Maternity, Newborn, and Pediatric Care under the Affordable Care Act

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Under the Affordable Care Act (ACA), many health plans — including Medicaid and all insurance plans sold through the Marketplace — must cover certain preventive services for children at no cost to you (even if you haven’t yet met your plan’s deductible). Check your plan’s SBC for your specific coverage, but here are some of the essentials the ACA provides for:

  • Autism screening at 18 and 24 months

  • Behavioral assessments at various recommended ages

  • Blood pressure screenings at various recommended ages

  • Depression screening for adolescents

  • Developmental screenings for children under age 3

  • Hearing and sickle cell screenings for all newborns

  • Height, weight, and body mass measurements

  • Hematocrit or hemoglobin screening

  • Oral health risk assessment at various recommended ages

  • Vision screenings for all children

In addition, children with specific risks are entitled to the following benefits:

  • Fluoride supplements

  • Iron supplements

  • Obesity screening and counseling

  • Screening for lead exposure

  • Screening for lipid disorders

  • Tuberculosis testing

The ACA also provides that children receive recommended vaccinations at no cost to you, including for flu; measles, mumps, and rubella; rotavirus; hepatitis A and B; diphtheria, tetanus, and pertussis; and human papillomavirus (HPV).

Before the ACA, many people got a nasty surprise when they discovered that their insurance policies excluded prenatal and maternity care. (As many as two-thirds of plans did so.) Under the ACA, prenatal care is classified as a preventive service that must be provided at no extra cost as part of nongrandfathered individual and small-group plans.

This means that a pregnant woman receives standard screenings, such as screenings for anemia, gestational diabetes, Rh incompatibility, and hepatitis B, at no cost to her.

In addition, the ACA requires that health plans cover expenses related to childbirth, as well as the newborn infant’s care. Keep in mind that insurers aren’t required to offer 100 percent coverage for childbirth expenses, so you can expect some out-of-pocket costs, depending on your specific plan. But plans must cover newborn screenings and tests that are considered essential preventive care at no additional expense to the parents.

If you have health insurance and are looking to change plans, keep in mind that you can go shopping for new coverage after the birth of a child, or you can add the child to your existing coverage. That event qualifies as a special enrollment opportunity, which means you have 60 days to purchase new coverage.

However, pregnancy itself doesn’t qualify as a special enrollment opportunity; you can’t go shopping for new coverage after you get pregnant (unless you experience some other event, such as a job loss or loss of a spouse, that triggers a special enrollment opportunity).

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