Many Women Receiving Social Security Disability Benefits Also Qualify For Medicare Coverage And Medicare Does Cover Pregnancy And Childbirth
by Patricia Barry, AARP Bulletin, June 1, 2009
Q. Im on Medicare because of disability, and Im pregnant. Does Medicare cover pregnancy and childbirth?
A. Yes, it does. Most people on Medicare are age 65 and older so the program isnt usually associated with childbearing, but many younger people who receive Social Security disability benefits also qualify for Medicare coverage, and some of them do indeed become pregnant.
The relevant regulation explains: Skilled medical management is appropriate throughout the events of pregnancy, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.
Medicare also covers the cost of treatment for miscarriages, and for abortions in circumstances where the pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesnt cover elective abortion if you choose to terminate your pregnancy.
This coverage for pregnancy, childbirth, or termination is just the same whether youre enrolled in the traditional Medicare program or a private Medicare Advantage health plan. The private plans must provide all Medicare-covered services.
Although you continue to be covered for postnatal care after your child is born, any treatment or services the infant needs are not covered under Medicare.
Patricia Barry is a senior editor at the AARP Bulletin.
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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.
If Youre Eligible For Both Medicaid And Private Insurance
There are a few upsides to being eligible for both Medicaid and private insurance. For services covered by both programs, private insurance will pay first, then Medicaid picks up the difference between your providers allowable charge and private insurance payment, up to your states Medicaid payment limit.
Private health insurance policies usually have copay and deductible requirements. If you qualify for both Medicaid and private insurance, Medicaid may cover these out-of-pocket expenses for you.
Besides collaborating with other payers on a third-party basis, Medicaid may also arrange for private insurance plans and other entities to pay health care providers for services covered by Medicaid. Most Medicaid beneficiaries receive some services through managed care plans that contract with states directly.
When enrolled in Medicare , generally, you wont get coverage through the health insurance marketplace. However, if you already have a marketplace plan but are not enrolled in Medicare, you can retain the marketplace plan even after your Medicare coverage kicks in. However, you can expect to lose the premium tax credits or savings youve been receiving on your marketplace plan.
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Pregnant Women And Infants
Healthy Connections provides coverage to pregnant women with low income. This coverage for the mother continues for 60 days after the baby’s birth. The infant is covered up to age one.
A woman who may qualify for this program must:
- Be pregnant
- Be a South Carolina resident
- Be a U.S. citizen or Lawful Permanent Resident Alien
- Have a Social Security number or verify an application for one
Individuals who are eligible will receive all Medicaid covered services.
Apply online or complete the following form and submit it electronically to , by mail to SCDHHS-Central Mail, P.O. Box 100101, Columbia, SC 29202-3101 or to your .
The Omnibus Budget Reconciliation Act of 1986 gave states the option to provide Medicaid coverage to pregnant women with low income.
What Benefits Does Pregnancy Medicaid Provide
Similar to other health care assistance programs, Medicaid does not pay monetary benefits directly to covered participants. Certain health care providers and health care facilities have a contract with Medicaid to treat those who are covered by Medicaid insurance.
When receiving Medicaid benefits, you should be given a list of medical providers who accept Medicaid or given a website to look for a provider in your area. As long as you receive care from a Medicaid provider, your health care costs will be submitted through Medicaid and will be covered. Pregnant women are covered for all care related to the pregnancy, delivery and any complications that may occur during pregnancy and up to 60 days postpartum.
Additionally, pregnant women also may qualify for care that was received for their pregnancy before they applied and received Medicaid. Some states call this Presumptive Eligibility and it was put in place so that all women would start necessary prenatal care as early in pregnancy as possible.
Talk with your local office to find out if you qualify for presumptive eligibility.
Pregnant women are usually given priority in determining Medicaid eligibility. Most offices try to qualify a pregnant woman within about 2-4 weeks. If you need medical treatment before then, talk with your local office about a temporary card.
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If You May Qualify For Medicaid Or Childrens Health Insurance Program
- Medicaid and CHIP provide free or low-cost health coverage to millions of Americans, including some low-income people, families and children, and pregnant women.
- Eligibility for these programs depends on your household size, income, and citizenship or immigration status. Specific rules and benefits vary by state.
- You can apply for Medicaid or CHIP any time during the year, not just during the annual Open Enrollment Period.
- You can apply 2 ways: Directly through your state agency, or by filling out a Marketplace application and selecting that you want help paying for coverage.
- Learn how to apply for Medicaid and CHIP.
Im Covered As A Dependent Under My Parents Plan And Im Pregnant Will My Parents Plan Cover My Prenatal Care And Delivery Will My Parents Plan Cover My Baby After Hes Born
The rules are somewhat different depending on the plan your parents have.
If your parents are covered under a small employer plan provided by an insurance company through the Marketplace or outside of the Marketplace, or if your parents are covered under a nongroup policy they bought themselves, then your parents plan is required to cover your prenatal care and delivery.
However, if your parents are covered under a group health plan offered by a large employer , then your parents plan is only required to cover your prenatal care, but is not required to cover the delivery. Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.
Your parents plan, regardless of the source, generally wont be required to cover your child as a dependent. You will be responsible for obtaining coverage for your baby. Depending on your income, your child may be eligible for coverage under the Medicaid/CHIP program in your state. Or, you can buy a family policy through the Marketplace and, depending on your income, you may be eligible for a premium tax credit to reduce your cost of that coverage.
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If You Currently Have Marketplace Coverage
- If you want to keep your current Marketplace coverage, dont report your pregnancy to the Marketplace. When filling out your application for Marketplace coverage, select the Learn more link when we ask if youre pregnant to read tips to help you best answer this question.
- If you report your pregnancy, you may be found eligible for free or low-cost coverage through Medicaid or the Childrens Health Insurance Program . If you are found eligible for Medicaid or CHIP, your information will be sent to the state agency, and you will not be given the option to keep your Marketplace plan.
- If you keep your Marketplace coverage, be sure to update the application after you give birth to add the baby to the plan or enroll them in coverage through Medicaid or CHIP, if they qualify.
Review Your Options And Stay Covered
Losing Medicaid coverage can be very scary and shocking at first, especially if you have ongoing health issues.
If you are dealing with losing Medicaid, remember that it is not the end of the road. You have multiple options. Keep both your healthcare needs and budget in mind when making a decision about how to move forward. And if you end up at the hospital without insurance coverage, there are options even in that situation.
No matter what path you choose to follow once youre denied Medicaid or you are dropped from Medicaid, the most important thing to do is to obtain some type of coverage. The physical and financial safety that you get from having health insurance can end up being well worth any cost.
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Early And Periodic Screening Diagnostic And Treatment
The Early and Periodic Screening, Diagnostic and Treatment benefit provides comprehensive and preventive health care services. EPSDT is key to ensuring that children and youth receive appropriate preventive, dental, mental health, developmental and specialty services.
All Health First Colorado coverable, medically necessary services must be provided even if the service is not available under the state plan to other people who qualify for Health First Colorado. Benefits not listed are not considered to be a state plan benefit and are therefore outside of EPSDT coverage and exceptions. No arbitrary limitations on services are allowed, e.g., one pair of eyeglasses or 10 physical therapy visits per year.
Children and Youth ages 20 and younger who are enrolled in Health First Colorado.
- Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
- Arrange for corrective treatment as determined by child health screenings
- Lead Screening
Children under the age of 19 do not have co-pays. Co-pay costs for youth ages 19 and 20 vary, see program information page.
|Program Information Page
About Medicare And Pregnancy Coverage
If you or a loved one falls within this category of Medicare beneficiaries who are of child-bearing age, you may be wondering What does Medicare may cover during pregnancy and child delivery? As explained in the CMS Medicare Benefit Policy Manual, Medicare may cover reasonable and necessary skilled medical care throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.
If you are pregnant or planning a pregnancy, your doctor may be your best source for advice on prenatal care, a safe delivery, and proper care after you give birth. Make sure your doctor accepts Medicare assignment, or you might have to pay more for your health-care services.
Your prenatal care might include services such as regularly scheduled visits to the doctor, certain vaccines such as seasonal flu shots, screenings for certain diseases that could be harmful to you or your unborn child, and nutrition counseling, according to the Department of Health and Human Services.
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Will A Marketplace Health Plan Also Cover A Newborn
Yes. The ACAs EHB requirement mandates coverage of maternity and newborn care. Newborn care covers childbirth and immediate care for the baby after birth. The specifics of this coverage will vary by state and by each individual plan, but all women in Marketplace coverage must also enroll their baby in coverage soon after birth.
If the newborn is eligible for Marketplace coverage, then the parents can choose to add the baby to the familys existing Marketplace plan or choose a new Marketplace plan for the baby. If they opt for the latter, they can enroll the baby into a new Marketplace plan at any metal tier. However, when enrolling a newborn into Marketplace coverage, other members of the household are generally not permitted to change their existing Marketplace coverage.
If Youre Pregnant How Do You Know What Health Insurance To Choose
When youre choosing your health plan, look at the plan summary. Each plan has a summary that includes the expected costs of pregnancy care. Every plan uses the same summary form, so its easy to compare costs and services. You can find plan summaries in the Health Insurance Marketplace. This is an online resource that helps you find and compare health plans in your state. If you are working, you may also have health insurance through your employer. Check with your employer to learn about the plan summary and benefits.
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How Long Does Medicaid Or Chip Coverage For Pregnancy Last
Medicaid or CHIP coverage based on pregnancy lasts through the postpartum period, ending on the last day of the month in which the 60-day postpartum period ends, regardless of income changes during that time. Once the postpartum period ends, the state must evaluate the womans eligibility for any other Medicaid coverage categories.
7. Is abortion covered by Medicaid or CHIP?
The Hyde Amendment, an annual requirement added by Congress to a federal appropriations bill, prohibits using federal funds abortion coverage except when a pregnancy results from rape or incest, or when continuing the pregnancy endangers the womans life. However, states may use their own funds to cover abortions, and 17 states currently do.
Is A Woman Who Has Access To A Family Members Employer
Possibly. If the employer-sponsored insurance is unaffordable or not MEC, the woman is eligible for APTCs. Affordability is determined by the IRS standards for the percentage of income a person is expected to spend on insurance. This calculation applies to the cost of the employees insurance, not the cost of the family plan. That means that if the premiums for the employees insurance are affordable, no member of the family is eligible for an APTC. If the individuals premium is unaffordable, the family will be eligible for APTCs in an amount determined by their income and the premium cost.
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Make Too Much For Medicaid
Women who are pregnant without health insurance and think they make too much money to qualify for Medicaid still have publically funded options that make it affordable to keep your baby.
If you are pregnant without insurance, you need to get an ultrasound especially if Medicaid turned you down because you earn too much money and want to file an appeal. Each state bases its income limit guidelines on a percentage of the Federal Poverty Level, adjusting to household size.
- Iowa: 138%
- Texas: 198%
- District of Columbia: 319%
A local clinics free pregnancy ultrasound is ideal for determining if you are carrying more than one baby. Each unborn infant counts as an additional family member and boosts your income cutoff. However, the bump in the earnings limit per infant differs based on your state of residence.
Women having a baby without insurance whose household members earn too much money to qualify for Medicaid could become eligible under the medically needy criteria. In this program, large unreimbursed medical expenses could subtract from your earnings and push you under the state income limit.
Each state sets income limits based on a percentage of the Federal Poverty Level.
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.
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Pregnancy Medicaid Income Limits
Medicaid often denies pregnant women because their household income exceeds the limit established by their state. Therefore, you do not want to over-report your earnings or live in a region with a low threshold.
- Uninsured women who make too much to qualify for Medicaid still have many options, including CHIP, private insurance, moving to another state, and the medically needy program.
- Maternity insurance with no waiting periods is one of the alternatives but you may have to hold off until January unless you have a qualifying life event