Do Marketplace Health Plans Provide Women With Comprehensive Coverage Including Maternity Care
Yes. All Marketplace plans must include the ten Essential Health Benefits , one of which is maternity and newborn care. HHS has not specified what must be covered under this category, delegating that authority to the states. Thus, specific benefits covered under maternity care vary by state.
2. What changes when a woman enrolled in a Marketplace plan becomes pregnant?
Nothing, unless she wants it to. The woman may choose to remain in a Marketplace plan or, if eligible, to enroll in Medicaid or CHIP. The woman will not lose eligibility for the APTCs as a result of access to MEC through full-scope or pregnancy-related Medicaid, but cannot be enrolled in both simultaneously and thus must choose. In deciding which coverage to select, overall cost, access to preferred providers, impact of transitioning across plans, and effect on family coverage influence preference.
How Does Medicaid Work
Once you have applied for Medicaid for your child and received their benefits cards, you will need to:
- Pick a managed care plan. You will receive a letter in the mail that will give you the options available in your area.
- Pick a main doctor that is in network with the managed care plan you pick. You can find a doctor in the following ways:
- Use the provider directories that came in the mail with your enrollment packet.
Your childs main doctor will then refer you to specialists and therapists who also take Medicaid and can help your child. All Medicaid programs encourage families to use the medical home model of care.
How Can Pregnant Women Apply
Providers who want to have applications available in their office can order them can order them online. The application is named Application for Health Coverage & Help Paying Costs the form number is H1205.
All applicants for CHIP perinatal services will be screened to see if they qualify for Medicaid for Pregnant Women. If they don’t qualify for Medicaid, HHS will determine if they qualify for CHIP perinatal coverage.
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Important Information For New Or Soon
If you have health coverage and are pregnant, you and your new child may be entitled to a 48-hour hospital stay following childbirth . If your employer or your spouses employer offers a health plan, birth, adoption, and placement for adoption may also trigger a special enrollment opportunity for you, your spouse, and your child, without regard to any open season for enrollment.
The Affordable Care Act adds important protections related to employment based group health plans that will improve health coverage for you and your family. Many of these protections are available now including extending dependent coverage until age 26, prohibiting preexisting condition exclusions for children under 19, and banning lifetime limits on coverage for essential health benefits. Additional protections will be available in 2014. This publication does not reflect the provisions of the Affordable Care Act. For more information, visit the Employee Benefits Security Administrations ACA Web page at dol.gov/ebsa/healthreform.
Income Guidelines For Children’s Medicaid
Your income is the money you get paid before taxes are taken out. Find your family size on the table below. If your monthly income is the same or less, your child might get Children’s Medicaid.
|Family Members||Monthly Family Income|
|For each additional person, add:||$791|
*A family of one might be a child who does not live with a parent or other relative.
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Your Protections Under The Newborns And Mothers Health Protection Act
If a group health plan, health insurance company, or health maintenance organization provides maternity benefits, it may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section.
You cannot be required to obtain preauthorization from your plan in order for your 48-hour or 96-hour stay to be covered.
The law allows you and your baby to be released earlier than these time periods only if the attending provider decides, after consulting with you, that you or your baby can be discharged earlier.
In any case, the attending provider cannot receive incentives or disincentives to discharge you or your child earlier than 48 hours .
If your state has a law that provides similar hospital stay protections and your plan offers coverage through an insurance policy or HMO, then you may be protected under state law rather than under the Newborns and Mothers Health Protection Act.
How Do I Add A Baby To My Aetna Insurance
If you plan on having your baby covered by your insurance plan, then youll definitely want to notify your insurance of your childs birth. Many Aetna plans automatically cover newborns for the first 31 days after birth. To officially add your newborn to your plan, youll need to contact your benefits administrator.
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How Much Does It Cost
Children’s Medicaid is free.
If we find your child can get Children’s Medicaid, there is no cost to receive services.
CHIP fees vary based on your income.
If we find your child can get CHIP, your enrollment fee and co-pays will be based on your family’s income. Enrollment fees are $50 or less per family, per year.
Co-pays for doctor visits and medicine range from $3 to $5 for lower-income families and $20 to $35 for higher-income families.
How Can Tanf And Medicaid Affect My Child Support
Federal law requires all parents who receive TANF or Medicaid benefits through the Texas Health and Human Services Commission to cooperate with the Office of the Attorney Generals efforts to identify the childs noncustodial parent, establish paternity, settle child support orders, complete child support modifications and enforce child support.
TANF recipients assign their right to child support collections to the state. This means the family will receive the first $75 collected during any month that a current child support payment is made. The remainder of the child support payment made will be applied toward reimbursing the state and federal governments for the TANF benefits received by the family. When the family no longer receives TANF, all current support payments made will be sent to the custodial parent.
Parents who receive certain types of Medicaid assign their right to cash medical support collections to the state. This money will be redirected to the Texas Health and Human Services Commission to reimburse the state and federal governments for the Medicaid benefits received by the family.
If the children receive Medicaid benefits, but the adult does not, the adult has the option to request child support services.
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What Services Are Not Covered
CHIP perinatal provides a basic prenatal care package. Participating health plans will distribute a provider manual that includes covered and non-covered benefits. Below are examples of non-covered services:
- Inpatient hospital care for the mother of the unborn child that is not related to labor with delivery, such as a serious injury, illness and more
- Labor without delivery of the baby
- Most outpatient specialty services, such as mental health and substance abuse treatment, asthma management, and cardiac care
A pregnant woman may apply for Emergency Medicaid in emergency situations. However, the bar-coded Form H3038-P that HHS mails to a pregnant woman with income at or below 198 percent of the FPL only may be used to apply for Emergency Medicaid for her labor with delivery. She may not use her bar-coded H3038-P, mailed by HHS, for services such as:
- Labor with no delivery
- Other non-delivery emergency services, such as hospitalization for a serious injury, illness and more
Important Facts When Having A New Baby
Know your rights. If your plan provides maternity benefits, you should be entitled to a minimum hospital stay of 48 hours following a vaginal delivery and 96 hours following a cesarean delivery.
You cannot be required to get a preauthorization from your plan in order for the minimum hospital stay to be covered.
Your plan must provide you with a notice regarding your rights relating to a hospital stay following childbirth. If your plan is insured, the notice must describe your protections under state law.
Contact your health plan or your spouses health plan as soon as possible to find out how to enroll your new baby in group health plan coverage.
As long as you enroll your newborn within 30 days of birth, coverage should be effective as of your babys birth date, and your baby cannot be subject to a preexisting condition exclusion.
Remember, you should enroll your baby within 30 days of the date of birth.
Can Uninsured Women Enroll In Marketplace Coverage Upon Becoming Pregnant
Only if it is within the established open enrollment period or a woman qualifies for a special enrollment period , does not have a plan that meets MEC through Medicaid or an employer, and meets income and immigration criteria. Note that except in the states of New York and Vermont, pregnancy does not trigger an SEP.
Under the ACA, people who do not qualify for Medicaid coverage that meets MEC, and have incomes between 100% and 400% FPL, qualify for advance premium tax credits and cost-sharing reductions , which they can use to reduce the cost of health insurance purchased through a Marketplace. Those with pregnancy-related Medicaid in the three states that do not constitute MEC are eligible for Marketplace subsidies. Certain lawfully-present immigrants with incomes under 100% FPL subject to Medicaids five-year ban in their state are also eligible for APTCs. Undocumented immigrants are not eligible for APTCs, CSRs, or Marketplace insurance.
How Is A Hospital Reimbursed For Labor With Delivery Charges For Chip Perinatal Patients With Incomes At Or Below 198 Percent Of The Fpl
The hospital will need to complete and submit the mother’s bar-coded CHIP Perinatal – Emergency Medical Services Certification to establish Emergency Medicaid for labor with delivery. This form is mailed to the woman before her delivery, and she is instructed to bring it with her to the hospital when she delivers. The form includes a place to add the dates the woman received emergency medical services . Once HHS receives the completed Form H3038-P, emergency Medicaid coverage will be established for the mother for the period of time reflected on the form, and her baby will receive 12 months of Medicaid coverage from date of birth.
In these situations, facility charges for both mom and the newborn are billed to TMHP. Professional charges for the mother are always billed to the CHIP perinatal health plan, while professional charges for the newborn are billed to TMHP.
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Can A Pregnant Woman Receive Medicaid Or Chip Services Prior To An Eligibility Decision
Maybe. States may elect, but are not required, to provide some categories of Medicaid enrollees, including pregnant women, with presumptive eligibility. This allows pregnant women to receive immediate, same-day Medicaid services, typically at the clinic or hospital where they submit an application for Medicaid presumptive eligibility. Currently, 30 states provide presumptive eligibility to pregnant women.
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What Changes When A Woman Already Enrolled In Medicaid Becomes Pregnant
Generally, nothing. A woman who was previously eligible and enrolled in full-scope Medicaid who becomes pregnant continues to be eligible, and will be able to access pregnancy services. A woman who becomes pregnant while enrolled in Medicaid Expansion can stay in that coverage, at least until redetermination. The state must inform the woman of the benefits afforded to pregnant women under other coverage categories, such as pregnancy-related Medicaid, and provide the option to switch categories if the woman is eligible.
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Pregnancy And Newborn Services
Prenatal care is an important way to keep you and your baby healthy during your pregnancy. These regular checkups allow doctors to find and treat health problems early, if needed. They also help make sure your baby is growing and developing properly.
Its important to see a doctor if you are planning on becoming pregnant, or as soon as you know you are pregnant. If you need help finding an OB-GYN, we can help. Use our Find a Provider tool or call Member Services at 1-855-463-4100.
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Information On Title V
Title V prenatal care contractors may provide prenatal care and bill Title V for a maximum of the first two prenatal care visits for women who are in the process of applying for and enrolling in CHIP perinatal services. Title V contractors must inform, encourage, and assist pregnant women in the CHIP perinatal application process.
Please direct your questions or requests for additional information regarding Title V to
What If I See A Chip Perinatal Newborn Who Has Not Yet Been Issued A Unique Id Card
Because most CHIP perinatal newborns change to Medicaid from their date of birth, their moms typically need to enroll the baby in a STAR health plan after they are born. Once enrolled, they will receive a new STAR health plan ID, as well as a Your Texas Benefits Medicaid card. Even if the baby does not have a Medicaid card or a STAR health plan ID, you can verify the baby’s Medicaid eligibility by doing one of the following:
- Go to TexMedConnect on the TMHP website
There is a gap between the time the child is born and he or she is enrolled in a STAR health plan. During this gap, newborn claims will be paid with traditional, fee-for-service Medicaid.
For babies who remain in CHIP perinatal after birth, contact the health plan that provided prenatal care under CHIP perinatal.
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Why Choose Community
As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.
I always tell people to choose Community Health Choice. I tell them its the best health insurance they will ever be with. Chandolyn
What Is The Cost
None. Medicaid law prohibits states from charging deductibles, copayments, or similar charges for services related to pregnancy or conditions that might complicate pregnancy, regardless of the Medicaid enrollment category. HHS presumes pregnancy related services includes all services otherwise covered under the state plan, unless the state has justified classification of a specific service as not pregnancy-related in its state plan. States may, however, impose monthly premiums on pregnant women with incomes above 150% of FPL and charge for non-preferred drugs.
Most states that cover pregnant women in their CHIP program do not have cost-sharing or any other fees associated with participation in the program.
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When Will Coverage Start
When you enroll in or change plans with a Special Enrollment Period, your new health coverage can start the day your baby is born or adopted, even if you enroll in the plan up to 60 days afterward.
Note: If you adopted, you may need to submit documents, like adoption letters or records, showing the name of the person who became a dependent and the date they became one.
Update To Texas Medicaid Provider Procedure Manual Medicaid Managed Care Services Handbook
Note:Texas Medicaid managed care organizations must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid and from MCO to MCO. Providers should contact the client’s specific MCO for details.
Beginning March 1, 2019, TMHP will add the following breast pump coverage chart to the Texas Medicaid Provider Procedures Manual, Medicaid Managed Care Services Handbook, Section 2.9, Claims Filing for Managed Care Services.
Texas Medicaid and the Childrens Health Insurance Program cover breast pumps and equipment when medically necessary after a baby is born.
Coverage in Prenatal Period
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How Does A Woman Enroll In A Chip Perinatal Health Plan
Once a woman is found to be eligible for CHIP perinatal services, her unborn child must be enrolled in a health plan. The woman has 15 calendar days to select a health plan. The 15-day window opens the day she receives a letter from HHSC saying she qualifies for CHIP perinatal services on behalf of her unborn child. If she does not choose a health plan within the 15-day timeframe, HHS will choose one for her.
Once she has enrolled, the woman will receive an ID card from her health plan that specifies CHIP Perinatal Program.