. These health plans have a lower out-of-pocket cost but may also have minimal coverage for out-of-network providers.
- Preferred Provider Organization (PPO). PPO plans are highly favorable among health insurance consumers because they offer flexibility in choosing healthcare providers, whether inside or outside the plan’s network. Though most individuals can see a provider outside their network, they may incur a higher out-of-pocket cost.
- Exclusive Provider Organization (EPO). EPO health plans combine the best parts of both HMOs and PPOs. They provide coverage within the network and do not require referrals to see specialists. Medical emergencies are covered regardless of the provider’s network.
- Point of Service (POS). Point-of-service health plans require a primary care physician and referrals to see specialists. However, individuals are permitted to seek care outside of their network, though they will face a higher cost.
Key terms and clauses in health insurance policies
The key terms and clauses in health insurance policies differ; however, most clauses are consistent because of the laws in place to protect individuals seeking health insurance coverage.
Pre-existing conditions are an individual's health issues before the health insurance policy was in effect. Before the Obama Administration, pregnancy had been considered a pre-existing condition that could have impacted eligibility for health insurance or resulted in higher premiums. Now, the (ACA) Affordable Care Act prohibits insurance companies from barring individuals from coverage based on pre-existing conditions, which include pregnancy. Based on this law alone, denial of insurance for pregnant women is not the norm.
While pregnancy insurance should never be denied, the coverage limits will vary based on policy. When selecting a health plan, it is vital to know all the coverage, limitations, and exclusions related to prenatal care, labor, and delivery. Some insurance plans have deductibles that must be met before coverage can kick in, while others have out-of-pocket expenses that may be higher than other health plans. We recommend reading these terms and limitations, especially regarding prenatal care, ultrasounds, maternity classes, and any additional care needed during and after the pregnancy.
Many health insurance companies have termination clauses in their policies. Most termination clauses permit the health insurance company to terminate coverage when monthly premiums are unpaid. In this case, the termination clause also requires the health insurance company to provide written notice of the upcoming cancellation, typically within ten business days of the notice.
What happens when a woman loses insurance for pregnancy
While health insurance companies are not allowed to deny coverage to pregnant women, it is evident that these situations still happen, like in the case of Claire Benson. When this occurs, people are rightfully upset due to the high cost of healthcare and the ongoing care and treatment women need while pregnant. The cost of labor and delivery is too high for most people to pay out of pocket.
When health insurance is denied for pregnant women, they may skip vital prenatal care, which helps oversee the pregnancy and manage any complications. Missing this care during pregnancy increases the risk of mortality for the mother and baby.
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Was Mrs. Benson’s termination of insurance legal?
The Affordable Care Act is a landmark legislation that provides comprehensive protection for pregnant women. This law prohibits insurance providers from denying coverage or charging higher premiums based on pre-existing conditions like pregnancy. This law has significantly enhanced the rights of expectant mothers in health insurance. Therefore, the termination of coverage that Mrs. Benson experienced with her health insurance was not carried out in compliance with the ACA.
What to do if your insurance is terminated during pregnancy
If you are in a situation where you are pregnant and your insurance is terminated unexpectedly, there are several options you can take to fight for your rights.
- Use the insurance provider’s internal appeals process to file a grievance or an appeal.
- File a complaint with your state’s Department of Insurance detailing the circumstances of the termination.
- If the insurance provider’s internal appeals process or the state Department of Insurance does not provide the necessary intervention, you can pursue legal action with the help of an experienced attorney in healthcare law.
- Research the health insurance provider’s provisions for mediation and arbitration, which will help dispute the issue and lead to a mutually agreeable resolution.
Denial of health insurance because of pregnancy does not align with the Affordable Care Act. However, the level of coverage an individual receives will vary depending on the policies, terms, limitations, and exclusions. Be sure to review your policy to understand the benefits afforded to you through your health insurance.
Can insurance companies deny coverage if pregnant?
No. The Affordable Care Act protects pregnant women from denial of coverage due to pregnancy. Denying coverage for pregnant women is a violation of this legislation. It should be reported as a grievance to the insurer’s internal appeals department or the Department of Health and Human Services.
Why would health insurance be terminated?
Your health insurance policy may be terminated if you miss payment on a monthly premium. There is a grace period of 90 days for insurance premiums, and only after these 90 days does an insurance company have the right to terminate after sending a written notice to the beneficiary.
Do I need to tell my insurance I'm pregnant?
It is not necessary to notify your insurer of your pregnancy. However, doing so may lead you to free resources that insurance companies make available to pregnant women. Those free resources may include classes for labor, delivery, or parenting. It is not necessary to notify your insurer of your pregnancy.
What type of insurance is best for pregnancy?
Choosing a health plan offered by your employer, your state’s healthcare exchange, or Medicaid is best. Pay attention to the monthly premiums, deductibles, and out-of-pocket costs you will owe to ensure they are affordable.
How does pregnancy affect insurance?
Your insurance should remain the same whether you’re pregnant or not. The ACA prohibits the denial of coverage or the increase of premiums in the case of pregnancy. However, depending on the deductible, you may have higher out-of-pocket costs.