How the Affordable Care Act (ACA) affects pregnant women and families

How the Affordable Care Act (ACA) affects pregnant women and families

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Landmark legislation

The Affordable Care Act (ACA), signed into law in March 2010 and put into effect in 2014, is the most significant healthcare legislation since 1965, when Medicare and Medicaid were created. Not only does "Obamacare" make healthcare available to people who were formerly unable to get insurance, but for women in particular it eliminates unfair obstacles to getting care.

The ACA requires all US citizens and legal residents to obtain basic health insurance coverage or pay a fine. Exemptions are possible under certain circumstances. And if you don't have affordable job-based coverage, you're able to take part in insurance exchanges that allow you to compare plans and find affordable healthcare.

Low- to middle-income earners may qualify for subsidies to help them afford insurance. And some low-income families will qualify for Medicaid in states that opt to expand that program.

In addition, the ACA establishes a series of benefits and protections, some of which are particularly important for women and children.

Does my plan offer all the ACA protections and benefits?

There are some protections that all insurers are required to provide. But there are other benefits you may receive only if you don't have a grandfathered insurance plan (plans created since March 23, 2010 – the day the law was signed). Most plans aren't grandfathered, but if you have a grandfathered plan that doesn't currently provide ACA benefits, you may want to shop around.

ACA rights and protections

If you're happy with your family's coverage, you may not notice much difference. But for those who have been struggling to get coverage or make sense of their plans, the ACA may offer some relief. Below is a list of benefits offered by non-grandfathered plans.

Readable benefits and coverage summaries: All health insurance companies are now required to provide you with an easy-to-understand summary of their plan's benefits and coverage. They must all use the same standard form so that you can easily compare their offerings.

Consumer assistance services: All states are now required to provide consumer assistance programs (CAP) to help you with health insurance problems, such as when your insurer refuses to pay for a needed treatment or when you need to file a complaint or choose new coverage. Only 13 states have them so far, though, so you may be referred to another agency depending on where you live. Find out what your state offers.

No dropping coverage for a paperwork mistake: Plans can no longer cancel your insurance because you or your employer made a mistake on your application.

Coverage for those with preexisting conditions: Plans can no longer deny or limit coverage due to a preexisting condition.

No more lifetime and annual limits: Plans can no longer put an annual or lifetime dollar limit on the essential covered benefits you receive.

No unreasonable rate hikes: Whenever an insurer wants to raise premiums 10 percent or more for an individual or small group policy, they must get the increase approved by independent evaluators and must clearly explain the reasons for the increase to consumers.

Choice of doctors: Plans must allow you to choose the primary care doctor or pediatrician you want from your health plan's provider network.

Easier access to ob-gyns: Plans must allow you to see an ob-gyn without a referral from another doctor.

Emergency care access: Plans must allow you to seek emergency care at a hospital outside your plan's network for your usual copayment and without prior approval from your health plan.

Young adult coverage: Plans must allow you to add or keep your children on your policy until they turn 26 years old, even if they're attending school or not living with you.

New rules for appeals: All plans must follow ACA rules regarding how they handle appeals when they deny payment. They must tell you why your claim was denied and alert you to your right to request an internal appeal. If you appeal, they must respond with a decision within two months or less. If the insurer denies your appeal, you have the right to request an external review by an independent organization.

You may even get a refund: For individual and small group policies, insurers must spend at least 80 percent of premiums on medical care versus overhead, salaries, and marketing. (For large group policies, the amount is 85 percent.) In 2013, nearly 7 million Americans received either a rebate check or a reduction in future premiums when their insurance company failed to spend the required amount on medical care.

ACA benefits: Free preventive services

One of the most important benefits of the ACA is comprehensive coverage of preventive services. This means that insurance plans must now pay the bill for many treatments and tests that can help you and your family stay healthy, with no copay from you. (Again, only non-grandfathered plans must provide this coverage.)

Below are the preventive care services for women and young children that plans must now cover in full when delivered by an in-network provider. See a complete list of covered services here.

For all women

Well-woman visits: An annual preventive care visit to your heathcare provider and any additional visits that are necessary to receive the following preventive services.

Contraception and contraceptive counseling: All contraceptive methods approved by the Food and Drug Administration, including sterilization procedures, and patient education and counseling. (Some religiously affiliated employers may be exempt.)

Folic acid supplements: Experts recommend that all women capable of getting pregnant take 400 micrograms of folic acid a day to reduce the risk of having a baby with a neural tube defect.

HPV DNA testing: Human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results, for women who are 30 or older.

Breast cancer screening: Mammograms every 1 to 2 years for women who are 40 or older. Counseling and screening for breast cancer gene mutations and preventive medication counseling for women at high risk.

STI and HIV screening and counseling: Annual counseling on sexually transmitted infections (STIs) and screening for human immunodeficiency virus (HIV) infection for all sexually active women. Annual screening for chlamydia, gonorrhea, and syphilis for women at high risk.

Domestic violence screening and counseling: Annual screening and counseling for interpersonal and domestic violence for all adolescent and adult women.

For pregnant women

Prenatal care visits: All preconception and prenatal care visits.

Alcohol misuse screening and counseling: For all adults. (All public health officials in the United States recommend that pregnant women avoid alcohol entirely.)

Tobacco counseling and cessation intervention: For all adults, with expanded counseling for pregnant women. Find help quitting smoking.

Rh incompatibility screening: Your blood will be screened to determine your Rh status at your first prenatal care appointment. (If there's a chance this blood protein is incompatible with your baby's, you'll need to take certain precautions.)

Iron deficiency anemia screening: Your blood will be tested for anemia at your first prenatal care appointment and again later in pregnancy.

Gestational diabetes screening: You'll most likely get screened for gestational diabetes between 24 and 28 weeks of pregnancy, or at your first prenatal visit if you're at high risk.

Infection screening: Screenings for infections that can affect your baby, including hepatitis B, chlamydia, gonorrhea, syphilis, and urinary tract infections (UTIs).

Breastfeeding support, supplies, and counseling: Comprehensive lactation support and counseling from trained providers during pregnancy and postpartum. Includes breast pump purchase or rental (your plan will determine what type of pump, manual or electric, and whether you get to keep or rent).

For young children

For newborns: Gonorrhea preventive medication for the eyes. Screening for congenital hypothyroidism, hearing problems, phenylketonuria (PKU), and sickle cell anemia.

For all children: Immunizations; medical history; blood pressure screening; hematocrit or hemoglobin screening; vision screening; developmental screening; behavioral assessments; height, weight, and body mass index measurements; and obesity screening and counseling.

Oral health risk assessment for young children.

Fluoride supplements for children without fluoride in their water source.

Iron supplements for children 6 to 12 months old at risk for anemia.

Lead screening for children at risk of exposure.

Autism screening for children at 18 and 24 months.

Tuberculosis testing for children at higher risk.

Dyslipidemia screening for children at higher risk of lipid disorders.

Learn more

Visit the website of your current insurance company to learn how the ACA affects your coverage, or go to to enroll.

Watch the video: NJFamilyCare Affordable Care Act Overview (January 2023).

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