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This 24-year-old mistakenly thought her health insurance covered her pregnancy—and 4.2 million others like her may be at risk
For years, federal laws have stipulated that employers need to cover maternity care for their employees and their spouses. But there are no laws that specifically state companies have to cover maternity care for adult children because, until the ACA passed in 2009, most employer-based health insurance plans cut off coverage when the children legally became adults or upon college graduation.
The ACA changed the rules, allowing dependent children to stay on their parents’ health insurance plans until the age of 26. The law also blocked insurers from turning away pregnant women and stipulated that maternity care was an “essential health benefit.”
On the surface, it seems like that should have solved everything. But the ACA’s essential health benefit stipulations apply only to individual health-care plans sold through the marketplaces and those offered by small employers (less than 50 employees), which is only a small percentage of plans. The bulk of Americans, 49%, get their health insurance through their employers, according to the Kaiser Family Foundation. Yet large employer plans (those with more than 50 employees) are not required to comply with the essential health benefit requirements.
Also exempt from these restrictions (unless mandated by the state law) are employers who opt to offer a self-insured (self-funded) health plan, says Julie Stich, vice president of content for the International Foundation of Employee Benefit Plans. These self-insured health plans may be run and handled by an insurance carrier, but the company is ultimately responsible for paying out on claims, instead of paying the insurer a premium.
For years, federal laws have stipulated that employers need to cover maternity care for their employees and their spouses. But there are no laws that specifically state companies have to cover maternity care for adult children because, until the ACA passed in 2009, most employer-based health insurance plans cut off coverage when the children legally became adults or upon college graduation.
The ACA changed the rules, allowing dependent children to stay on their parents’ health insurance plans until the age of 26. The law also blocked insurers from turning away pregnant women and stipulated that maternity care was an “essential health benefit.”
On the surface, it seems like that should have solved everything. But the ACA’s essential health benefit stipulations apply only to individual health-care plans sold through the marketplaces and those offered by small employers (less than 50 employees), which is only a small percentage of plans. The bulk of Americans, 49%, get their health insurance through their employers, according to the Kaiser Family Foundation. Yet large employer plans (those with more than 50 employees) are not required to comply with the essential health benefit requirements.
Also exempt from these restrictions (unless mandated by the state law) are employers who opt to offer a self-insured (self-funded) health plan, says Julie Stich, vice president of content for the International Foundation of Employee Benefit Plans. These self-insured health plans may be run and handled by an insurance carrier, but the company is ultimately responsible for paying out on claims, instead of paying the insurer a premium.
