By Kristin Effland LM CPM

We’ve all heard various rumblings about “Obamacare” and the Affordable Care Act. Now that much of it has gone into effect, you are probably wondering even more how it will affect your clients and their families. As primary maternity care providers, we are in a unique position to hi-light some of the key ways that these new changes to our health care system will influence women, babies and families. Click here for a Client Handout (PDF) that you can share with your clients.

After March 31, 2014, not just anyone can apply for health insurance for the rest of the year. The "open enrollment" period to attain coverage for this year has ended for many individuals. Luckily for some of our clients, a qualifying event — such as the birth of a child, marriage, divorce, or a job loss — will allow them to still have the opportunity to apply for coverage if they are or become uninsured or under-insured. Despite these exceptions that may apply to some of our clients including newborns, after March 31, most Americans including women who realize they are pregnant in April or later will not be able to apply for health insurance until the next open enrollment for coverage starting in 2015 begins. Open enrollment periods were created to prevent sick, newly pregnant or injured individuals for applying for care in the event of the onset of pregnancy or illness and canceling when they are healthy or not pregnant. Some populations, such as Native Americans in federally recognized tribes, can enroll any time. For more information about exceptions to the open enrollment deadline, see below.

As part of the changes to health care services resulting from the Affordable Care Act, annual check-ups for all family members are completely covered for almost all insurance plans*

  • Well-baby and well-child visits are free of charge
  • Your clients’ deductibles do not apply to one Annual Wellness Visit per person per year for each of their family members
  • Co-payments are waived for one Annual Wellness Visit per year per person
  • For women over 21, this includes their gynecological exam & pap
  • Mammograms are also included free of charge
  • Flu shots are available free of charge for all adults and children
  • Since your clients won’t pay an extra penny for each of their family members to have an Annual Wellness Visit, they no longer have to skip this preventative service even if they have a high deductible or a co-pay for other visits.

Pregnant mothers-to be:

  • Don’t need a referral for Midwife or OB-GYN services
  • Can receive a breast pump free of charge - see below for more info!
  • Are all eligible for lactation services to help increase breastfeeding success
  • May be surprised to find that while they are pregnant, they may qualify for complete coverage under Washington Apple Health at no monthly premium cost to them. They can determine what plans they are eligible for by visiting: wahealthplanfinder.org

For children:

  • Well-baby and well-child services are free of charge
  • Flu shots are available free of charge for all children and adults for those who elect them
  • Clients may be surprised to find that their children qualify for complete coverage under Washington Apple Health at no monthly premium cost to them. They can find out with no strings attached at: wahealthplanfinder.org

Older children:

  • Children can now be covered under their parent’s health insurance plan until they are 26 years old even if they are married, not living with their parent(s), attending school, not financially dependent on their parent(s) and/or eligible to enroll in their employer’s plan.
  • This means, for example, if you have a young married 25 year old client who is pregnant but does not have health insurance, she may be eligible for coverage under her parent’s plan if it covers children.

For clients who are breastfeeding or planning to breastfeed:

  • The cost of a breast pump or a rental for the duration of breastfeeding is covered
  • Clients can call their insurance company for details about when and how they can get their breast pump: They should ask about the specifics of their coverage for HCPC equipment code E0603
  • All health insurance plans* must provide breastfeeding support, counseling, and equipment for the time that a mother breastfeeds her baby.
  • Medela (a maker of breast pumps) provides a webpage where you can get more information about finding a supplier who accepts your clients’ insurance: medelabreastfeedingus.com/tips-and-solutions/168/where-can-i-get-my-pump
  • PMSI (Pacific Mothers Support, Inc.) is a local supplier of breast pumps who processes your client’s insurance. Clients can call them directly for more information, but some plans may require you as the provider to fill out a simple form. Pumps and other supplies (such as maternity or PP support belts) that you order through PMSI will arrive on your client’s doorstep just a few days after you fax in their order form.
  • Find PMSI at: pacificmsi.com or call (425) 462-0577
  • Some of your clients may be able to acquire a breast pump for themselves directly and others will need you as their provider to fill out a form for them depending on the details of their insurance plan.

For Postpartum clients inquiring about their birth control options:

  • Contraceptive methods and counseling for all women, as prescribed by a health care provider must be covered by all plans in the Health Insurance Marketplace.
  • Clients cannot be charged a copayment, coinsurance, or deductible when these contraceptive methods and services are provided by an in-network provider*.

Covered contraceptive methods include:

  • All Food and Drug Administration-approved contraceptive methods prescribed by a woman’s provider are covered, including:
  • Barrier methods (used during intercourse), like diaphragms and sponges
  • Hormonal methods, like birth control pills and vaginal rings
  • Implanted devices, like intrauterine devices (IUDs)
  • Emergency contraception, like Plan B® and ella®
  • Sterilization procedures
  • Patient education and counseling
  • Plans aren’t required to cover:
  • Drugs to induce abortions
  • Services related to a man’s reproductive capacity, like vasectomies

Clients who do not currently have care and who apply for new health insurance coverage:

  • Can’t be denied coverage for being pregnant at the time they apply.
  • Can’t be denied coverage for a pre-existing condition that they or their children have.
  • Can no longer be charged more because they are a woman of childbearing age who may choose to have a family.

What if my client needs health care but has missed the opportunity to apply for health insurance coverage during the open enrollment period for that year?

If you or one of your clients or their family members experiences a tragic accident or emergency:

  • They can’t be asked to pay more for accessing the nearest emergency room even if that hospital is out-of-network. They also don’t need prior approval before accessing these services.
  • Their health insurance plan can’t stop paying after the costs of care for them or their child has reached a certain limit for any reason including expensive diseases like cancer.
  • This means that families who find themselves in these terrible circumstances don’t also have to file bankruptcy as many of them did in the past when their lifetime plan limits were exceeded. Medical bills are currently the leading cause of personal bankruptcy.

All of these changes are new and they may feel overwhelming or confusing to clients. You are in a unique position to help them better understand these changes:

  • For more detailed information than this article provides about how Medicaid expansion will affect you and your clients, view the ACNM webcast: services.choruscall.com/links/hrsa131104.html
  • Advise your clients to look for some paperwork from their insurance company called a “Summary of Benefits and Coverage.” This paperwork is meant to be a short, easy-to-understand summary of what a plan covers and costs.
  • For more information about plans available in Washington or to apply for coverage anyone can visit: wahealthplanfinder.org
  • For general questions clients can google their query + “healthcare.gov” for more information about a particular topic or visit the website: healthcare.gov.
  • Maternity and newborn care are included in the 10 essential benefits that all insurance plans* must cover under the Affordable Care Act. For more information about what this means for your clients, visit: growingfamilybenefits.com/affordable-care-maternity/essential-benefits/
  • For resources compiled by the ACNM, visit: midwife.org/Implementation-of-the-Affordable-Care-Act

*Note: A select few plans have been “grandfathered” in and do not have to follow the new rules established by the Affordable Care Act. Grandfathered plans are those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increase costs for consumers. If your client holds one of these plans, their insurance company was required to notify them. For more information about the benefits that may not be available with grandfathered plans, visit: healthcare.gov/what-if-i-have-a-grandfathered-health-plan/

Article written by MAWS Board member Kristin Effland LM, CPM