High-Risk Pregnancy Open Enrollment Tips
Having health insurance to help foot the bill for any pregnancy is important. But it's especially crucial if your pregnancy is high-risk. Unfortunately, pregnancy itself is not considered a qualifying life event that lets you enroll in an insurance plan at any time. Ironic, since giving birth (or adopting a child) is.
But health insurance coverage is essential for the delivery-and for all the care leading up to giving birth. So to obtain insurance or switch plans before or during pregnancy, you'll have to take advantage of an open enrollment period.
"Being insured gives the patient the ability to get the highest level of care without outrageous sticker shock," says Peace Nwegbo-Banks, MD, a board-certified OB-GYN based in Houston, Texas. "Because healthcare costs in the United States are exorbitant, it is important for patients to protect themselves. Even an uncomplicated pregnancy and delivery costs tens of thousands of dollars. The costs begin to skyrocket if additional care is needed."
Here's how to take advantage of Marketplace or employer-sponsored open enrollment periods. Plus, what you need to know about choosing a health plan if you're currently pregnant or are planning to conceive.
Open enrollment details
If you do not currently have insurance, or you wish to change your plan, you can take advantage of the Health Insurance Marketplace's special open enrollment period (SEP) through August 15 to obtain 2021 coverage. This SEP is unusual and is in response to the COVID-19 pandemic and recovery. As part of the American Rescue Plan Act, more people now have access to savings and subsidized costs when buying insurance on the Marketplace.
Marketplace open enrollment for 2022 coverage will begin November 1 of this year. If you have existing coverage for 2021 and you've paid a significant portion of your deductible, you may wish to hold off on switching plans.
Most employer-sponsored plans hold their open enrollment periods in November for following year coverage. So you won't be able to opt in or change coverage with your employer until then. Keep in mind you may qualify for Medicaid through your state. The good news is you can apply for Medicaid at any time.
The high price of high-risk
Pregnancy and childbirth are the most expensive of hospital-based healthcare needs, according to a report by Agency Healthcare Research and Quality. The average charge for a vaginal birth is more than $15,000. And a caesarean section (C-section) can cost another $5,000 and up, according to the Center for American Progress. But a high-risk delivery can run an uninsured patient even more out of pocket.
Pregnancies are high risk based on a number of considerations. These include if you're a teenager or over 35 and pregnant for the first time, if you have certain pre-existing conditions, if you're having multiples, or if you develop pregnancy-related conditions, like gestational diabetes.
"If you include additional tests, fetal ultrasounds, consultations with specialists, and possible NICU stay, the final price tag is unpredictable," says Nwegbo-Banks. "If mom ends up needing special care along with the infant, this further drives costs up."
Choosing a plan
If you're shopping for insurance during open enrollment, there are a few things to consider, says Erin Scott, LCP, a maternal mental health specialist and owner and clinical director of The Healing Space Counseling and Wellness Center.
Scott recommends checking to see if your OB-GYN is listed as an in-network provider with the new plan. You don't want to get hit with out-of-network fees. And you don't want to have to change doctors if you're comfortable and happy with your current provider. Also consider if you need to meet a deductible prior to insurance covering 100% of costs for doctor's appointments and hospital stays, she says.
Marketplace plans must cover preventive services without charging out-of-pocket costs regardless of your deductible status. Preventive services for pregnant people include gestational diabetes screening, preeclampsia prevention and screening, breastfeeding support and counseling, and more. Maternity care and newborn care are considered essential health benefits. Marketplace plans must cover them. But patients may be responsible for copays, coinsurance, or deductibles. The Affordable Care Act requires new private insurance plans to cover many, but not all, recommended preventive services without out-of-pocket costs falling to pregnant people. Check any new prospective plan carefully for what's covered.
"Early prenatal care is of paramount importance for both mother and child," explains Kecia Gaither, MD, MPH, FACOG, double board-certified in OB-GYN and maternal fetal medicine and Director of Perinatal Services at NYC Health + Hospitals/Lincoln.
"Comorbid conditions, like diabetes or hypertension," she adds, "can affect pregnancy outcomes. Detection and potential treatment modalities of such issues can preclude poor clinical outcomes such as preterm labor, low birth weight infants, and congenital anomalies, to name a few."
The 'fourth trimester'
Gaither says those planning to have a baby should think about insurance needs that might arise before pregnancy and those that may come after.
"It is helpful to choose a plan that affords coverage for preconceptual counseling, genetic services, for the 'fourth trimester,' and has help for mental disorders associated with the peripartum period," Gaither says. A 2013 study published in the British Journal of Midwifery found that having a high-risk pregnancy is a risk factor for postpartum depression, for example.
Before you sign on to a new plan, also ensure that coverage is adequate to meet the needs of a newborn, especially if anything unexpected arises. Under a 1996 law, your plan should cover your newborn's care from their moment of birth, as long as you enroll your baby within 30 days of their arrival in the world.