If you have just welcomed a new baby into your family, you’ll want to ensure that the whole family is now covered by health insurance. Fortunately, the birth or adoption of a child is a Qualifying Life Event (QLE) that allows the entire family to get Marketplace insurance (also known as Obamacare plans or Affordable Care Act plans). QLEs trigger what is known as a Special Enrollment Period (SEP), granting access to the Marketplace outside of the annual Open Enrollment Period (OEP).
Here’s more about what to know about how to get health insurance after the birth or adoption of a child.
How does the birth or adoption of a child trigger a Qualifying Life Event?
Qualifying Life Events (QLE) for Special Enrollment Periods (SEP) can be triggered by changes in the nature of your household. And welcoming a new baby or child to your household is one such kind of change. While you can add your new child to your existing plan, if you have one, you can also shop for a new plan because of your QLE. This QLE may prompt a SEP allowing you to sign up for your own ACA-compliant Obamacare plan through the Marketplace. An SEP triggers a 60-day period in which you can apply and get covered through the Marketplace. Grab our free guide to see the full list of the Qualifying Life Events (QLEs).
What happens during a Special Enrollment Period?
While typically you can only enroll in health insurance through the Marketplace once a year during the annual Open Enrollment Period, there are exceptions. If you have a Qualifying Life Event like the birth or adoption of a child, you may be able to enroll during a Special Enrollment Period.
You may need to verify your eligibility and submit certain documents to confirm your QLE. If you have given birth or adopted a child, you will need to submit the child’s birth certificate or letter of adoption. Grab our free guide here to see what documents you need to submit for a QLE.
After your QLE is verified, you will be able to shop the Marketplace just as you would during Open Enrollment Period. You can compare available plans and premiums, and see what premium tax credits for which you may be eligible.
Remember, you will have 60 days from your QLE for your SEP. After the close of your SEP, you will need to wait for the next Open Enrollment Period to enroll in Marketplace insurance if you still have not enrolled.
You can enter your zip code below to see plans and prices in your area—you’ll just need to verify the SEP when you complete your application.
What are my other options for health insurance?
To get Marketplace insurance (aka Obamacare or Affordable Care Act insurance), go to healthsherpa.com or call us at (872) 228-2549. You also have a couple other options listed below.
Medicaid health insurance
Depending on your income level, you may also qualify for Medicaid health insurance. Medicaid is a program jointly funded by the federal government and the states to provide health insurance coverage to low-income Americans. Medicaid eligibility is determined based on income level. Adults, children, pregnant women, the elderly, and people with disabilities all can become Medicaid recipients.
You can get our guide to Medicaid here, and you can enter your zip code below to see if you’re eligible for Medicaid.
Each state sets up and administers their own Medicaid program and determines the scope of services provided. This is based on a broad set of federal guidelines.
Federal law requires that all Medicaid programs cover a certain set of “mandatory benefits.” These benefits include inpatient and outpatient hospital services, nursing facility services, home health services, physician services, and laboratory and x-ray services. Also mandatory are family planning services, nurse midwife services, certified pediatric and family nurse practitioner services, freestanding birth center services (when already licensed and recognized by the state), and smoking cessation counseling for pregnant women.
Medicaid eligibility
The Affordable Care Act (ACA) allowed states to choose to expand their Medicaid programs to cover low-income adults. Whether or not you qualify for Medicaid, and what the income limits are, depends on whether your state expanded Medicaid and whether you meet any other criteria (for example, if you are pregnant, are parenting a child under the age of 19, or have a disability.).
So far, 37 states and DC have chosen to cover otherwise ineligible adults through their Medicaid programs, although two states – Idaho and Nebraska – have not yet implemented the expansion. In most of these states, anyone making less than 138% of the Federal Poverty Level can qualify for Medicaid. That’s $17,608 for an individual and $36,156 for a family of four. In the 14 states that have chosen not to expand their Medicaid programs, adults usually do not qualify for Medicaid unless they meet additional conditions.
As of January 2020, 49 states cover children with incomes up to at least of 200% of the the Federal Poverty Level through Medicaid. (That would be an annual income of $43,440 for a family of three.) Additionally, 34 states cover pregnant women with incomes at or above 200% of the Federal Poverty Level (FPL).
And 32 states cover parents and other adults with incomes up to at least 138% FPL as a result of the ACA’s allowance of Medicaid expansion to low-income individuals. A few additional states have also opted in to Medicaid expansion, but their programs have not been implemented yet.
Applying for Medicaid
You can apply for Medicaid at any time, even outside of the annual Marketplace Open Enrollment period.
Through HealthSherpa, you can immediately find out whether you qualify for Medicaid based on your income, where you live, and whether your state has opted into Medicaid expansion. You can get started by entering your zip code here.
If you’re eligible, you can start your Medicaid application through HealthSherpa. Once you’re finished, your application will be submitted to your state’s Medicaid agency. They will review your information and send you an official letter of determination within a few weeks. However, if you don’t hear from them, we always recommend giving them a call.
CHIP
The Children’s Health Insurance Program (CHIP) helps fund health coverage for children at the state level. Each state has their own program in place, working to primarily serve low-income households. These households are often out of the eligibility range to qualify for Medicaid, or may have workplace insurance that does not cover their children. CHIP eligibility differs state by state, with the majority of states covering children with household incomes up to at least 200% of the Federal Poverty Level (FPL).
You can see if you’re eligible by entering your zip code here.
Who is covered by CHIP?
Although CHIP receives fund matching from the federal government, each individual state has their own operating guidelines. However, every state’s program will provide basic coverage for uninsured children 19 years old and under, belonging to households with an income too high to qualify for Medicaid. Since rules vary, the best way to determine your children’s eligibility is to check in with your state.
What is covered by CHIP?
Despite the fact that each state determines eligibility a bit differently, all states provide the same basic coverage under their CHIP programs. Required components of CHIP include:
- Routine check-ups
- Immunizations
- Primary care visits
- Prescriptions
- Dental
- Vision
- Hospital care (in and out patient)
- Emergency services (ambulance, ER)
It’s important to note that annual “well child” primary care and dental visits are free under this program