Pregnancy Viewed as Pre-Existing Condition by Many Individual Insurance Plans – Say Ahhh! A Children’s Health Policy Blog

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By Amanda Jezek, March of Dimes

If you are pregnant, it is highly unlikely that you would
be able to get maternity coverage in the individual insurance market.  An investigation conducted by the House
Committee on Energy and Commerce confirmed that major insurers consider
pregnancy to be a pre-existing condition that would result in an automatic
denial of coverage, and that insurers typically exclude maternity coverage from
the plans they offer individuals who are not pregnant.  The memorandum issued regarding this
investigation, entitled Maternity Coverage in the Individual Health Insurance
, highlights one of the many reasons that the Patient Protection and
Affordable Care Act
is necessary to help all Americans access meaningful health

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The Energy and Commerce Committee investigation is
further documentation that maternity coverage is largely unavailable in the
individual market except in states where it is required by statute.  The investigation found that one
company did not offer any policies in the individual market that covered
maternity expenses in 2009 or 2010 except as mandated by law in one state. In
California, nine of the fourteen plans another company offered provided no
benefits for pregnancy-related medical claims. One company’s largest subsidiary
in the individual market does not offer benefits for routine pregnancies in
half its plans in the individual market. One health insurance company offers
maternity coverage as required by law in Pennsylvania, Kansas, and Maryland,
but otherwise has no individual policies that provide maternity coverage.

Even when maternity coverage is offered, it is typically
only available as a costly rider and only to women who are not pregnant.  Riders tend to offer limited benefits
with high deductibles. The Committee investigation found that after paying
maternity rider premiums to one health insurance company for four years, an
insured woman will receive no more than $6,000 from the company even if her
pregnancy and related medical claims cost much more.  This inadequate coverage would leave many women and their
families with significant out-of-pocket expenses. 

In 2007, the March of Dimes partnered with Thomson
Healthcare to estimate expenditures for maternity care by large employer health
plans drawn from the MarketScan database for 2004.  The results show that expenditures for maternity care
averaged $8,802.  When analyzed by
type of delivery, expenditures averaged $7,737 for a vaginal delivery and
$10,958 for a cesarean section.

The March of Dimes has long been concerned with the lack
of available maternity coverage in the individual market, and in 2006,
commissioned a study from Georgetown University’s Health Policy Institute on this issue which yielded
similar findings.  In addition,
March of Dimes volunteers have shared their own stories about the difficulty in
obtaining maternity coverage.

Consider a March of Dimes family in Virginia who took out
private insurance because their COBRA coverage from a previous job was about to
end. They took the precautionary step of adding a maternity rider, which had a
six-month waiting period before covering pregnancies.  They didn’t think there would be any issue as they used
fertility treatments to conceive their first child.  Despite being told by doctors that they had only a five
percent chance of getting pregnant naturally, four months into the six-month
waiting period, they discovered they were expecting.  At that point, no other insurance company would pick-up the
coverage as pregnancy is considered a pre-existing condition. Pregnancy-related
care cost the family $20,000 out-of-pocket.

Because of the Patient Protection and Affordable Care
Act, insurers will be required to discontinue many of these practices and
provide improved access to maternity coverage.  Beginning in 2014, insurers will no longer be able to deny
coverage to anyone based upon a pre-existing condition such as pregnancy.  In addition, the essential benefits
package, which all plans will be required to cover beginning in 2014, includes
maternity care.  This means that
maternity coverage will be part of standard health insurance, no longer
segregated as a costly rider or excluded altogether.

Advocates will still need to continue working closely
with federal and state governments to ensure strong implementation of these
provisions across the country.  But
it is clear that health reform represents a tremendous step forward in the
effort to ensure that all women of childbearing age have access to maternity
coverage.  If the Energy and
Commerce Committee re-examines this issue again after 2014–and we hope they
do–results will likely find many more pregnant women who are able to obtain the
maternity coverage they need to give their children a healthy start.

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