You’ll make several trips to the doctor’s office in the first month of your baby’s life. You can avoid wrangling with your health insurance provider (and unexpected medical bills) by understanding how newborn insurance coverage works and what you need to do in order to get your baby covered.
Before Your Baby Is Born: Look at Your Current Coverage
Evaluate both parents’ coverage options.
While the proverbial bun is still in the oven, set aside some time to review your and/or your partner’s respective healthcare plans. The specifics of adding your baby to the policy will depend on the plan, but most private insurance plans will allow you to add the baby to the plan, regardless of medical needs, with coverage retroactive to the date of birth.
[Note that Medicare—which is available to people under age 65 if they’re disabled—does not cover dependents.1 So if one or both parents have Medicare coverage, the baby cannot be added to that plan and would need its own coverage instead.]
If one or both of you get your health coverage through your employer, you will almost certainly be able to add the baby to that plan. Large employers are required to offer coverage to full-time workers and their dependents (but not necessarily to their spouses) in order to avoid a penalty under the employer mandate. 2 Small employers are not required to offer coverage at all, and are allowed to offer coverage only to employees, without covering dependents. But if they do offer dependent coverage—and most small group plans do—they must allow a covered employee to add a new baby to the plan, and must also allow dependents to remain on the plan until age 26. 3
If one or both of you have coverage that you purchased on your own, either in the health insurance exchange or directly from an insurer in the ACA-compliant market, you’ll be able to add the baby to your plan, with coverage retroactive to the date of birth.
You’ll want to ask your employer or insurer if adding dependents to your plan will affect the cost of your premium, and if so, by how much. Your premium may increase when you add the baby, but you may find that you don’t pay any extra premiums—or potentially even pay lower premiums after adding the baby if you’re eligible for a premium subsidy through the exchange—depending on how your plan is structured.
Within 30 Days of Your Child’s Birth or Adoption: Contact Your Insurance Provider
New parents typically have a 30-day window to enroll in, or add a newborn child to, a healthcare plan offered by an employer. 4 Parents who have individual market coverage through the marketplace/exchange in their state (run by either the federal government or the state), as well as parents who are enrolled in ACA-compliant individual market coverage directly through an insurer (ie, “off-exchange” coverage) have 60 days following their baby’s birth or adoption to add their child as a dependent on their policy. 5 Regardless of whether the plan is offered by an employer or purchased in the individual market, the baby’s insurance benefits are retroactive, dating back to the baby’s date of birth or adoption, as long as the baby is added to the plan within the required time frame.
Though you may have a month or two to add your baby to your healthcare policy, it’s best to inform your insurer of your new addition as soon as possible in order to avoid billing mix-ups and delays.
1. If You Have Employer-Sponsored Coverage
Under longstanding federal rules, employer-sponsored plans that cover dependents are required to give eligible employees a 30-day window after the birth or adoption of a child, during which the child can be added to the plan, or, if the parent is not already enrolled, the parent can enroll in the plan together with the child. 6
If you are enrolled in an employer-sponsored group plan, your HR department or insurance provider may be able to provide you with enrollment or application forms in advance. It can take several weeks to receive your newborn’s birth certificate and Social Security number in the mail; check with your provider to find out if other documentation, such as a notarized letter from your hospital, can be used in the interim to confirm your child’s birth or adoption.
You’ll want to double-check to make sure that you’re complying with the exact process that your employer has for adding newborns, as you don’t want to find out—after your enrollment window has closed—that you didn’t actually get your baby added to your plan.
2. If You Have Coverage Through Your State’s Obamacare Health Insurance Exchange
Under the Affordable Care Act, having a baby is considered a “qualifying life event,” entitling you to a special enrollment window during which you can make changes to your healthcare coverage. Parents have 60 days to enroll their newborn as a dependent on their plan, or switch to a new plan altogether and add the baby to that plan. As long as a parent or legal guardian does this within 60 days of the baby’s birth or adoption date, coverage will apply retroactively.
If you have your coverage through the exchange/marketplace in your state, you’ll need to contact the exchange directly in order to add your new baby to the plan. The exchange will then transmit the information to your insurance company, along with any changes in your premium subsidy amount, if applicable.
In the 38 states that use HealthCare.gov, new parents can report the birth or adoption of a child via the marketplace’s “report a change” system, or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). In DC and the 12 states where a state-run marketplace is used, a similar “report a change” process is available, and new parents should reach out to the exchange as soon as possible to add the baby to their plan or enroll in a new plan.7
3. If You Have Coverage Through an Off-Exchange Plan in the Individual Market
The 60-day special enrollment period for adding a new baby to your plan (or switching to a different plan or enrolling for the first time) applies both on- and off-exchange. But if you purchased your plan directly from an insurer—or you want to do so following the birth of your baby—you’ll work directly with the insurer instead of contacting the exchange.
When you call your insurer, a representative can walk you through the process of adding your baby to your plan. The representative will also let you know if adding a dependent to your plan will affect the cost of your monthly premium, and can inform you of any further steps you need to take to ensure your baby has coverage.
In the ACA-compliant individual market, both on- and off-exchange, insurers only charge premiums for up to three children under the age of 21.8 So for example, if you already have three young kiddos on your plan and you’re adding your baby to an ACA-compliant plan in the individual market, you won’t have to pay any additional premiums to cover the new baby.
4. If You’re Uninsured
Having a baby is a qualifying event for employer-sponsored plans and also for individual market plans. And unlike some other qualifying events, there’s no prior coverage requirement.
If either parent is eligible for an employer-sponsored plan but not yet enrolled in it, the birth of the baby will allow them to enroll in the employer’s plan together with the baby, assuming the plan offers coverage for dependents (nearly all plans do).
If neither parent has access to an employer-sponsored plan, or if you’d simply rather enroll in a different plan, individual market plans are available nationwide, either through the exchange/marketplace or directly from an insurance company. In both cases, there’s a 60-day enrollment window after the baby is born, during which the family can enroll in a health plan with coverage retroactive to the baby’s birth.
Assuming your family is not eligible for employer-sponsored coverage that’s considered affordable and provides minimum value, you may be eligible for premium subsidies and/or cost-sharing reductions, as long as you purchase your coverage in the exchange/marketplace in your state.
5. If You Want to Buy Health Insurance for Your Newborn Alone
In some circumstances, you may want to purchase a child-only health plan. These plans are useful, for example, if your existing employer-based insurance doesn’t extend coverage to family members, or if the cost to add a child to your plan is prohibitively expensive.
Child-only plans are the same Affordable Care Act plans you’re familiar with. They can be purchased through the health insurance exchange in your state, directly from an insurer, or via a health insurance broker (note that brokers who are certified with the exchange can help you enroll in a plan through the exchange). These plans have all the essential health benefits found in standard ACA coverage, including certain preventive care covered at no cost.
Newborns’ and Mothers’ Health Protection Act of 1996
The Newborns’ and Mothers’ Health Protection Act of 1996 requires health insurance plans to cover the cost of care for mothers and their newborns during and immediately following the labor and delivery process.9 Under this law, mothers and newborn children are entitled to a 48-hour hospital stay following a vaginal childbirth, or a 96-hour hospital stay if the baby was born via cesarean section.
The law applies to both individual and employer-sponsored health plans (prior to the Affordable Care Act, most health insurance plans in the individual market simply did not cover maternity costs at all—although if they did, the NMHPA rules applied).10
If a mother’s health insurance plan provides coverage for a longer hospital stay, this is certainly permitted. Prior authorization is not required in order for the cost of the hospital stay to be covered, though some providers may ask the mother to notify their insurer of their due date and childbirth plan.
Medicaid or CHIP
Depending on your finances, your new baby may qualify for coverage under Medicaid or the Children’s Health Insurance Program (CHIP). Both of these programs can have different names in different states, and eligibility rules vary from one state to another.11 Children who are eligible for these programs receive low-cost or free coverage, and out-of-pocket costs under these programs are generally very low as well, helping to make healthcare more affordable.
As a result of the Affordable Care Act, children’s eligibility for Medicaid and CHIP is now based simply on modified adjusted gross income (MAGI), without any asset tests or other requirements.12 And in many states, CHIP eligibility extends well into the middle class.
If you think your new baby might be eligible for Medicaid or CHIP, you can reach out to the local office in your state for more information.
Armed Forces: Getting TRICARE for Your Child
If you’re a parent serving in the military, you can get TRICARE for your child in two steps:
- Register your newborn or adopted child in the Defense Enrollment Eligibility Reporting System (DEERS). You must enroll in DEERS to receive TRICARE coverage.
- Choose a TRICARE healthcare plan and enroll your child. Note: parents don’t need their child’s Social Security number in order to register their child in DEERS. Once the SSN for their child is issued, parents can update DEERS with that information.
Parents or legal guardians must register their child in DEERS within 90 days (or 120 days if stationed overseas) of his or her birth or adoption. Once the child is registered in DEERS, the parent has 90 days to enroll in health coverage or select a different plan.13
How Often Will Baby and Mother Need Postpartum Checkups After Birth?
The American Academy of Pediatrics recommends at least seven visits to the pediatrician during an infant’s first year.14 Those are for standard checkups and screenings, not including any health issues that may arise. As long as your baby is enrolled in an ACA-compliant health plan—via an employer or a plan you purchased on your own—these preventive care visits, including recommended vaccinations, will be covered in full, at no charge to you.15
It’s just as important not to neglect your own recovery from pregnancy. The American College of Obstetricians and Gynecologists suggests a postpartum check-in with your healthcare provider within 3 weeks of giving birth, and an in-person visit no more than 12 weeks after delivery.16
Key Points: Baby Health Insurance & Health Insurance for Newly-Adopted Children
- All state and federal marketplace health insurance plans, ACA-compliant plans sold outside the marketplace, employer-sponsored plans, and Medicaid and CHIP plans, cover the cost of prenatal care and childbirth/delivery. This is true even if a woman was pregnant before enrolling in a plan.
- Adopting a child or having a baby counts as a qualifying life event, entitling parent(s) to a Special Enrollment Period. During this period, parents can make changes to their insurance plan, or enroll in a new one.
- Parents have a 30-day window (or a 60-day window for Obamacare plans, on- or off-exchange) to add their baby to their health insurance policy or enroll in a new plan. As with most deadlines, the sooner parents do this, the better.
- As long as parents are insured and add their newborn as a dependent to their healthcare policy within 30 days of their child’s birth or adoption, the newborn will be covered from the moment of his or her birth.
- Health insurance plans are required by law to cover care for mothers and their newborns during and immediately following the labor/delivery process.
- As long as a newborn is enrolled in a health plan within the allowable window, coverage is guaranteed issue. Insurance companies cannot reject an application or make children pay more due to pre-existing medical conditions.
Taking the Next Steps
Check with your current health insurance policy to see what rules apply to newborn children, and check if there are any necessary steps you must take to ensure that you have baby insurance for your newborn.