H.R. 6242 — Healthy MOM Act

This section sets forth 14 congressional findings on the importance of maternity coverage, maternal mortality disparities (e.g., Black women face rates three to four times higher than White women, with about 700 annual U.S. pregnancy-related deaths and 3 in 5 preventable), and benefits of prenatal and postpartum care; and declares the Act's purpose to ensure pregnant women eligible for Exchange coverage or other individual or group health plans can access affordable health coverage during pregnancy.

This section establishes a special enrollment period for pregnant individuals—beginning on the date the pregnancy is reported to the group health plan, issuer, or Exchange (or confirmed by a health care provider, for group plans)—in group health plans under the Internal Revenue Code and ERISA, health insurance Exchanges under the Affordable Care Act, and specified provisions of the Public Health Service Act, effective for plan years beginning on or after January 1, 2027. (Thus, eligible pregnant employees or dependents not previously enrolled may enroll during this period.) It further directs the Secretary of Labor, Health and Human Services, or Treasury, as applicable, to promulgate regulations specifying the enrollment time period and coverage effective date.

This section requires group health plans and health insurance issuers offering group or individual health insurance coverage that provide coverage for dependents to include coverage for maternity care—associated with pregnancy, childbirth, postpartum care, and labor and delivery—for all participants, beneficiaries, enrollees, and dependents regardless of age. The section makes parallel amendments to the Public Health Service Act, ERISA, and the Internal Revenue Code, with the requirements applying to plan years beginning on or after January 1, 2027.

This section directs the Director of the Office of Personnel Management (OPM) to issue regulations ensuring that pregnancy is a change in family status and qualifying life event for eligible individuals not enrolled in a Federal Employees Health Benefits Program (FEHBP) plan under 5 U.S.C. ch. 89, with the requirement applying to contracts entered into under 5 U.S.C. §8902 beginning 12 months after enactment. The section also amends 5 U.S.C. §8905 by adding subsection (j) to deem OPM services related to enrolling individuals in or changing FEHBP enrollments due to pregnancy as excepted services under the Anti-Deficiency Act (31 U.S.C. §1342)—i.e., services for emergencies involving the safety of human life or protection of property—with the amendment applying to lapses in appropriations on or after enactment. (Thus, OPM may process pregnancy-related FEHBP enrollments during government shutdowns.)

This section revises Medicaid income eligibility standards for pregnant individuals and infants (i.e., those under age 1) by (1) striking the upper limit of 185% of the federal poverty level (FPL) in clause (i); (2) extending the schedule in clause (ii) through January 1, 2027, to the percentage under new clause (v); and (3) requiring that, for coverage on or after January 1, 2027, states maintain income eligibility thresholds at or above the percentage specified in a state plan amendment (approved or pending) as of January 1, 2025—or, absent such specification, the level in state authorizing legislation or appropriations as of that date. (Thus, states are prohibited from lowering income eligibility for these groups below 2025 levels.)

This section requires state Medicaid plans (Title XIX) and CHIP plans (Title XXI) to provide 12 months of continuous coverage with full benefits during pregnancy and the postpartum period to pregnant women and postpartum individuals (previously optional under Medicaid pursuant to section 1902(e)(16) of the Social Security Act). (1) For Medicaid, it adds a new state plan requirement under section 1902(a)(90) for compliance with subsection (e)(16), converts the coverage from optional to mandatory, updates related language, and strikes the subparagraph sunsetting the provision. (2) For CHIP, it amends section 2107(e)(1)(K) to expressly require the Medicaid pregnancy and postpartum coverage provisions and makes a conforming amendment to section 2112(d)(2)(A). The requirements apply to services furnished on or after one year after enactment, with an exception for states requiring state legislation (not deemed noncompliant until the first quarter after the first regular legislative session following enactment).

This section provides that nothing in this Act preempts or limits any federal, state, or local law that provides equal or greater protections—including remedies, rights, and procedures—for enrollees in group health plans or group or individual health insurance coverage.