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Q&A: Must Our Plan Cover the Pregnancy Expenses of Employees' Children?

03.17.2015

Question & AnswerQuestion: Our company’s major medical plan covers the pregnancy-related expenses of employees and their spouses. But, in light of the many changes to health care law recently, is our plan now also required to cover pregnancy-related expenses of employees’ children who are enrolled as dependents?

Answer: The Affordable Care Act (ACA) does indeed require group health plans that provide dependent coverage for participants’ children to make such coverage available until a child turns age 26. But plans don’t necessarily have to cover the pregnancy-related expenses of those children.

Under the Pregnancy Discrimination Act (PDA), a health plan of an employer with 15 or more employees that covers medical expenses of female employees’ spouses must also cover medical expenses of male employees’ spouses — including expenses arising from pregnancy-related conditions. But the PDA doesn’t require plans to cover the pregnancy-related expenses of other covered individuals (such as employees’ children), so long as pregnancy-related expenses of male and female employees’ dependents are treated equally.

Nevertheless, your plan may still have to cover some pregnancy-related expenses of employees’ children. If your plan is a small group market insurance plan that’s nongrandfathered (in other words, subject to the ACA and not subject to transitional relief), it will be required to cover maternity care as one of the ACA’s 10 essential health benefits (EHBs).

The EHB rules generally apply to the small group market. These are plans of employers with 50 or fewer employees. (Starting in 2016, that number will increase to include employers with 100 or fewer employees.) Although larger employers’ plans aren’t subject to the EHB rules, the ACA’s preventive services mandate requires all nongrandfathered group health plans to provide first-dollar coverage of in-network prenatal and postnatal care for all covered individuals under the plan — including an employee’s children.

Ron Present, CALA, CNHA, LNHA, FACHCAIf you have more questions about the Affordable Care Act, contact Ron Present, Partner and Health Care Industry Group Leader, at 314.983.1358 or rpresent@bswllc.com.

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