Many people forget, but around 15% of those who have Medicare haven’t turned 65 yet so yes, the program covers pregnancy care.
Having a baby is expensive. Costs related to pregnancy, childbirth, and postpartum care average nearly $19,000 for individuals with insurance according to a 2022 study by Peterson Center on Healthcare and KFF. Differences in cost can depend on factors like the mother’s health, the baby’s health, complications during delivery, personal preferences, and more. That’s why it’s important to know what your insurance coverage is vs. what you’ll owe out-of-pocket.
If you have Original Medicare, much of your prenatal care, delivery, and postnatal care will be covered. In addition to those ages 65 and older, Medicare also provides health care coverage for younger beneficiaries of any age who qualify due to a permanent disability or end-stage renal disease (ESRD). Read on to learn more about specific Medicare benefits and costs related to pregnancy.
Average pregnancy services
Each pregnancy is different, but in general, there are several services and tests that are commonly performed on pregnant women.
The first, of course, is regular checkups with an obstetrician. For the first 28 weeks, visits are typically scheduled once every four weeks. From weeks 28 to 36, you’ll likely see your obstetrician every two weeks. Then, from week 36 until delivery, visits happen once per week.
Additional pregnancy services covered by Medicare may include:
· Blood tests
· Genetic screenings
· Fetal monitoring
· Glucose screening
· Chorionic villus sampling
Most of these tests are designed to provide more information about the health of your baby so you can create the best prenatal care and birth plan possible.
Some women also require additional visits with specialists or even inpatient stays in the hospital to ensure their health and the health of the baby.
Medicare coverage for pregnancy
Medicare may cover all medically necessary care from the time a woman learns she’s pregnant, continuing through the delivery, and ending after necessary postnatal care.
Original Medicare includes two parts. Part A (hospital insurance) covers all pregnancy-related care you get when formally admitted to the hospital as an inpatient. This includes hospitalization, services, tests, and other hospital services associated with the child’s birth.
Medicare Part B (medical insurance) covers all doctors’ visits, tests, and other outpatient services related to pregnancy.
Original Medicare doesn’t include prescription drug coverage. You get that with a Medicare Part D plan, which would cover any prenatal vitamins, supplements, or other prescription drugs you may need before, during, or after the pregnancy.
Medicare Advantage plans (Part C) provide the same coverage as Original Medicare plus additional benefits like hearing, vision, and dental. This means Part C plans also cover pre-natal, delivery, and post-natal services, and they may also have additional coverage not offered by Original Medicare.
Pregnancy costs with Medicare
Costs can vary significantly from one pregnancy to the other, which makes it difficult to determine exact costs. However, if you have Original Medicare:
· Once you have met your Part B deductible ($226 in 2023), you will owe 20% of the Medicare-approved amount for services you receive related to prenatal care or postnatal care. Medicare will usually pay the other 80%.
· After you meet the Part A deductible ($1,600 per benefit period), Medicare will likely pay 80% of the Medicare-approved amount for the birth and you’ll be responsible for the other 20%.
There is no maximum for out-of-pocket costs with Original Medicare, so depending on your circumstances, your total out-of-pocket costs will vary.
Part C plans, however, do have a maximum out-of-pocket, which is $8,300 in 2023 (although most plans set lower limits). This means if you have a Part C plan, you will pay no more than $8,300 out-of-pocket for the entire year.
How to qualify for Medicare before turning 65
To qualify for Medicare, you must first qualify for Social Security Disability benefits. You can apply for these benefits if you’re unable to work because of a medical condition that’s expected to last at least 12 months or will result in death. These benefits are paid through either:
· Social Security Disability Insurance (SSDI)
· Supplemental Security Income (SSI)
Note that the Social Security Administration’s (SSA) definition of a disability is very strict, and they will likely confer with your doctors about your condition as well as consider other factors and evidence to determine if you qualify. You must also have worked long enough and paid Social Security taxes on your earnings.
If you aren’t 65 and collect disability benefits, you’ll qualify for Medicare after 24 months. In month 25, you’ll be automatically enrolled in Medicare Part A and Part B. If you have ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease), you’ll be automatically enrolled in Parts A and B during the first month your disability benefits begin. If you have ESRD (end-stage renal disease), you can choose to enroll if you’re eligible.
How to apply for disability benefits
When applying for disability benefits through the SSA, the more prepared you are in advance, the smoother the process will be. We walk you through the application process – and how to prepare for it – here.
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