Does Medicaid Cover OB-GYN Services in Pregnancy?
- Does Medicaid cover OB-GYN? Find out what services Medicaid covers during pregnancy, childbirth and the postpartum period, including eligibility information.
OB-GYN services during pregnancy, childbirth and the postpartum period are essential for infant and maternal health, but many families can't afford private health care insurance. Therefore, it's essential to know what support is available if you're pregnant and on a low income.
Does Medicaid cover OB-GYN care? Find out how pregnancy-related Medicaid works, including who qualifies and what to do if you're ineligible for Medicaid.
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Does Medicaid Cover OB-GYN?
Medicaid covers OB-GYN care during pregnancy and birth for all enrollees. You may also be eligible for the Children's Health Insurance Program (CHIP), which extends health care benefits to pregnant women in some states. Some other states cover the fetus, entitling the woman to health care to safeguard the fetus' well-being. It's worth checking if you're entitled to CHIP coverage even if you're ineligible for Medicaid because the income eligibility cap is often higher.
If you're enrolled in Medicaid, you won't be required to contribute towards prenatal or postpartum care costs. However, a few states allow cost-sharing for pregnant women enrolled in the CHIP program.
Who Qualifies for OB-GYN Care Through Medicaid?
You can apply for Medicaid even if you are already pregnant. Eligibility criteria vary across states, but all states are required to cover categorically needy, medically needy and special groups. You'll automatically qualify for Medicaid if your income is equivalent to 133% of the Federal Poverty Level (FPL) or lower.
Pregnancy may qualify you as medically needy, even if you would not usually be eligible for Medicaid. Some states set a higher income cap for women requiring pregnancy-related health care, so you may be eligible for Medicaid during pregnancy if your income would usually be considered too high. You can contact your state's Medicaid Agency to find out the income cap for pregnancy-related Medicaid.
If you're pregnant or have recently given birth, you may have presumptive eligibility (PE) for Medicaid-funded care. PE allows you to access OB-GYN care without waiting for your Medicaid application to be granted. Your PE will be determined using a verbal questionnaire or written application by a qualified entity. There are various entities capable of granting PE, including health care providers and social services providers.
What Services Does Medicaid Cover During and After Pregnancy?
All states are required to cover prenatal and postnatal care for pregnant women and new mothers enrolled in Medicaid and pay for treatment for any condition that could threaten the safe delivery of the baby. However, states have a certain amount of leeway in the types of services they fund through Medicaid.
A 2017 study found that all surveyed states' Medicaid programs covered prenatal vitamins and ultrasounds, and most states covered the cost of delivery in a birth center. Most states covered supportive prenatal and postnatal home visits, breast pumps, hospital-based breastfeeding support and diagnostic tests like amniocentesis. However, coverage for services such as home births, genetic counseling and doula support was less consistent.
In practice, 47 states fund comprehensive pregnancy-related care to Medicaid enrollees because they meet the CMS minimum essential coverage (MEC) guidelines. Arkansas, Idaho and South Dakota are the only states that don't provide comprehensive coverage during pregnancy.
How Much Does Medicaid Cover for Birth?
Medicaid will generally cover all the costs involved in giving birth in a hospital for eligible beneficiaries, and more than 99% of Medicaid-funded births occur in hospitals in most states. However, you may not be entitled to funding for childbirth if you wish to give birth in an alternative setting such as your home or a birth center.
How Long Does Medicaid Last?
Medicaid covers eligible women for 60 days postpartum. This means that women who would not usually be eligible for Medicaid but qualify for pregnancy-related Medicaid services won't lose their eligibility immediately following childbirth, letting them access postpartum health care. The infant is eligible for Medicaid coverage for a year after birth, even if their mother loses her eligibility after the 60-day postpartum period.
If you live in a state with expanded Medicaid and have a household income of 138% FPL or less, you may be entitled to continued Medicaid coverage after the 60 days is up. If your income is above the threshold, you may be eligible for financial assistance in obtaining insurance through the ACA Marketplace in states with expanded Medicaid. Women living in non-expanded states may still be entitled to Medicaid coverage, but the income caps are typically lower than those for pregnant women.
What If I Don't Qualify for Medicaid?
If you don't qualify for Medicaid or CHIP, you may be eligible for ACA Health Insurance Marketplace subsidies. The ACA Marketplace provides affordable health insurance policies, and all new Marketplace plans must cover pregnancy and childbirth. Marketplace insurers can't increase your premiums or reject your application due to pregnancy, even if you're already pregnant at the point of enrollment.
Bronze, silver, gold and platinum plans are available. As you move up the scale, the premium costs increase while the deductibles and copayments decrease. This means that the cheapest plans per month result in higher costs when you receive health care.
People with incomes below 400% of the FPL are entitled to Advanced Premium Tax Credits. The amount you're required to contribute toward the cost of your plan increases on a sliding scale depending on your household earnings, along with the maximum amount you can be expected to pay per year. You can apply advanced premium tax credits to any Marketplace insurance plan.
Unlike Medicaid, Marketplace plans are subject to cost-sharing that varies between plans. You may also be entitled to cost-sharing subsidies if your household income is between 100% and 250% FPL to help you cover the costs of coinsurance, copayments and deductibles. You can claim cost-sharing subsidies alongside advanced premium tax credits, but you can only apply them to silver plans. Subsidies are calculated using a sliding scale according to your household income.
