Have you recently found out you’re expecting? Congratulations! A new pregnancy kicks off a very exciting nine months. Along with preparing a nursery and stocking up on diapers, however, you may be wondering about the medical costs—especially if you don’t have health insurance.
The good news is, in most cases, health insurance for pregnant women is accessible and affordable. Here’s a look at the laws around pregnancy and health insurance, where you can get coverage, and how much insurance for pregnant women costs.
Can I Get Health Insurance If I Am Pregnant?
Soon after a positive pregnancy test, you may find yourself asking, “Wait, can I get health insurance if I am pregnant?” Generally, the ability to get health insurance is not impacted by a pregnancy. Being pregnant is considered a pre-existing condition and ACA-compliant insurers (meaning those with plans listed on the Health Insurance Marketplace or your state’s exchange) aren’t allowed to deny or charge more due to pre-existing conditions.
However, if you’ve missed open enrollment (November 1 to January 15 each year), or aren’t eligible for a special enrollment period, getting insurance that covers your pregnancy could be more challenging. You may be able to get health insurance that covers your pregnancy through your employer or through Medicaid or CHIP, if your income qualifies.
Open enrollment periods can vary by state. Be sure to check if your state has a different window.
How to Get Health Insurance Coverage
If you’re pregnant and don’t have health insurance, you can get coverage through the Health Insurance Marketplace during open enrollment or if you qualify for a special enrollment period. You can also get coverage through your employer, private insurers, or Medicaid or CHIP.
You can browse health insurance plans in the ACA Health Insurance Marketplace (or your state’s marketplace if it has one). These platforms make it easy to compare plans from various providers side by side and let you apply for premium tax credits (subsidies). However, you can also go directly to insurers’ sites to check the plans they have available.
Premium tax credits are refundable credits that can be applied throughout the year to lower your health insurance premiums. If you’d like to apply and use them, you’ll need to go through the Marketplace to get your health plan.
Plans through private insurers (not through the Marketplace) may not be the best option if you’re already pregnant. This is because they’re allowed to require a waiting period before pregnancy coverage kicks on and, generally, don’t provide the same level of benefits available on the Marketplace.
Another option to explore is Medicaid. Medicaid is a joint federal and state program that provides health insurance coverage for low-income Americans. While the programs must follow certain federal guidelines, the coverage, costs, and income limits vary from state to state. You can find out if you qualify using healthcare.gov’s online tool, or by applying for health coverage through the Marketplace.
You may also be eligible for health insurance through an employer (your current one, your partner’s, or if you get a new job with health insurance coverage). Check when your employer’s open enrollment period is. This may be an excellent option if you’ve missed open enrollment at Healthcare.gov and aren't eligible for Medicaid or CHIP.
When Can Pregnant Women Sign Up for Health Insurance?
Health Insurance Marketplace
Pregnant women can sign up for health insurance through the Marketplace during the open enrollment period—which typically runs from November 1 to January 15.
Unfortunately, once the window has passed, you’ll have to wait until the following year unless you qualify for a special enrollment period. Special enrollment periods allow people to enroll in health plans outside of open enrollment due to qualifying events such as losing health insurance coverage, moving, or having a baby. Unfortunately, getting pregnant doesn’t trigger special enrollment eligibility.
You can sign up for your employer’s plan during its open enrollment period. If you’re out of work or your employer doesn’t offer health insurance, strongly consider getting a job that does.
Medicaid or CHIP
If you qualify for Medicaid or CHIP, you can enroll anytime throughout the year.
Factors Influencing the Cost of Health Insurance
Here’s a breakdown of the common factors that influence the cost of health insurance plans.
The premium is the amount you pay per month to maintain coverage. Lower premiums are typically associated with higher out-of-pocket costs (such as deductibles and copays) and vice versa.
A health insurance deductible is an amount that must be paid before your insurance coverage kicks in (for anything other than preventive care). Health insurance plans typically come with a yearly deductible and a separate drug deductible.
For example, if your plan has a yearly deductible of $4,750, your insurer won’t cover non-preventive care until you pay $4,750 in qualifying medical expenses during a policy year. Similarly, if your drug deductible is $85, you have to spend $85 on prescription drugs during a policy year before your plan will begin to help with your drug costs.
While most health insurance plans have yearly deductibles, insurers often cover certain services before the deductible is paid. For example, preventive care, physician visits, and specialist visits may not be subject to the deductible.
Copays are amounts you must pay for specific medical services listed on your plan. For example, your plan may require a $45 copay for primary care visits and an $85 copay for specialist visits. Once the copay and any required deductible are paid, your insurance coverage kicks in.
Coinsurance is a percentage of a medical service’s cost that you have to pay. For example, if your policy covers 80% of outpatient surgery services, you would be responsible for 20% coinsurance.
Maximum Out-of-Pocket Limits
Health plans also come with a maximum out-of-pocket limit, which is the maximum amount you’re allowed to pay during a given policy year for covered healthcare services. Once you’ve hit the limit, your health plan covers 100% of the covered costs for the rest of the year.
The plan type you choose will also impact your cost. Common plan types include:
- Health Maintenance Organizations (HMOs): HMOs are typically the most affordable but only cover care provided by doctors, specialists, and hospitals within an insurer’s network, although emergency care outside the network is often covered as well. You’re required to choose a primary care physician (PCP) who will refer you to specialists when needed.
- Preferred Provider Organizations (PPOs): PPOs offer lower prices if you obtain medical care from their networks, but will also cover out-of-network providers at higher prices. They are typically more expensive than HMOs but don’t require referrals for specialist visits.
- Exclusive Provider Organizations (EPOs): EPOs are managed care plans that cover the costs of medical care if you use in-network doctors, specialists, or hospitals. They typically come with larger networks than HMOs and their pricing falls between HMOs and PPOs. Specialist referrals by PCPs may or may not be required.
- Point of Service (POS) Plans: POS plans are slightly more expensive than HMOs. They offer discounts on in-network care, and they cover out-of-network providers at a higher cost.
The best plan for you will depend on your needs and preferences. If you’re happy with an insurer’s network and don’t mind seeing a primary care physician to get referrals to specialists, an HMO or EPO could be a cost-effective plan. However, if you prefer flexibility and don’t want to be tethered to a PCP, you may prefer a POS or PPO plan.
Plans in the Marketplace are also organized by metal tiers; bronze, silver, gold, or platinum. Bronze plans have the lowest premiums and highest out-of-pocket costs while platinum plans have the highest premiums and lowest out-of-pocket costs. Silver and gold fall in between.
How to Save Money on Health Insurance for Pregnant Women
Looking to fit health insurance into a tight budget? Here are a few cost-saving tips:
- Low-cost or free health insurance for pregnant women is available through Medicaid, but you’ll have to meet your state’s income requirements to qualify.
- If you don’t qualify for Medicaid, you can still save on health insurance if you qualify for premium tax credits through the Marketplace.
- Consider your medical care needs before selecting a policy. If you expect to need a high level of care, it can make sense to pay a higher premium for lower out-of-pocket costs.
- To find the best health insurance for pregnant women, shop around and compare plans offered by various insurers. A good place to start is with our list of the most affordable health insurance companies of 2023.
Cost of Health Insurance for Pregnant Women
Wondering about the costs of health insurance for pregnant women? Here’s a look at quotes from a handful of providers for HMO plans (Oscar’s is an EPO).
|Company||Cost for a 25-year-old||Cost for a 30-year-old||Cost for a 40-year-old|
|Blue Cross Blue Shield (Anthem Blue Cross)||$276.83||$313.08||$334.57|
|Oscar||$357.40 (EPO)||$404.16 (EPO)||$437.13 (EPO)|
These quotes are based on an applicant who’s a pregnant female living in Los Angeles who is head of household and earns $60,000 per year. All of the quotes are for Silver 70 plans with a $4,750 yearly deductible, an $85 separate drug deductible, an $8,750 annual out-of-pocket maximum, and a $250 maximum cost per prescription. They don’t include any subsidies and all are HMOs, except Oscar’s plan which is an EPO.
As you get older, you can expect your health insurance premium to increase. However, at any age, premiums vary from one provider to the next, so it’s always smart to shop around. Many of these plans are nearly identical when it comes to deductibles, copays, coinsurance rates, and maximum cost limits. The biggest variation is each insurer’s quality ratings, which are a reflection of how the insurer’s care and member experience compare to national standards.
How Much Does Health Insurance Cost for a Pregnant Woman?
The cost of health insurance for pregnant women depends on a wide variety of factors including age, plan type, provider, deductibles, coinsurance percentage, and more. When looking at unsubsidized silver HMO plans for pregnant women between the ages of 25 and 40, premiums ranged from $270 to $375 per month (for women in the Los Angeles area). Bronze plans offer lower premiums and higher out-of-pocket costs, while gold and platinum plans offer higher premiums and lower out-of-pocket costs.
Does Health Insurance Cost More for Pregnant Women?
Health insurance coverage won’t cost more for a pregnant woman if you buy health insurance through your employer or the Health Insurance Marketplace. ACA-compliant insurers are not allowed to refuse coverage or charge more for any pre-existing condition—including a pregnancy. However, maternity insurance plans that aren’t ACA-compliant may cost more and impose a waiting period on pregnancy coverage.
What Insurance Should I Get If I’m Pregnant?
If you’re pregnant, it’s often best to get health insurance through the ACA Marketplace (or your state’s healthcare exchange) or coverage through Medicaid. Maternity and newborn care are considered essential health benefits, which means they must be included in qualified health plans sold on the Marketplace. Medicaid also offers covers care for pregnancies and childbirths.
Should I Get a PPO or HSA If I’m Pregnant?
According to the Kaiser Family Foundation, pregnancy and childbirth costs average $19,000, of which $2,854 is typically paid out of pocket. Health savings accounts (HSAs) are associated with high deductible health plans (HDHP), which require you to pay expensive deductibles before your coverage begins. Since pregnancy and childbirth bring hefty costs, a lower-deductible PPO plan may be a more affordable option.