Why the Affordable Care Act Matters for Women: Health Insurance Coverage for Lower- and Moderate- Income Pregnant Women

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1 Why the Affordable Care Act Matters for Women: ISSUE BRIEF Health Insurance Coverage for Lower- and Moderate- Income Pregnant Women Many women of childbearing age will gain access to affordable health insurance for the first time as a result of the Affordable Care Act (ACA). Thanks to the ACA, eligibility for Medicaid will be expanded and more affordable health insurance plans will be offered to individuals in state-based health insurance marketplaces. In states that choose to take advantage of the newly expanded Medicaid program, adults at or below 138 percent 1 of the Federal Poverty Level (FPL) will receive Medicaid coverage. 2 Additionally, subsidized private health insurance plans will be available in new, state-based health insurance marketplaces for women whose family incomes are 100 percent to 400 percent of the FPL. 3 Individuals not eligible for subsidies also will have the option to buy coverage in their state s marketplace. Implementation of the ACA and its changes to Medicaid eligibility will have a particular impact on lower- and moderate-income pregnant women. This issue brief aims to help pregnant women who are eligible for premium or cost-sharing assistance through Medicaid or through premium tax credits and cost-sharing reductions decide what type of coverage is best for them and their families. Additional information about eligibility for these coverage options is addressed in the National Partnership for Women & Families companion piece, Frequently Asked Questions: Health Insurance Coverage for Low- and Moderate- Income Pregnant Women. Coverage Options Available to Lower- and Moderate-Income Pregnant Women The ACA requires nearly every American to have minimum essential health care coverage. 4 Unless a pregnant woman falls into an exempted group, she will need to enroll in a health plan 1875 Connecticut Avenue, NW Suite 650 Washington, DC

2 that qualifies as minimum essential coverage in Several coverage options are available to lower- and moderate-income pregnant women. If a pregnant woman does not have access to affordable, adequate employer-provided insurance 5 and cannot afford to purchase health insurance on her own, she may be eligible to obtain coverage through Medicaid or by purchasing a private subsidized plan in her state s health insurance marketplace. Whether a pregnant woman is eligible for financial assistance for health insurance coverage and what programs she is eligible for likely will depend on the state in which she lives. For the most part, a lower- or moderate-income woman will be choosing between Medicaid coverage and purchasing a subsidized private plan in her state s health insurance marketplace. Medicaid Medicaid is a publicly funded health insurance program jointly paid for by federal and state governments. For eligible pregnant women, there can be more than one pathway to Medicaid coverage, and the scope of benefits for which she is eligible may vary by state. The type and scope of Medicaid coverage that a pregnant woman will be eligible for will depend on the timing of her pregnancy, her income, and her state s Medicaid policies: Medicaid The federally required minimum Medicaid income-eligibility standard for parents with dependent children is tied to 1996 cash-assistance levels used by the former Aid to Families with Dependent Children program (which was replaced by the Temporary Assistance for Needy Families program in 1996). Thus, minimum income thresholds for parents and caregivers tend to be very low. Across states, the average income eligibility for employed parents is 63 percent FPL ($14,834 for a family of four) and the average income-eligibility cap for unemployed parents is 37 percent FPL ($8,714 for a family of four). 6 Medicaid Coverage of Pregnancy Services Federal law requires states to offer Medicaid coverage to pregnant women who have incomes at or below 133 percent FPL ($15, for individual, $31, for family of four). 7 For pregnant women who fall into this category, states are only required to cover pregnancy-related services, but are permitted to cover full Medicaid benefits at the option of the state. (Most states define pregnancyrelated services broadly, and thus pregnancy only Medicaid coverage programs often equal traditional Medicaid coverage. 8 ) Infants born to pregnant women who are receiving Medicaid when they deliver are automatically eligible for Medicaid, and they remain eligible for one year. 9 States have the option to offer Medicaid coverage to pregnant women with incomes higher than 133 percent, and many have chosen to do so. Several states have extended Medicaid coverage to pregnant women and children up to 185 percent FPL, and some states offer coverage of pregnancy-related services to pregnant women with incomes as high as 300 percent FPL. 10 The scope of benefits offered to pregnant women with incomes higher than 133 percent FPL varies by state. Medicaid Coverage of Pregnancy Services coverage for pregnancy-related services only is not considered minimum essential coverage under the Affordable Care Act. 11 However, for calendar year 2014, women enrolled in Medicaid pregnancy-only plans will not be subject to an individual mandate penalty. The U.S. Department of the Treasury is expected to issue additional guidance on this issue soon. Medicaid Expansion Under the Affordable Care Act, states now have the opportunity to revise their eligibility rules and extend Medicaid coverage to millions more people by covering uninsured adults whose incomes are at National Partnership for Women & Families issue brief Health Coverage for pregnant women 2

3 or below 138 percent FPL regardless of whether they are parents or parents-to-be. 12 In states that choose to do so, many individuals, particularly adults without dependent children, will become newly eligible for Medicaid coverage. Expanded Medicaid coverage for these newly eligible beneficiaries is referred herein as Medicaid Expansion. Women applying for Medicaid coverage who are pregnant at the time of application are not eligible for Medicaid Expansion coverage. If an applicant is pregnant and her income falls within the Medicaid Expansion income range, she will be deemed eligible for enrollment in her state s version of Medicaid pregnancy only coverage. (If a pregnant woman has an income higher than 100% FPL at the time of her application, she also may be eligible to receive advanced premium tax credits, should she choose instead to purchase a qualified health plan (QHP) in her state s marketplace.) Women who become pregnant while enrolled in Medicaid Expansion will remain covered by it until the next eligibility redetermination date. At that time, if the woman is still in her pregnancy period, she likely will be deemed ineligible to remain in Medicaid Expansion and required to transition to Medicaid pregnancy only coverage or to a private, subsidized QHP. State Children s Health Insurance Program States can also offer coverage to pregnant women through their State Children s Health Insurance Program (CHIP). States can provide comprehensive health benefits to pregnant women throughout pregnancy and for 60 days postpartum. States offering coverage through this option must provide Medicaid to pregnant women with incomes up to at least 185 percent FPL and must provide CHIP to children with family incomes up to at least 200 percent FPL. 13 Medicaid Premium Assistance A few states are exploring Medicaid premium assistance, an alternative Medicaid expansion option. This option allows states to use federal and state Medicaid funds to pay for private insurance coverage of Medicaid beneficiaries. 14 Under this program, states can use Medicaid funds to pay for costs associated with a private insurance plan purchased in a state health insurance marketplace, such as premiums, copays and deductibles. Under premium assistance arrangements, beneficiaries remain Medicaid enrollees and continue to be entitled to all Medicaid benefits and cost-sharing protections. 15 If states are able to prove that premium assistance is a cost-effective way to expand their Medicaid programs, they may be permitted to finance their Medicaid expansion by encouraging Medicaid beneficiaries to enroll in private plans that are purchased with Medicaid funds. Though Medicaid premium assistance programs will vary by state, certain federal provisions are important for women and their families to know: Individuals who enroll in Medicaid premium assistance are entitled to the same benefits, protections, legal rights and cost-sharing limitations that they would have received through the state-run Medicaid program. This means that private insurance plans financed through Medicaid premium assistance must cover the same services that Medicaid is required to cover, including maternity and postpartum care. They also must limit the out-of-pocket costs to the Medicaid-equivalent amount: no higher than five percent of a family s income. 16 If a state s Medicaid premium assistance program fails to meet any Medicaid coverage or costsharing requirement, the state must offer and pay for the required benefits or cost-sharing assistance a mechanism known as wraparound coverage. 17 Beneficiaries cannot be forced to enroll in a private plan paid for with Medicaid premium assistance National Partnership for Women & Families issue brief Health Coverage for pregnant women 3

4 dollars. States must offer Medicaid premium assistance as an option but cannot require Medicaideligible individuals to participate. If a state offers premium assistance, the state is required to make a state-run Medicaid option available and provide materials needed to compare the two programs. 18 Private Insurance: Premium and Cost-Sharing Assistance Women and families will have a new option for acquiring affordable health care in 2014: purchasing private insurance plans in state-based health insurance marketplaces. These marketplaces will offer consumers a menu of health insurance plans that are available for purchase online. Insurance plans offered in state marketplaces must abide by federal and state regulations. At minimum, they must be designated as QHPs, which means that they will, amongst other requirements, include a set of minimum essential health benefits, comply with limits on cost-sharing (including out-of-pocket costs) for those essential health benefits and meet all applicable private-market reforms specified in the ACA. 19 Marketplace QHPs will be categorized as Bronze, Silver, Gold or Platinum, and tiered based on their actuarial value. 20 Bronze plans will have an actuarial value of 60 percent (which means these plans will cover roughly 60 percent of costs), Silver 70 percent, Gold 80 percent and Platinum 90 percent. Subsidized and unsubsidized consumers alike will be able to enter their state s marketplace to compare and purchase health care coverage. Enrollment in plans offered in a state marketplace is voluntary; no one can be compelled to enroll in a marketplace plan. Premium Tax Credits Lower- and moderate-income individuals with incomes between 100 percent and 400 percent of FPL (up to $45,960 for an individual and $94,200 for a family of four in ) and who are not eligible for comprehensive Medicaid, Medicare or affordable, adequate employer-sponsored insurance may be eligible for tax credits to reduce premium costs and make coverage more affordable. Premium tax credits are awarded on a sliding scale, based on income: individuals with incomes close to 400 percent of FPL will receive less financial assistance (by way of tax credits) than individuals with incomes closer to 100 percent of FPL. For individuals who qualify for premium tax credits, subsidies will be made available immediately and will be paid directly to the individual s health-insurance company each month. 22 The premium tax credit amount an individual receives will be pegged to the premium cost of the second-lowest-cost Silver plan offered in that individual s state marketplace. 23 If the cost of the premium for the second-lowest-cost Silver plan offered in a state marketplace exceeds what an individual is expected to pay (between 2 and 9.5 percent of household income, depending on the individual s income), the government will subsidize the difference through a tax credit paid to the insurance plan. The tax credit will disperse on a sliding scale based on income, limiting what a person will pay in premium costs each year. An individual who is eligible for a tax credit may purchase a higher-value plan, such as a Gold or Platinum plan, but he or she is limited to the Silver-level-plan subsidy and would be responsible for covering the difference between the subsidy and the cost of the plan. Cost-Sharing Subsidies In addition to premium tax credits, women with incomes between 100 and 250 percent of FPL ($28,725 for an individual and $58,875 for a family of four in ) may be eligible for reductions in their cost-sharing responsibilities. 25 Similar to the premium tax credit, cost-sharing subsidies operate on a sliding scale, based on an individual s income, and are paid directly to the individual s insurance National Partnership for Women & Families issue brief Health Coverage for pregnant women 4

5 provider each month. Cost-sharing subsidies effectively increase the actuarial value of the plan purchased by an individual by reducing the amount the individual must pay out-of-pocket for care in the form of deductibles and co-pays. For a woman to be eligible for a cost-sharing subsidy, she must enroll in a Silver plan offered in her state marketplace. 26 If an individual chooses a non-silver-level plan, she will become ineligible for cost-sharing assistance, and will be responsible for paying all out-ofpocket costs. Selecting a Health Plan: Key Considerations for Pregnant Women For pregnant women who are comparing coverage options, there are a number of key factors to consider. These include: How comprehensive are the benefits? Does the plan limit the number of prenatal visits? Does the plan restrict my access to home birth, doula or midwife services? What diagnostic tests can I have done? How high is my monthly premium? Will premium tax credits make a plan that covers expected birth, delivery and perinatal care affordable? What are my cost-sharing responsibilities? Does the plan have a high deductible? Is the co-pay unaffordable for my family? How will my new baby gain health insurance coverage? Does the plan cover all federally approved contraceptives so I can plan my future pregnancies after having the baby? Am I entitled to receive the generic contraceptive only or can I get the brand name contraceptives? What abortion services do I have access to? How Can I Get More Information? The website healthcare.gov is a great, user-friendly resource for more information on the health insurance marketplaces, as well as important information on enrollment. Consumers can also call a hotline, toll-free, at The hotline is operational 24 hours a day 7 days a week. 1 The ACA requires Medicaid expansion states cover all persons at or below 133 percent of FPL, but 5 percent of a family s income cannot be included in determining financial eligibility, which makes this effective threshold higher, or 138 percent of FPL. 2 Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation. (2013, March). Where are states today? Medicaid and CHIP eligibility levels for children and non-disabled adults. Retrieved from 3 Kaiser Family Foundation. (2012, July). Explaining health care reform: Questions about health insurance subsidies. Retrieved from kaiserfamilyfoundation.files.wordpress.com/2013/01/ pdf. 4 The ACA exempts the following groups, amongst others, from having to buy coverage: (1) individuals and families that would have to pay more than 8 percent of their income for health insurance; (2) individuals and families with incomes below the threshold required for filing taxes; (3) individuals for qualify for a religious exemption; (4) incarcerated persons, undocumented immigrants, and members of Native American tribes. 5 Employer-sponsored coverage is considered adequate and affordable if it has an actuarial value of at least 60 percent and the plan s premium cost does not exceed 9.5 percent of your household income. ( 6 Kaiser Family Foundation. (2012, December). Medicaid s Role for Women Across the Lifespan: Current Issues and the Impact of the Affordable Care Act. Retrieved from Kenney, G., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., & Anderson, N. (2012, August). Opting in to the Medicaid expansion under the ACA: Who are the uninsured adults who could gain health insurance coverage?: Timely analysis of immediate health policy issues. Retrieved from 7 Calculations by the National Partnership based on data from the U.S. Department of Health and Human Services. Retrieved June 20, 2013 at National Partnership for Women & Families issue brief Health Coverage for pregnant women 5

6 hhs.gov/poverty/13poverty.cfm. 8 Medicaid and CHIP Payment and Access Commission. (2013, June). June 2013 Report to the Congress on Medicaid and CHIP. Washington, DC: Author. 9 Centers for Medicare & Medicaid Services. (n.d.). Pregnant women. Retrieved from Population/Pregnant-Women/Pregnant-Women.html. 10 Kaiser Family Foundation. (2013, January). Income eligibility limits for pregnant women as a percent of federal poverty level (FPL), January Retrieved from 11 Kenney, G., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., & Anderson, N. (2012, August). Opting in to the Medicaid expansion under the ACA: Who are the uninsured adults who could gain health insurance coverage?: Timely analysis of immediate health policy issues. Retrieved from org/uploadedpdf/ opting-in-medicaid.pdf. 12 Parisi, L., & Klein, R. (2010, July). Covering pregnant women: CHIPRA offers a new option. Retrieved from Covering-Pregnant-Women.pdf. 13 Centers for Medicare & Medicaid Services. (2013, March). Medicaid and the Affordable Care Act: Premium assistance. Retrieved from 14 Centers for Medicare & Medicaid Services. (2013, March). Medicaid and the Affordable Care Act: Premium assistance. Retrieved from 15 Centers for Medicare & Medicaid Services. (n.d.). Cost sharing out of pocket costs. Retrieved from Information/By-Topics/Cost-Sharing/Cost-Sharing-Out-of-Pocket-Costs.html. 16 Centers for Medicare & Medicaid Services. (2013, March). Medicaid and the Affordable Care Act: Premium assistance. Retrieved from 17 Centers for Medicare & Medicaid Services. (2013, March). Medicaid and the Affordable Care Act: Premium assistance. Retrieved from 18 Centers for Medicare & Medicaid Services. (n.d.). Qualified health plan. Retrieved from 19 Actuarial value measures how much the insurance provider pays of the total plan value. It is calculated by comparing how much of the plan the provider pays to how much the consumer will pay through a combination of premiums, deductibles, and co-pays. 20 Calculations by the National Partnership based on data from the U.S. Department of Health and Human Services. Retrieved June 20, 2013 at hhs.gov/poverty/13poverty.cfm. 21 Center on Budget and Policy Priorities. (2013, July). Premium tax credits: Answers to frequently asked questions. Retrieved from files/qa-on-premium-credits.pdf. 22 Center on Budget and Policy Priorities. (2013, July). Premium tax credits: Answers to frequently asked questions. Retrieved from files/qa-on-premium-credits.pdf. 23 Calculations by the National Partnership based on data from the U.S. Department of Health and Human Services. Retrieved June 20, 2013 at hhs.gov/poverty/13poverty.cfm. 24 Health Resources and Services Administration, U.S. Department of Health and Human Services. (n.d.). Affordable Care Act and HRSA programs. Retrieved from 25 Andrews, M. (2013, July 9). In addition to premium credits, health law offers some consumers help paying deductibles and co-pays. Kaiser Health News. Retrieved from The National Partnership for Women & Families is a nonprofit, nonpartisan advocacy group dedicated to promoting fairness in the workplace, access to quality health care and policies that help women and men meet the dual demands of work and family. More information is available at National Partnership for Women & Families, All rights reserved. National Partnership for Women & Families issue brief Health Coverage for pregnant women 6

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