The Obamacare Loophole That May Be Denying Coverage To Pregnant Women


Although Obamacare has made big strides in expanding coverage for women’s health services, including mandating maternity coverage in the plans offered on the marketplaces, some pregnant women may be falling through the cracks.

A coalition of nonprofit organizations that includes Planned Parenthood, the March of Dimes, and Young Invincibles says the Obama administration needs to tweak its current special enrollment policy, giving pregnant women the opportunity to sign up for new plans year round.

Right now, there are several big life changes — turning 26 years old, graduating from college and losing a student health plan, moving to a new home, getting married, and having or adopting a baby — that qualify Americans for a special enrollment period outside of the regular three-month window to sign up for coverage during open enrollment. They’re known as “qualifying life events” under the health law.

But when it comes to maternity coverage, the groups say there’s something of a loophole. Pregnancy doesn’t currently count as a qualifying life event, and if women discover they’re expecting a baby outside of the open enrollment period, they can’t sign up for an Obamacare plan until after they’ve given birth.

According to a new report released by Young Invincibles on Wednesday, that can have potentially serious consequences for pregnant women who otherwise can’t afford care. Giving birth in a hospital can cost anywhere between $10,000 and $20,000. A young woman lacking maternity coverage may choose to skip out on prenatal care, which could increase her risk of serious medical complications like preeclampsia or placental abruption.

Young Invincibles says the issue isn’t limited to uninsured women; there are also people who have grandfathered plans that aren’t yet required to offer coverage for pregnancy-related services. If those people found out they were pregnant, they would likely want to take advantage of the coverage options on the marketplaces and switch to a different plan. But they would be locked out.

“Women who find themselves pregnant and uninsured or with a plan that does not cover maternity care should have the same opportunity to access comprehensive coverage through the marketplaces,” the report concludes.

It’s not a policy change that would be very popular among health insurers, who typically don’t want people to wait to purchase coverage until they’re faced with an expensive health condition. They worry that, with the potential for pregnant women to enroll at the last minute, it would be too difficult for insurers to set their prices.

“If you only create incentives for people to enroll when they have a health need, it poses a tremendous risk to the risk pool and affordability for everyone else,” Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the leading trade group for the industry, told Kaiser Health News.

The advocacy push around pregnant women has been timed to coincide with the end of Obamacare’s second open enrollment period, which drew to a close on Sunday. According to the White House, an estimated 11.4 million people enrolled in private insurance over the past three months.

In addition to expanding the definition of a qualifying life event, a growing number of health care advocates have also been calling for an enrollment extension around Tax Day, when some uninsured Americans may realize for the first time that they owe a tax penalty for failing to purchase insurance. They argue those people should have the opportunity to enroll in a plan to avoid the fine. A group of Democratic senators led by Sen. Tammy Baldwin (D-WI) recently wrote to the Department of Health and Human Services to request the change.

By the end of this month, Health and Human Services Secretary Sylvia Mathews Burwell is expected to announce a final decision on whether the administration will expand its special enrollment periods. Burwell hasn’t yet indicated whether she plans to add pregnancy to the list of life events.


On Wednesday, Burwell responded to some of the concerns raised by Young Invincibles. She said that HHS has not included pregnancy as a qualifying life event because “we have based it on how insurance companies made the determinations when they have periods for open enrollment or not,” but she added that the agency is happy to further consider the issue.