r/HealthInsurance • u/Elhombredesnudo • 26d ago
Individual/Marketplace Insurance Healthcare Marketplace voided my wife's coverage due to pregnancy notification
We are a family of 4 and the policy is under my (the husband) name. My wife and 2 sons are on the policy.
We are 1 month pregnant so I called my health insurance provider to notify them of this. They said I need to speak to Healthcare Marketplace about this so they passed me over to them. Healthcare Marketplace created a new application (I didn't ask them to do this) and after some confusion about household income details they told me that a medicaid application was being filed. Told them I don't want medicaid or tax credits because we don't qualify for them. Healthcare Marketplace told us that due to them being unable to recall the medicaid application my wife's cover has been completely dropped and will not be re-instated until September 1st. In a panic I explained to them that my wife cannot be uninsured while pregnant due to upcoming prenatal appointments and if a medical emergency happens. They said they've raised an urgent escalation and that they are going to try to backdate the insurance so that my wife can be reinstated to the policy and if she has any out of pocket expenses to contact our insurance provider and ask them to reimburse us once she's been reinstated to the insurance policy. However they told us that they cannot guarantee that this will be approved and they cannot give a timescale other than "urgent escalations have resolutions within 2 weeks".
So technically my wife has no insurance while pregnant, which is absolutely terrifying. And even more terrifying is not knowing if they will backstate/reinstate the insurance! Has anyone ever heard of this before? I don't understand how this is even legal for Healthcare Marketplace to say "your wife can't have insurance for now". Looked into other options and she doesn't qualify for temporary insurance because she's pregnant
Everyone I speak to at Healthcare Marketplace seems to have very little sympathy and interest in resolving this. Is there anything that I can do to get her reinstated on my policy right now? Appreciate any advice anyone has on this.
UPDATE: I received a phone call from my health insurance provider who confirmed that they received an urgent escalation from Healthcare Marketplace requesting that my wife be reinstated and backdated on the policy. The insurance provider confirmed that my wife has now been readded to the policy as if she had never been removed. Checked on the dashboard and can see her name there once again.
I hope this has been informative and helpful for anyone that may experience a similar situation. I hope nobody has to go through this ever. Thanks for the good suggestions and input
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u/Ranked-choice-voting 26d ago
- Call you insurer in the morning to see what her insurance status is. 2. Why did you call your insurer to notify them of the pregnancy?
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u/Elhombredesnudo 26d ago
I thought that becoming pregnant counted as a life event, supposedly it does not. However Healthcare Marketplace are telling me that it is a life event and that I was supposed to notify them of this. Even the Healthcare.gov website says that I don't need to tell them, so why is everyone at the Healthcare Marketplace over the phone telling me otherwise?
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u/Ranked-choice-voting 26d ago
And you're 100% sure you were talking to the healthcare.gov people? Not some intermediaries or fraudsters?
You can go to an FQHC for the early pre-natal care if your wife is truly uninsured. But this is so strange. You can also file a complaint with your state Department of Insurance, which may have more luck getting your wife reinstated if she indeed was kicked off.
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u/Cercy_Leigh 25d ago
I got sucked in by fraudsters when applying for Pennie. It was the website sent directly to me by the COO of my husband’s small company so I brush aside any feelings that told me it was wrong. They did hook me in with Blue Cross but then also charged me $780 a month for a bunch of their bullcrap. It was a full on argument with them to get it across that they cannot take one more dime from my bank account.
This is how I learned about these scam companies you speak of. If his company wasn’t paying for it and also at fault I would have lost my mind. It was their mistake in the first place, the signed on with new insurance and failed to enroll anyone but my husband so I had to wait 6 months for the next enrollment period to get us on it.
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u/Elhombredesnudo 26d ago edited 26d ago
It's definitely the healthcare marketplace, it's the same phone number as the number on the website. Healthcare Marketplace said they can't stop the medicaid application and that a "case handler" has to pick up the "urgent escalation" that has been raised but otherwise there's nothing they can do. Thanks for your advice
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u/OceanPoet87 26d ago
Are you sure it's not their number being spoofed? Can you call the number on the healthcare.gov website (don't call the number in the phone history).
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u/Elhombredesnudo 26d ago
It is the same number as the phone number located on the Healthcare.gov website
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u/CoasterThot 26d ago
Scammers are able to make their number look like any number, in the world. They could call you from your own number. You’re dialing the number and not letting them call you, right? Most health insurance carriers don’t use phone communication, and use traditional mail, for this reason.
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u/dismal-duckling 25d ago
A Medicaid application doesn't end your insurance coverage. That's ridiculous. And dropping insurance due to pregnancy is also ridiculous. That's not how any of this works.
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25d ago
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u/dismal-duckling 25d ago
True. And a lot of customers don't know that errors can be appealed or worked through. Even if it takes time and is very frustrating and you just need to keep calling until they get you to the right person.
But, applying for Medicaid doesn't discharge you from marketplace insurance. You can have marketplace insurance and Medicaid secondary. I know quite a few families who do that because it expands the services they can get for their disabled children. Medicaid pays the premium.
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u/Foreign_Afternoon_49 26d ago
In some states, pregnancy can qualify the mother for pregnancy Medicaid. I wonder if that's what the miscommunication was about.
Not a QLE for the marketplace, but possibly a chance for your wife to get on Medicaid. Sounds like they initiated that application for her. If approved, it will be retroactive. Look up pregnancy Medicaid in your state (eligibility criteria are different than regular Medicaid).
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u/Elhombredesnudo 26d ago
We explained that we know we don't qualify for medicaid and that we don't want to apply but they told us we didn't have a choice
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u/KateTheGr3at 25d ago
You might want to call whoever handles medicaid applications for your area (it may be your county job and family services vs your state, but google should tell you) and explain the situation and see what options you have to cancel the medicaid application IF (in your state) this would send you back to the marketplace.
This is location-specific enough that reddit can't really tell you how to problem-solve it.3
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u/Regular_Focus 25d ago
Former health insurance employee here. You have to notify your insurance with 30 days of the child being BORN not within a month of being pregnant. Health insurance companies don’t consider the baby an individual to insure while they are útero. It’s just your wife they care about insuring.
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u/CeilingCatProphet 26d ago
Having a baby is an event. Not to be morbid but not all pregnancies make it to term. A fetus is not a person.
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u/StrikingConcept6646 26d ago
You generally do not need to notify insurance provider of a QLE if it does not impact eligibility of anyone on your policy.
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u/Forward-Wear7913 26d ago
Contact your actual insurance company and see what status they show.
If she has been removed against your wishes, contact your state Department of Insurance and ask them for assistance
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u/Mysterious-Art8838 26d ago
OP I know this probably seems like an exercise in futility and I can’t speak for your state, but in California they sometimes help expeditiously and it could be the same in your state. I’ve had surprising success complaining to the insurance commissioner. I believe you can also file with CFPB, although I think Trump constructively shut that agency. I would do both. Having done that could help you if it doesn’t get backdated and you have to fight, even if you don’t get immediately help. Keep notes obviously.
If you don’t get an answer you like call back early morning, lunch or evening and see if you get someone different. I called CA commissioner during lunch and the commissioner answered the phone himself because everybody was at lunch. I was shocked, but he was a very helpful guy! Insurance companies are somehow immediately more interested when you complain to the government. So don’t leave that stone unturned.
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u/Foreign_Afternoon_49 26d ago
You mean Ricardo Lara picked up the phone? 🤣 That's civil service right there.
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u/Mysterious-Art8838 26d ago
I think Dave Jones cause it was 2017. I was so startled cause I was prepared for vm but not for that. I wondered shouldn’t he have something better to do? 😆
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u/Elhombredesnudo 26d ago
I've logged into my healthcare insurance dashboard and I can see my wife is still listed there (due to the time it's now the next day afterI spoke to Marketplace). Have the Healthcare Marketplace been talking nonsense to me?
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u/knitting-yoga 26d ago
I don’t know why Healthcare Marketplace would be involved at all. The marketplace is just where you find qualified insurance plans and find out if you qualify for subsidies. It doesn’t administer your plan. You don’t need to update them about pregnancy. I don’t even know if they will cancel one person out of your plan. You should talk to your insurance provider. If she shows up on your dashboard, that’s good news.
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u/Afraid_Primary_57 26d ago
About Medicaid, there are different income limits for pregnant women. If you don't qualify, the application gets denied and you move on. If you do qualify, it backdates 90 days. I'm not sure why you're worried about it going through.
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u/Elhombredesnudo 26d ago
I'm worried because I know we dont qualify for Medicaid and have been told its not guaranteed that my wife will be backdated and she may be uninsured from August 5 to August 31
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u/Afraid_Primary_57 26d ago
But it won't cancel anything out if it doesn't work. They just forget about it.
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u/Elhombredesnudo 26d ago
Who forgets about what? My wife has been told she is currently uninsured
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u/Afraid_Primary_57 26d ago
If you don't qualify for medicaid, the application gets voided and doesn't affect her commercial insurance, whatever that may be.
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u/Elhombredesnudo 26d ago
By commercial insurance you mean the family plan that the 4 of us are on or something else? What if there was an error on Marketplace's part and she mistakenly gets approved for medicaid?
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u/QuantumDwarf 26d ago
If she’s approved for Medicaid, she’ll be insured. That would be a good thing, right?
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u/Elhombredesnudo 25d ago
She won't be approved, we don't qualify
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u/QuantumDwarf 25d ago
Yes you keep saying that, but you asked ‘what is she is approved for Medicaid’. The exchange doesn’t determine if she qualifies. I’m just answering your question
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u/BumCadillac 25d ago
They wouldn’t have started the application if you don’t qualify. There are different limits for pregnant women, and the baby counts as part of the family.
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u/CrimsonBlackfyre 25d ago
I use to work for the Marketplace when it pops up in our system that someone might be eligible for Medicaid,then you have to wait for approval or disapproval by them even if you know you make too much. Only other option is to click on not looking for extra savings at the beginning of the application so you don't get flagged for it or get the tax credit. You also mentioned the person at the Marketplace started a new application. Are you sure they didn't open your existing one and just update it? If they created an entirely new application it would have tried to get everyone on an entirely new plan with a new effective date. Also, the average person you speak to at the Marketplace can't just immediately reinstate policy. Its a tedious process unfortunately.
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u/Elhombredesnudo 25d ago
Yeah you're correct they updated the existing application. The Marketplace never told us that there was an option of not looking for extra savings. Had I known this I would of course have chosen this option. I'm still absolutely baffled that my wife needs to be dropped from the policy until the case handler approves the urgent escalation to have her backdated. To me it still makes zero sense, why is she unable to stay on the policy until the outcome is met? She's being forced to have no insurance. I understand it will likely be backdated but Marketplace also say they can't guarantee it
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u/CrimsonBlackfyre 25d ago
Trust me it's a dumb process. Id have a lot of issues when someone would put on their application that they were denied by Medicaid and let their policy roll over the next year and if they called in to change anything on the application we have to update the denial date and it has to be in the last 3 months and ive had times where someone called to update their address and then it tried to get them on Medicaid again. So dumb.
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u/camelkami 25d ago
If your wife is eligible for Medicaid, she can’t receive subsidized Marketplace coverage. The Marketplace representative believes she’s eligible for Medicaid so had to remove her from your plan pending the results of the application.
You keep saying she’s not eligible for Medicaid — why? Immigration reasons, income, or something else? If you were previously denied due to income, that doesn’t mean she’s ineligible now, because income limits are higher for pregnant women.
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u/Elhombredesnudo 25d ago
It's income reasons. We definitely don't qualify
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u/camelkami 25d ago
Gotcha. Once she’s denied Medicaid, you’ll be able to re-enroll her. Sorry you’re dealing with this, I know it’s extremely stressful. Definitely worth continuing to call the Marketplace but unfortunately they are dealing with a lot of pressure from Trump admin right now to root out Medicaid-eligible people and get them off Marketplace plans. So an employee is probably not going to want to reinstate your wife without hard proof she’s not Medicaid eligible. It could potentially risk their job.
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u/momoftwoboys1234 26d ago
I think there is a misunderstanding somewhere.
Is your commercial health insurance through your job? If so, healthcare.gov is not involved in your insurance at all. You wouldn’t have any sort of account with healthcare.gov.
Did you just cold call healthcare.gov and tell them your wife is pregnant? Pregnancy is not a QLE so it would make sense that they would assume you are asking to sign up for insurance and since it is out of enrollment period, the only option in their eyes is Medicaid.
Your commercial health insurance through your work has NOTHING to do with healthcare.gov. Check your commercial health insurance portal. If your wife is still listed, then you should be good to go.
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u/Elhombredesnudo 25d ago
- We don't get health insurance through a job and pay out of pocket
- I called my insurance provider and they said I need to speak to Healthcare Marketplace about it so they put me through
- My wife is no longer listed on our policy I can seen on my dashboard that she is gone
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u/Cornnole 25d ago
I'm confused..Why did you call your insurance provider in the first place? They'll know she's pregnant from the claims that start rolling in.
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u/Elhombredesnudo 25d ago
Because I didn't realize that you're not supposed to report this. I've been heavily down voted on my comment about this but I'm new to US Healthcare as I've moved here from Europe last year
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u/Elhombredesnudo 26d ago
We are in SC and we definitely do not qualify for medicaid. Healthcare Marketplace aren't interested and say that we just need to wait for a decision to be made but frankly that's not good enough.
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26d ago
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u/Elhombredesnudo 26d ago
I can't see any information on my profile about household annual income but I can definitely see coverage period for today until September 1 and my wife's name has been removed. My insurance provider dashboard shows that my wife is covered from January 1 2025 to January 1 2026
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u/BaltimoreBee Moderator 25d ago
Complain to your state Department of insurance. They were wrong to remove her for a pending Medicaid application and need to reinstate her retroactively to fix their mistake.
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u/Elhombredesnudo 25d ago
That's exactly what they should be doing. But it sounds like there is up to a 2 week wait for the case handler to make a decision and it's not guaranteed that she'll be backdated for August. My fear is if I contact department of insurance then they will tell me I need to wait the 2 weeks and that there's nothing they can do
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u/No-Donut-8692 26d ago
Your wife was going to get free Medicaid. There are higher income thresholds for pregnant women, so when you called the exchange to report this, it automatically triggered the “give them free healthcare” path.
So… you said you don’t want Medicaid for your wife. You should be aware that if you are eligible for Medicaid and refuse it, you are generally no longer eligible for premium tax credits for the individual(s) that could be covered my Medicaid.
If your wife cannot be reinstated in your previous health plan at full cost, she wouldn’t be without health insurance… because she can turn around and re-enroll in Medicaid. This can even be made retroactive up to three months before she enrolls.
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u/Elhombredesnudo 25d ago
We know that we don't qualify for it. Healthcare Marketplace have now informed us that the medicaid application has been cancelled but they still need one of their own case handlers to approve the backdated insurance for my wife. We were never eligible for premium tax credits to begin with.
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u/BumCadillac 25d ago
In the US she won’t see a doctor until she’s 8-10 weeks along, so at least there is that.
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u/Crafty_Engine3131 26d ago
This is an understandably terrifying and confusing situation. Follow-up with market place and continue to escalate; might help to call medicaid for a quick decision if you have the case details. In the mean time, get your wife the needed care but do not pay any of her bills yet (mention to providers about your situation) - wait for her insurance through marketplace (your policy or new) which should be back-dated so her coverage is continuous.
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u/Elhombredesnudo 26d ago
Marketplace said I can keep calling them but it will take up to 2 weeks for them to have a decision made. Marketplace said they don't need to wait for the medicaid decision and the Marketplace case handler has the final say. I can see her name has been removed from Healthcare.gov section showing policy from August 5 to September 1 but my health insurance company is still showing her as being covered on her profile there
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u/Crafty_Engine3131 26d ago
It is good to know Marketplace handler can make the call without waiting for medicaid decision - which can take long. The insurance company has probably not yet applied the update from marketplace. It looks likely that her coverage will be restored in two weeks, back-dated so there is no gap. Nice work escalating with Marketplace!
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u/hidden_sunrise 25d ago
Agree with many other comments. Since you have notified the marketplace of her pregnancy, if they feel she may qualify for Medicaid that application goes to your local agency. If she qualifies for Medicaid and you choose for her to not be on it, you will lose the tax credits for her. The household composition for a pregnant person for Medicaid is different. The unborn child count as a person when looking at her eligibility. So for the rest of your family, the household size would be a four, but for her, it would be five. Are you positive? She will not qualify? Additionally, typically the income limit they have for Medicaid for pregnant women is gross income minus pre-tax deductions. So if anyone in the home that is working contributes to a 401(k) or something similar, that can be deducted as long as it is pre-tax. I would contact your local agency that handles Medicaid and see about getting that processed because the worst that will happen is they say she doesn’t qualify. Also, unless she is high risk, she’ll be fine not seeing a doctor until September 1.
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u/Elhombredesnudo 25d ago
Due to our household income she definitely doesn't qualify for medicaid and premium tax credits. Healthcare Marketplace informed us today that the medicaid application has been cancelled but we still need to wait for the case handler to approve the backdate on the insurance. She has a prenatal appointment prior to September 1 that she's had to rearrange for after September 1. Our worry is if she for whatever reason needs to go to the ER (accident etc) then we'll be hit with an expensive ER bill and there's still a small chance that the backdate will be rejected. Plus even if the backdate is approved we would need to pay out of pocket prior to our insurer reimbursing us, which is not comforting
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u/dog_dragon 25d ago
Some states regardless of income have a Medicaid expansion to immediately cover pregnant women and baby. That’s why they tried to immediately enroll her into Medicaid. She likely would’ve been approved if your state has Medicaid expansion. This is also likely why they voided her insurance. Since she refused the Medicaid they won’t cover her because she is now eligible for Medicaid and unless they get a denial they won’t attempt to re-enroll her due to possible eligible coverage with the state.
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u/MWebb2112 25d ago
When she gets denied for Medicaid, that will qualify as an SEP and you can add her back on. As many have mentioned, not sure why she was removed in first place unless the pregnancy question on the application flagged her. Never have answered yes to that question for the reason I thought they might automatically want to send the pregnant female to Medicaid. Even if she were pregnant.
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u/fme222 25d ago edited 25d ago
I had a similar situation with the marketplace plan where my spouse was trying to update something about their income on it, just to see if we would qualify for any sort of tax benefits, and thought we were required to report any income changes anyways, but knowing we still had too high of an income for Medicaid, and what they ended up doing was taking me off of the insurance, making some new profile for my spouse (I think also to check to see if they were qualifying for Medicaid) , and it was the same week I was doing IVF! . I ended up doing IVF procedure technically uninsured knowing that if it didn't get fixed and back dated I would be on the hook for tens of thousands of dollars. Thankfully my IVF clinic allowed me to proceed without an upfront payment like they normally require as long as I sign some waivers saying that I would be responsible after a certain amount of time if the insurance issue didn't get resolved.
Unlike your case every time I talked to them (both marketplace employees and also Blue Cross Blue shield employees) they were saying there was nothing they could do about it most likley. That I would have to wait till it re-starts the following month, can't backdate that far, so no insurance coverage in the meantime since I got unenrolled from it. They admitted I shouldn't have been unenrolled but the employee apparently wasn't trained properly and Miss clicked on something with the application and that they messed it up. We simply wanted to see if we would qualify for some tax credits or anything due to the income change (we weren't low enough however to qualify for Medicaid and we did know that since I still had income) However I just had to fill out a contact us form online and answer like two phone calls from my states attorney general's office as they have a patient advocacy insurance division and they got everything fixed for me, everything back dated, even though the marketplace kept telling me repeatedly that there's nothing they could do... Or if anything I could maybeeee try certain appeals or possibly even go to court to plead my case and all this stuff ... but thankfully I didn't have to go through all that. The attorney general's office got it all fixed for me super easily. I filled out a form online and then they called me to go over more of the details and everything got fixed pretty quickly. They have more power to bend some of their regulations and rules and normal procedures.
I ended up having to use attorney general's office again later after my son was born because he was born during the New years and our plan changed while I was in the hospital, so even though he got on to our second insurance plan after the new year they would not put him on the first insurance to cover the beginning of his hospital stay because they were saying that plan was already closed out/termed and they can't reopen a plan to add a person onto it and told me a thousand times there's nothing they could do... that his NICU stay for the first couple days would all be out of pocket forme... The attorney general's office once again got that all fixed me very quickly. Each time just like going on the website filling out the contact us form and then after a day or so the case worker would call me to go over like the details and then they would get things fixed, bypassing a lot of the regular appeals process and stuff that you normally would have to go through.
Don't wait on a response from the marketplace, I would go straight to contacting your attorney general's office now they are your advocate, even if the marketplace is actually doing everything correctly right now and stuff The advocate can check on it to make sure and reassure you that yes they've taken the proper steps or not to get everything resolved, that's what an advocate does and the case manager is there for you. they'll be the in between person so no point in delaying or waiting to reach out to them.
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u/Bobzyouruncle 25d ago
The Medicaid fiasco with the marketplace is very frustrating. I lost work earlier this year (self employed) and reported an income drop. Even though I was squarely above the Medicaid level they sent my kids over to chip to be considered. I’m the meantime my insurance premiums were paused. It all went through snail mail and took forever.
Medicaid (chip) finally asked for income documents, which I sent. Only to get a denial due to “documents” which is akin to saying ignored their request. I called and found out I didn’t format my business income in monthly statements (I did quarterly, and their request form and website never specified formatting or any details at all). This really screwed me because we were now showing full responsibility for payment (rather than state and federal credits that would have otherwise covered much of the premium). The marketplace was informed of our denial for reasons other than income which meant we lost our subsidy.
I scrambled and called to find out the issue but was told I’d have to start a new application to send the docs in and they informed me exactly how they wanted the docs to look (too little too late!). Fast forward another month and I finally got what I always SHOULD have had: an income denial. NOW I was getting almost 95% of my premium covered.
But of course since I was denied on the original application there are those FIVE months in limbo where the marketplace thought I was not eligible For credits and had me on the hook for almost double what I was paying BEFORE I altered my income down . It has become an absolute nightmare to get this resolved because it is two different agencies and Medicaid seems unwilling to fix the first denial I got. Even though all the agents on the phone tell me that I followed the process in accordance with their requests and that it was basically just a formatting error that causes the denial.
So so so frustrating. I made less money, reported it, was poor enough for Medicaid, got stuck in a document loop that even a Fortune 500 CFO could have fumbled, and now I have to pay MORE than I would have if I had never reported the income change in the first place.
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u/Elhombredesnudo 24d ago
UPDATE: I received a phone call from my health insurance provider who confirmed that they received an urgent escalation from Healthcare Marketplace requesting that my wife be reinstated and backdated on the policy. The insurance provider confirmed that my wife has now been readded to the policy as if she had never been removed. Checked on the dashboard and can see her name there once again.
I hope this has been informative and helpful for anyone that may experience a similar situation. I hope nobody has to go through this ever. Thanks for the good suggestions and input
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u/Mipeligrosa 26d ago edited 25d ago
This whole thing is so confusing and strange. Just a bunch of wrong things happening at once leading to disaster…
How far along is your wife?
Your wife will need to lean on the county health department in this time where she has a coverage gap. Their low cost services will get her what she needs until things are fixed.
From what you hear though, does it even sound like she will get her insurance back?
Sounds like you’re saying you don’t qualify for Medicaid. But let’s say, worst case scenario, everyone is useless and you can’t get the insurance back, apply for Medicaid anyway. Technically as a pregnancy woman she has special qualifications. But, if you make too much money, she will likely get denied and sometimes the denial can trigger a qualifying event such that Healthcare.gov opens up for her again. She just may need to get her own policy just to get out of this chaos. Open Enrollment is in a few months and you can fix it again later.
Just some thoughts.
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u/KateTheGr3at 25d ago
Just to be clear, Medicare and Medicaid are two separate programs with different criteria for coverage.
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u/Admirable_Height3696 26d ago
Op said absolutely nothing about Medicare. And there are no special qualifications for pregnant women in OPs state.
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u/rtaisoaa 26d ago
It’s not that there’s a disinterest it’s that you have to let these mistakes work themselves through the system.
You should have called or gone online to the marketplace first because a pregnancy is a QLE and can change the household size and income requirements.
Chalk this up to a learning experience. Any changes to be made to the Household (such as birth of baby) need to have the Marketplace notified and NOT the insurer.
Same as if you had insurance through a job: You’d call HR first to notify of baby’s birth and add baby to insurance. You would not call the insurance company themselves.
FWIW: This scenario happens often with employer insurances too. Parents will often call the insurance to add baby, instead of calling HR and it can be a long, nightmare of a process to remedy in some cases.
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u/Admirable_Height3696 26d ago
Pregnancy is not a QLE in the vast majority of states including OPs state (South Carolina). The birth of a child is the qualifying life event, not the pregnancy.
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u/KateTheGr3at 25d ago
When a woman is pregnant, the healthcare is being provided to her under her medical record; SHE is the patient.
The baby is added once it's born.
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