S. 3274 — Healthy MOM Act

This section sets forth 14 congressional findings concerning maternity coverage as an essential health benefit under the Patient Protection and Affordable Care Act (including its inclusion in 42 U.S.C. 18022(b)(1)), maternal mortality disparities (e.g., African-American rate four times the White rate; Black and American Indian/Alaska Native women three times more likely to die from pregnancy-related causes than White women; approximately 700 annual U.S. pregnancy-related deaths, with 3 in 5 preventable), the benefits of prenatal and postpartum care (e.g., three-to-four times higher mortality without care; more than half of deaths at delivery or in the first postpartum year), and limitations in certain plans (e.g., Medicaid pregnancy coverage lapsing at the end of the 60th postpartum day). It states the purpose of the Act as ensuring that women eligible for coverage through Exchanges under the Patient Protection and Affordable Care Act or other individual or group health plans can access affordable health coverage during pregnancy.

This section establishes a special enrollment period for pregnant individuals under the Public Health Service Act, Employee Retirement Income Security Act of 1974 (ERISA), Internal Revenue Code, and Patient Protection and Affordable Care Act (ACA), permitting otherwise eligible employees or dependents to enroll in group health plan coverage or through ACA Exchanges upon reporting pregnancy to the plan, issuer, or Exchange (or confirmation by a health care provider). (As background, special enrollment periods allow enrollment outside standard open enrollment upon qualifying life events.) It directs the Secretaries of Labor, Health and Human Services, and Treasury to promulgate regulations specifying the enrollment time period and coverage effective date, applicable to plan years beginning on or after January 1, 2027.

This section requires group health plans and health insurance issuers offering group or individual health insurance coverage that provide dependent coverage to include maternity care associated with pregnancy, childbirth, labor and delivery, and postpartum care for all participants, beneficiaries, enrollees, and dependents regardless of age. The requirement applies to plan years beginning on or after January 1, 2027.

This section directs the Director of the Office of Personnel Management to issue regulations treating pregnancy as a change in family status and qualifying life event for mid-year enrollment in Federal Employees Health Benefits Program (FEHBP) plans under 5 U.S.C. chapter 89, effective for contracts under 5 U.S.C. 8902 entered into on or after one year after enactment. It also amends 5 U.S.C. 8905 to deem agency services related to such pregnancy-based enrollments or enrollment changes as excepted services under the Anti-Deficiency Act (31 U.S.C. 1342), applicable to lapses in appropriations beginning on or after enactment. (Thus, during government shutdowns, the Office may process these pregnancy-related FEHBP enrollment actions.)

This section modifies Medicaid income eligibility requirements for pregnant individuals and infants by (1) striking the upper limit of 185% of the federal poverty level (FPL) in section 1902(l)(2)(A)(i) of the Social Security Act (42 U.S.C. 1396a(l)(2)(A)(i)), and (2) requiring that, for coverage provided on or after January 1, 2027, states maintain eligibility for such individuals (i.e., those described in 42 U.S.C. 1396a(l)(1)(A) and (B)) at no less than the percentage specified in a state plan amendment (whether approved or not), authorizing legislation, or appropriations as of January 1, 2025. (As background, Medicaid requires states to cover pregnant women and infants whose family incomes do not exceed at least 138% FPL, with states permitted to adopt higher thresholds; thus, this provision freezes those state-specific thresholds and removes the prior 185% FPL cap.)

This section requires state Medicaid plans to provide medical assistance consisting of full benefits during pregnancy and throughout the 12-month postpartum period (previously optional under section 1902(e)(16) of the Social Security Act), making such coverage mandatory and permanent by adding a new plan requirement in subsection (a)(90), mandating compliance with subsection (e)(16), and striking the optional language and subparagraph (e)(16)(C). It further requires state Children's Health Insurance Program (CHIP) plans to provide equivalent coverage during pregnancy and the 12-month postpartum period for targeted low-income pregnant women and children. The amendments apply to services furnished on or after one year after the date of enactment, with an exception for states requiring State legislation (not deemed noncompliant until the first day of the first calendar quarter after the first regular legislative session following enactment).

This section provides that nothing in this Act or its amendments invalidates or limits remedies, rights, or procedures under any federal law or state or local law that provides greater or equal protection for enrollees in a group health plan or group or individual health insurance coverage.