Pregnancy and Special Enrollment Periods

A year ago, I wrote an article about a petition in Colorado that was trying to get pregnancy added to the list of things that make people eligible for a special enrollment period during which they can enroll in a health insurance plan. Nothing has changed in Colorado on this issue since then, but I wanted to write an update with more details.

At the time I wrote the post about the petition, New York’s pregnancy SEP law had passed, but had not yet been signed into law by the governor. And California’s was still under consideration. The pregnancy SEP provision ended up taking effect in NY in January 2016, but the legislation was altered significantly in California and the state did not end up with a SEP triggered by pregnancy.

pregnancy special enrollmentSo as of 2016, in every state except New York, pregnancy is not a qualifying event for health insurance enrollment. Having a baby is a qualifying event, so the baby—along with the parents—can enroll in a plan with coverage back-dated to the date of the birth.

But that means the prenatal care and labor/delivery charges are not covered if the mother was uninsured during the pregnancy. This can amount to thousands or tens of thousands of dollars, and it’s also more likely to mean that the mother goes without prenatal care during her pregnancy. This in turn, is more likely to result in complications with the pregnancy, and poorer outcomes for the mother and baby following the birth.

If a woman becomes pregnant outside of open enrollment and does not have maternity coverage, she’s unable to enroll in a private health insurance plan—on or off the exchange—unless she has a qualifying event. Her next opportunity to enroll will be the next open enrollment period that begins in November, and the earliest possible coverage effective date she’ll be able to get is January 1 of the following year.

Depending on when she becomes pregnant, this schedule may or may not work well. A woman who becomes pregnant in October can sign up for a health insurance plan in November or December and have coverage by the time she’s in her second trimester.

But a woman who becomes pregnant in February—after open enrollment has ended—will have her baby in November without any opportunity to enroll in coverage until after the baby is born.

Why do qualifying events matter?

Under the Affordable Care Act, enrollment in individual market health insurance is now limited to annual open enrollment periods, and special enrollment periods triggered by qualifying life events. This is in contrast to how things were before 2014, when individual health insurance was available for purchase year-round, but with medical underwriting in most states (meaning that insurers could reject applicants or charge them higher premiums based on medical history, and could refuse to cover pre-existing conditions).

Most people purchase new coverage or make changes to their coverage during the annual open enrollment period that begins in November. But special enrollment periods triggered by qualifying events are an important aspect of ensuring that everyone has access to coverage. If you move to a new state or lose your job—and your job-based health insurance—there has to be a way to allow people to sign up for coverage at that point, rather than going uninsured for the rest of the year.

The debate over making pregnancy a qualifying event

When the guidelines for special enrollment periods under the ACA were first specified, pregnancy was not among the qualifying life events that trigger a special enrollment period. Advocates began pushing the Department of Health and Human Services (HHS) to add pregnancy as a qualifying event, and in several states, efforts were made by consumer advocates to make pregnancy a qualifying event within the state.

Consumer advocates note that nearly half of pregnancies are unintended, and that women without health insurance might become pregnant even if they have no intention of doing so. There are also still a significant—but declining—number of women with grandfathered and grandmothered health plans that are not required to cover maternity care. Without maternity coverage, the impact of a pregnancy can be a financial challenge for the parents. But the increased likelihood that a lack of prenatal care might result in complications for the mother and baby ultimately results in higher costs for health insurers—and thus higher premiums for everyone—since the baby’s birth is a qualifying event that allows the mother and baby to have coverage starting with the date of birth.

On the other side of the argument, people opposed to making pregnancy a qualifying event note that doing so would just add one more way that people could “game” the system and wait to begin paying premiums until they’re in need of care. This issue has been paramount in 2016, with HHS scrambling to tighten up enforcement of special enrollment period eligibility after insurance carriers noted that claims costs were running significantly higher among people who were signing up for coverage during special enrollment periods as opposed to during general open enrollment.

In response, consumer advocates note that pregnancy is different from other situations that require medical care, since there’s another person involved who has no say in the matter. The mother might have skipped the opportunity to enroll in a health plan during open enrollment, but the baby had no choice—and yet his or her health might suffer if the mother isn’t able to afford proper medical care during her pregnancy and delivery.

The government’s response

In early 2015, HHS released the 2016 Benefit and Payment Parameters, which did include some adjustments to the rules surrounding qualifying events. But they clarified at the time that although they had considered the requests to designate pregnancy as a qualifying event, they had ultimately opted not to include pregnancy in the list of things that trigger a special enrollment period.

That doesn’t mean they’ll won’t ever reverse course on that issue—the guidelines surrounding the ACA are still very much in a state of being fine-tuned. But for now, they have considered the issue, and have decided that pregnancy should not be a qualifying event.

Although HHS declined to make pregnancy a qualifying event at the federal level, they specifically noted that states were free to establish additional special enrollment periods.

New York

Within a few months, lawmakers in New York introduced Senate Bill 5972, which was eventually signed into law in December 2015, and took effect in January 2016. The law allows a pregnant woman to enroll in a plan through New York State of Health (the state-run ACA exchange in New York) once her pregnancy has been confirmed by a licensed healthcare provider. Her coverage can be backdated to the first day of the month that the pregnancy is confirmed in her medical record.

Consumer advocates have pushed for something similar in other states, but have not yet been successful. In Nevada, coverage can be purchased outside the exchange (ie, with no subsidies available) year-round, although there’s a 90-day waiting period before coverage takes effect. Nevada is unique in this regard; in every other state, off-exchange plans follow the same enrollment period rules as on-exchange plans.

In Colorado, the rules remain as they have been since ACA-compliant coverage was first marketed in the fall of 2013: the birth of a baby triggers a special enrollment period, but a pregnancy does not.

Help for pregnant women without coverage

Although pregnancy is not a qualifying event in Colorado, there are numerous resources for uninsured or under-insured pregnant women.

And although private health plan enrollment is limited to open enrollment and special enrollment periods, Medicaid enrollment continues year-round, and eligibility guidelines are more generous for pregnant women, with Medicaid eligibility extending up to 260 percent of the poverty level for pregnant women (note that a pregnant woman also counts as two people when determining how household income compares with the federal poverty level, which futher increases eligibility). So a woman who was previously ineligible for Medicaid might find that she’s eligible for Medicaid during her pregnancy.

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