medicare pregnancy coverage in USA

In rare cases, Medicare does cover some services connected to pregnancy and delivery. This is not unexpected given that Medicare beneficiaries include those under the age of 65 who qualify due to a handicap. According to a 2017 CMS study, around 9 million Medicare enrollees (or approximately 16% of all Medicare recipients) qualify for Medicare due to disability. Find out more about this Medicare coverage.

About Medicare and Pregnancy Coverage

If you or a loved one is a Medicare beneficiary of child-bearing age, you may be asking, "What does Medicare cover throughout pregnancy and child delivery?" According to the CMS Medicare Benefit Policy Manual, Medicare may pay "reasonable and required" skilled medical treatment "during pregnancy, starting with the diagnosis of the disease, continuing through delivery, and terminating just after necessary postnatal care."

If you are pregnant or considering pregnancy, your doctor may be the finest source of information for prenatal care, a safe delivery, and correct postpartum care. If your doctor does not accept Medicare assignments, you may have to pay extra for your healthcare services.

According to the Department of Health and Human Services, your prenatal care may include services such as frequent doctor visits, certain immunizations such as seasonal flu injections, testing for conditions that might affect you or your unborn child, and dietary advice.

What does Medicare cover for Pregnancy and Delivery?

Medicare Part B may help pay for certain medical treatments if they are administered in your doctor's office or if they are ordered by your doctor and provided in a clinic or outpatient setting. Once your Medicare Part B deductible has been reached, Medicare will normally cover 80% of the cost of prenatal and postpartum (after birth) medical treatment.

For these services, you will normally pay 20% of the Medicare-approved price. Medicare does not cover your newborn after birth.

Medicare Part A may cover inpatient hospital services, such as childbirth and hospitalization. Once you've reached your Medicare Part A deductible, Medicare will normally pay 80% of the Medicare-approved cost for hospital treatments, with you paying the remaining 20%.

Pregnancy-related care may potentially be covered by Medicare. After you have satisfied your yearly deductible, Medicare coverage may extend to the therapy you get if you suffer a miscarriage, often paying 80% of the Medicare-approved cost.

Medicare coverage is offered for abortions when the pregnancy is the result of incest or rape or presents a substantial risk to your life if you carry your unborn child to term. If you want to end your pregnancy for other reasons, Medicare does not fund elective abortions.

What if Medicare does not cover all the Costs of Pregnancy and Child Delivery?

If you need assistance paying for the amount of your medical treatment that Medicare does not cover, there may be options available to you. You and/or your infant may be qualified to enroll in Medicaid. For further information, contact your state Medicaid department.

If you’re pregnant or planning to get pregnant:

  • If you don’t have health coverage
  • Having health insurance makes it simpler to undergo medical check-ups and screening tests that will keep you and your baby healthy during your pregnancy.
  • If a life event, such as moving or losing current coverage, qualifies you for a Special Enrollment Period, you might be able to enrol in a Medicare health plan right away. You must have a child to qualify, not just be pregnant.
  • Sign up for an account right now to apply for medicare coverage during the Open Enrollment Period or a Special Enrollment Period. If you choose the option to get assistance in paying for coverage on your application, you will be asked if you are pregnant. Declaring your pregnancy may assist you and your family members in obtaining the most economical coverage.
  • If you do not qualify for a Special Enrollment Period right now, you will be able to apply within 60 days following the birth of your child. You can also enroll in coverage for the next plan year during the next Open Enrollment Period, which will take place this autumn.

If you currently have Medicare coverage

  • If you wish to retain your existing medicare coverage, don't notify medicare about your pregnancy. When we ask if you're pregnant on your medicare application, click the "Learn more" link to get recommendations on how to effectively answer this question.
  • If you declare your pregnancy, you may be able to get free or low-cost health insurance via Medicaid or the Children's Health Insurance Program (CHIP). If you are determined to be eligible for Medicaid or CHIP, your information will be forwarded to the state agency, and you will not be able to maintain your medicare plan.
  • If you maintain your medicare coverage, be sure to update your application after giving birth to add the baby to the plan or enrol them in Medicaid or CHIP coverage if they qualify.

If you may qualify for Medicaid or the Children’s Health Insurance Program (CHIP)

  • Medicaid and CHIP provide free or low-cost health insurance to millions of Americans, particularly low-income individuals, families with children, and pregnant women.
  • Eligibility for these programs is determined by the size of your home, your income, and your citizenship or immigration status. State-specific laws and advantages differ.
  • You may apply for Medicaid or CHIP at any time of year, not just during Open Enrollment.
  • You may apply in two ways: directly through your state agency or by filling out a medicare application and specifying that you need financial assistance to pay for coverage.
  • If you are deemed to be eligible throughout your pregnancy, you will be covered for 60 days after giving birth. You may no longer be eligible after 60 days. If your coverage ends, your state Medicaid or CHIP agency will tell you. You may prevent a gap in coverage by enrolling in a medicare plan during this period.
  • If you have Medicaid when you give birth, your infant is immediately enrolled and will be eligible for at least a year.

If you Recently gave Birth

If you don’t have health coverage

It is critical for both the new mom and the infant to have access to healthcare services. Make your application within 60 days of your baby's birth. Your policy can cover you, your kid, and any other members of your home. If your Medicaid or CHIP coverage expired after you gave birth (or if your state has informed you that it will expire soon), you can apply for Medicare coverage.

If you lose your other coverage, you are eligible for a Special Enrollment Period. When completing your application, indicate that you were determined ineligible for Medicaid or CHIP by the state agency.

If you currently have Medicaid coverage

IMPORTANT: Having a baby qualifies you for a Special Enrollment Period

  • If you already have medicare coverage when your baby is born, you have two options: - keep your existing plan and add your baby to it, OR - create a separate enrollment group for your newborn and enroll him or her in any plan for the rest of the year. Please keep in mind that you can choose any plan for your baby. In most cases, you will not be permitted to amend your plans.
  • Regardless of when your kid is born, you should notify medicare as soon as possible by updating your application. As a result, your coverage options and possible savings may vary. You may be eligible for more savings than you are now receiving, which could reduce the amount you pay in monthly premiums.
  • When you update your application, we'll let you know if you or your child qualify for Medicaid or CHIP.

If you have Medicaid or CHIP

  • If you are deemed to be eligible throughout your pregnancy, you will be covered for 60 days after giving birth. You may no longer be eligible after 60 days. If your coverage ends, your state Medicaid or CHIP agency will tell you. You may prevent a gap in coverage by enrolling in a medicare plan during this period.
  • If you have Medicaid when you give birth, your infant is immediately enrolled and will be eligible for at least a year.

By Sam Peterson | Dec 29 2022

Get Social

Recent Posts
  • Does Medicare Cover Respite Care?
  • Medicare Advantage enrollments
  • What you pay in a Medicare Advantage Plan
  • Are you eligible for medicare ?
  • Why Medicare Matters to All Americans

DISCLOSURES - This is an advertising referral and comparison service that matches consumers with prospective agents and companies depending upon your information. The operator of this website is not an insurance company, an agent, a provider, a broker, a representative, a bank, or a financial or lending institution. We do not represent any specific provider and do not provide insurance or financial quotes, or policies. Quotes are provided by independent participating companies that participate in network. Lowest advertised rates may vary and are not necessarily available from all participating service providers. We do not endorse or charge you for any product or service. Any compensation received is paid by participating providers and only for advertising services provided. This service is void where prohibited. We are not connected with or endorsed by the U.S. government or any federal programs. This service and these disclosures are provided to you for information purposes only and should not be used as a substitute for informed professional advice.