Medicaid and CHIP Coverage for Pregnant Women: Federal Requirements, State Options by Maggie Clark Introduction Medicaid and the Children’s Health Insurance Program (CHIP) women improved access to essential prenatal, birth-related, are key supports for pregnant women and new mothers,1 as and postpartum care. But more can be done to ensure that well as their children in the critical early years of life. Medicaid Medicaid and CHIP coverage for pregnant women provides pays for nearly half of all births in the United States, including affordable, comprehensive care that supports optimal a greater share of births in rural areas, among young women, pregnancy outcomes for mothers and babies, and helps build and women of color.2 Medicaid and CHIP also cover close to the foundation for a strong, nurturing relationship between half of the nation’s children under age 3, making it the largest mother and child. This brief describes the existing Medicaid source of coverage for infants and toddlers.3 and CHIP eligibility pathways for pregnant women and outlines federal minimum standards and state options to expand Federal minimum standards and state expansions have coverage to more pregnant women and opportunities to better created public health coverage pathways that give millions of align maternal and infant health coverage. Medicaid and CHIP Eligibility Pathways for Pregnant Women Medicaid and CHIP coverage for pregnant women is a States are required to cover any pregnant woman who has patchwork of federal mandatory minimum requirements and a household income up to 138 percent FPL in Medicaid who state options that have evolved since the 1980s. As a result, meets certain immigration requirements.6, 7 The pregnancy Medicaid and CHIP income eligibility thresholds, program coverage lasts from the date of application to 60 days after structures, enrollment procedures, and benefit packages for the pregnancy ends (see Figure 2).8, 9 Before coverage ends, pregnant and postpartum women vary by state. Every state states must determine if the pregnant woman is eligible for has opportunities to raise coverage standards for pregnant another Medicaid coverage category or for other insurance and postpartum women, expand eligibility pathways, and affordability programs before she is disenrolled.10, 11 streamline enrollment processes. States also have the tools States can also go beyond the federal minimum income to better align maternal coverage with eligibility and access eligibility limits to increase the number of pregnant women to care for babies and young children. eligible for Medicaid or CHIP. As of early 2020, 47 states had uMedicaid Medicaid eligibility levels beyond the federal 138 percent FPL minimum, ranging as high as 380 percent FPL in Iowa (see Many low-income women are enrolled in Medicaid prior Figure 1).12 The median income eligibility level for Medicaid to pregnancy, which allows opportunities to improve their pregnancy coverage was 200 percent FPL in 2020. health using preconception care.4 Women with health coverage at the time they become pregnant face fewer barriers to early prenatal care, such as enrolling in coverage and subsequent managed care plans, or finding a provider.5 November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 1 Figure 1. Upper Income Eligibility Levels in Medicaid or CHIP for Pregnant Women WA MT NH ME ND VT OR MN MA ID SD NY WI RI WY MI CT IA PA NJ NV NE OH MD UT IL IN DE CO WV DC CA KS VA MO KY NC TN 138% FPL (2 states) AZ NM OK AR SC 139%-204% FPL (20 states) AL GA MS LA 205%-299% FPL (23 states) TX 300% FPL (5 states and D.C.) FL Note: Median income eligibility across Medicaid and CHIP is 205% FPL. AK HI Source: T. Brooks, et al., “Medicaid and CHIP Eligibility, Enrollment and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Georgetown University Center for Children and Families and the Kaiser Family Foundation (March 2020), available at http://files.kff.org/ attachment/Report-Medicaid-and-CHIP-Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of- January-2020.pdf. Pregnant women who are not citizens may be eligible for coverage16 include both lawfully residing women who do not Medicaid if they have a qualified immigration status (e.g., meet the specific immigration rules required by Medicaid lawful permanent resident, refugee, asylee, etc.), though (e.g., do not have “qualified status” or have not had such some groups must have such status for at least five years status for five years) and women who are undocumented.17 before becoming eligible. States can opt to disregard Six states and Washington, D.C. use state-only dollars to the five-year waiting period for qualified lawfully residing provide some services not covered by emergency Medicaid immigrant pregnant women so that the women can be to some pregnant or post-partum women not otherwise eligible for pregnancy and postpartum coverage in Medicaid eligible due to immigration status.18 or CHIP sooner.13 As of January 2020, 29 states covered States may not impose waiting periods, pre-existing lawfully-residing immigrant pregnant women without a five- condition restrictions, enrollment caps, or cost sharing year waiting period (25 states in Medicaid, four of six states for preventive or pregnancy-related services for any covering pregnant women in CHIP). (See Table 1.)14 pregnant women covered in Medicaid or CHIP.19 For those who would be eligible for Medicaid but for their immigration status, Medicaid must cover labor and delivery costs.15 Women eligible for such “emergency Medicaid” 2 Medicaid and chip coverage for pregnant women CCF.GEORGETOWN.EDU November 2020 uCHIP Options to expand pregnancy coverage in CHIP build on states to consider the fetus a “targeted low-income child” Medicaid’s foundation by allowing states to extend coverage for purposes of CHIP coverage, which allows pregnant to women at higher income levels while receiving the higher women regardless of their immigration status to receive CHIP federal matching rate. To offer full pregnancy and prenatal care and labor and delivery services. postpartum benefits under CHIP, a state must raise its Coverage for pregnancy-related services ends for the pregnancy Medicaid income eligibility level to at least 185 mother after the birth of the child and does not include percent FPL.20 Any state meeting this prerequisite can then postpartum care, unless the postpartum services are set its CHIP income eligibility limit for pregnant women up included in a payment bundle that includes prenatal, labor to, but not above, the state’s CHIP income eligibility limit and delivery, and postpartum care.24, 25 for children.21 Currently, six states offer CHIP pregnancy coverage through this pathway (see Table 1).22 As of January 2020, 17 states have adopted the unborn child option, effectively covering pregnant women with a median States can also use CHIP funds to offer coverage from income eligibility level of 213 percent FPL (see Table 1).26 conception to birth when the mother is not eligible for Medicaid.23 The so-called “unborn child” option permits Figure 2. Medicaid and CHIP Pregnancy Coverage Timeline Income Preconception Pregnancy Baby coverage, Eligibility Limit coverage coverage postpartum coverage for mother 400% FPL ACA Marketplace coverage 262% FPL Median CHIP Pregnant Women Option (6 states) 213% FPL Median CHIP Unborn Child Option (17 states) 200% FPL Median Pregnancy Medicaid 138% FPL Adult Medicaid expansion (39 states and D.C.) 45% FPL Median Medicaid low-income adult (12 states) Pregnancy Birth 60-day Baby’s first determination postpartum birthday Source: T. Brooks, et al., “Medicaid and CHIP Eligibility, Enrollment and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Georgetown University Center for Children and Families and the Kaiser Family Foundation (March 2020), available at http://files.kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of- January-2020.pdf. November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 3 Extending Postpartum Medicaid and CHIP Coverage Policymakers in more than 20 states are working to extend postpartum coverage for at least some Black women and pregnant women beyond the current 60-day American Indian/Alaska Native statutory limit.27 In many cases, they are seeking women are 2 to 3X a solution to the alarming U.S. maternal mortality and morbidity crisis. About 700 women die each year due to pregnancy-related complications, and the rate is continuing to rise.28 But the crisis is not more likely to die from a experienced equally. Black women and American pregnancy-related cause Indian/Alaska Native women are two to three times than White women. more likely to die from a pregnancy-related cause than White women.29 While four states (Illinois, New Jersey, Missouri, About 24 percent of all pregnancy-related deaths and Georgia) have applied to CMS to extend occur between 43 to 365 days after birth, well postpartum coverage for at least some pregnant beyond the time when Medicaid and CHIP women, none have so far been approved. Congress pregnancy coverage ends, according to a recent has proposed measures to allow or require states to review of maternal mortality data.30 There is extend postpartum coverage while receiving federal growing evidence that covering women for longer matching funds,36 and the Trump administration periods of time can reduce preventable maternal included extending postpartum coverage for 12 deaths, particularly among Black women.31 months only for women with substance use disorder in its fiscal year 2021 budget request for the Extending postpartum Medicaid and CHIP Department of Health and Human Services.37 coverage to one year after delivery has the potential to help at least 200,000 low-income The Affordable Care Act’s (ACA) Medicaid uninsured mothers retain coverage.32 Twelve expansion is a comprehensive long-term coverage months of continuous postpartum coverage would solution that has been shown to reduce maternal also bring mothers’ enrollment in line with the one mortality, with the greatest benefit for non-Hispanic year of coverage federal law guarantees for infants Black mothers, suggesting that expansion could whose birth was paid for by Medicaid or CHIP.33, 34 be contributing to decreasing racial disparities in maternal mortality.38, 39 However, 12 states have not Currently, some states are covering postpartum yet taken the critical first step to expand Medicaid to extensions with state-only funds.35 Extending low-income parents and adults with incomes below pregnancy Medicaid and CHIP coverage beyond 60 138 percent of the federal poverty level under the days postpartum with a federal match is currently ACA,40 a step which ensures that more women have only available to states by requesting section 1115 sustained coverage and access to comprehensive demonstration authority from the federal Centers care before, during, and after pregnancy.41, 42 for Medicare and Medicaid Services (CMS). 4 Medicaid and chip coverage for pregnant women CCF.GEORGETOWN.EDU November 2020 Enrollment Options ACA Marketplaces may cover pregnant States have options to streamline the Medicaid and women who do not qualify for Medicaid CHIP enrollment process for eligible pregnant women. or CHIP Just as for children, states can choose to adopt For pregnant women with incomes higher than their state’s presumptive eligibility for pregnant women in Medicaid Medicaid and CHIP eligibility levels, the ACA’s health insurance or CHIP.43 The option permits states to authorize Marketplaces may provide an important coverage avenue, specific types of “qualified entities,” such as federally though without many of the consumer protections provided by qualified health centers, hospitals, and local health Medicaid and CHIP. Marketplace plans must cover prenatal, departments, to screen a pregnant woman’s eligibility labor and delivery, and postpartum care.46 based on her gross income and temporarily enroll her in coverage. Presumptive eligibility serves a dual Birth of a child triggers a special enrollment period for the purpose of providing immediate access to needed new parents (including the parent not physically giving birth) health care services while putting people on a path to as well as for the new child, up to 60 days after birth.47 ongoing coverage.44 However, while birth is a qualifying event allowing for a special enrollment period, pregnancy is not.48 Women who become Thirty states have adopted presumptive eligibility pregnant outside of the Marketplace’s annual open enrollment for pregnant women in Medicaid and three of the period cannot enroll in Marketplace coverage until after the six states that have expanded full CHIP coverage birth of their child, leaving them exposed to thousands in to pregnant women have adopted the presumptive out of pocket medical costs if they do not otherwise have eligibility option for this group as well.45 Once a woman coverage.49 However, five state-based Marketplaces—New is enrolled in Medicaid or CHIP pregnancy coverage, York50, Connecticut 51, Vermont52, Maryland53, and D.C.54—have the coverage is effective as of the date of application changed their rules to allow pregnancy to be a qualifying event and typically covers any costs incurred for care while for a special enrollment period. she was waiting to have her coverage approved. Benefit Provisions under Medicaid and CHIP Coverage for Pregnant Women uMedicaid Most states provide full Medicaid benefits for pregnant because the health of a pregnant woman is intertwined with women regardless of eligibility pathway, but states the health of her expected child.”58 are able to offer fewer benefits for these women if Pregnancy Medicaid coverage includes prenatal, labor and they choose. Should a state decide to offer a more delivery, postpartum, and family planning services, as well limited benefit package to pregnant women than as an array of services which may include prenatal vitamins, for other adults in Medicaid, the state must receive genetic counseling, prenatal care coordination, doula CMS approval for determining which services are services, and childbirth education classes.59 In addition, not pregnancy related.55, 56 Four states (Arkansas, states routinely now cover the women’s preventive services New Mexico, North Carolina, and South Dakota) limit included under the Affordable Care Act, such as smoking benefits to pregnancy-related coverage.57 Federal cessation, HIV screening and counseling, depression guidance has clarified that such pregnancy coverage screening and referrals, domestic violence screening and includes services beyond just prenatal care, stating counseling, and breastfeeding support and supplies. that “it is difficult to identify what is ‘pregnancy-related’ November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 5 Emergency Medicaid only reimburses medical professionals services (12 of 17 states).63, 64 States electing the unborn for labor and delivery services provided to women who child option may also cover postpartum care for the woman would otherwise be eligible for Medicaid but for their in several ways, including potentially using CHIP Health immigration status.60 Neither prenatal care nor other Services Initiative funding, or paying for the services through preventive services are covered under emergency a global fee that includes prenatal, labor and delivery, Medicaid.61 and postpartum care for 60 days after the end of the pregnancy.65 uCHIP Additionally, as a result of the SUPPORT Act, passed in States have additional flexibility to design benefits in 2018, states must also cover behavioral health services to separate CHIP programs, with the option to base benefits both children and pregnant women covered in separate on existing coverage models, called benchmarks, or define CHIP programs, including those covered via the “unborn another set of benefits with approval of the federal HHS child” pathway.66 This includes screenings and treatment for Secretary.62 In effect, the six states with separate CHIP tobacco and opioid abuse, depression, and other mental programs serving pregnant women have opted to provide health and substance abuse services, all of which help to them with full CHIP benefit packages for the perinatal ensure a healthy start for mother and child together.67 period. Most states with separate CHIP programs covering pregnant women through the “unborn child” option also offer full CHIP benefits for prenatal care and labor and delivery Conclusion Medicaid and CHIP are the largest source of coverage for pregnant women, new mothers, and their young children, in the United States. States have many options in these programs to ensure that eligibility, enrollment, and benefits help new mothers and their children get the care they need during this critical window for early childhood development and maternal health. This brief was written by Maggie Clark. The author would like to thank Elisabeth Wright Burak, Kaitlyn Borysiewicz, Kelly Whitener, Tricia Brooks, Phyllis Jordan, Kay Johnson, and Ema Bargeron for their contributions to the report. Design and layout was provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. 6 Medicaid and chip coverage for pregnant women CCF.GEORGETOWN.EDU November 2020 Figure 3. Features of Pregnancy Coverage Pregnancy CHIP Pregnant CHIP Unborn Marketplace Medicaid Women Option Child Option Where is this All states 6 states 17 states All states and Washington, D.C. and Washington, D.C. coverage available? What’s covered? Most states provide full The full CHIP benefit Most states with separate Coverage includes Medicaid benefits for package includes all CHIP programs covering prenatal, labor and pregnant women. This prenatal, labor and pregnant women through delivery, and postpartum comprehensive coverage delivery, and postpartum the “unborn child” option care, and continues must include all prenatal, care. offer full CHIP benefits for beyond the posptartum labor and delivery, and prenatal care and labor period. postpartum care. and delivery services. Coverage begins Coverage for pregnancy- following an open related services ends for enrollment period or Emergency Medicaid the mother after the birth special enrollment period. reimburses medical of the child. professionals for labor and delivery services provided to women who would otherwise be eligible for Medicaid but for their immigration status. Who’s eligible? States are required to States have the option The “unborn child” option Women receive tax cover any pregnant woman to offer full CHIP benefits permits states to consider credits for coverage who has a household to pregnant women with the fetus a “targeted low- based on income up to income up to 138% FPL higher incomes than are income child” for purposes 400% FPL. in Medicaid who meets eligible for Medicaid who of CHIP coverage, certain immigration meet certain immigration which allows pregnant The coverage may require requirements. requirements. women regardless of co-pays, premiums, and their immigration status an annual deductible. The median income The median income to receive prenatal care eligibility limit is 200% eligibility limit is 262% Certain immigration and labor and delivery requirements apply. FPL. FPL. services. The median income eligibility limit is 213% FPL. What options do States can opt to disregard States can opt to States may cover States that operate the five-year waiting disregard the five- postpartum care for the their own state-based states have? period for qualified year waiting period for woman in several ways, marketplaces can lawfully residing immigrant qualified lawfully residing including potentially using allow pregnancy to be pregnant women so immigrant pregnant CHIP Health Services a qualifying event for a that the women can be women so that the Initiative funding, state- special enrollment period. eligible for pregnancy and women can be eligible only funds, or paying for postpartum coverage in for pregnancy and the services through a Medicaid sooner (24 states postpartum coverage global fee that includes and Washington, D.C. in in CHIP sooner (4 of 6 prenatal, labor and delivery Medicaid). states covering pregnant and postpartum care. women in CHIP). Source: T. Brooks, et al., “Medicaid and CHIP Eligibility, Enrollment and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Georgetown University Center for Children and Families and the Kaiser Family Foundation (March 2020), available at http://files.kff.org/ attachment/Report-Medicaid-and-CHIP-Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of-January-2020.pdf. November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 7 Table 1. Medicaid and CHIP Coverage for Pregnant Women, January 2020 Lawfully-Residing Presumptive Eligibility in Income Eligibility Limits for Pregnant Immigrants Covered Medicaid and CHIP for Women (percent of FPL) State without 5-Year Wait Pregnant Women Unborn Child Medicaid CHIP Medicaid CHIP Medicaid CHIP Option Median or Total 200% 262% 213% 25 4 30 3 Alabama 146% N/A N/A Alaska 205% N/A N/A Arizona 161% N/A N/A Arkansas 214% 214% Y N/A N/A California 213% 322% Y N/A Y N/A Colorado 200% 265% Y Y Y Y Connecticut 263% Y N/A Y N/A Delaware 217% Y N/A N/A District of Columbia 324% Y N/A Y N/A Florida 196% N/A Y N/A Georgia 225% N/A Y N/A Hawaii 196% Y N/A N/A Idaho 138% N/A Y N/A Illinois 213% 213% N/A Y N/A Indiana 218% N/A Y N/A Iowa 380% N/A Y N/A Kansas 171% N/A Y N/A Kentucky 200% N/A Y N/A Louisiana 138% 214% N/A N/A Maine 214% Y N/A Y N/A Maryland 264% Y N/A N/A Massachusetts 205% 205% Y N/A N/A Michigan 200% 200% N/A Y N/A Minnesota 283% 283% Y N/A N/A Mississippi 199% N/A N/A Missouri 201% 305% 305% Y Y Montana 162% N/A Y N/A Nebraska 199% 202% Y N/A Y N/A Nevada 165% N/A N/A New Hampshire 201% N/A Y N/A New Jersey 199% 205% Y Y Y Y New Mexico 255% Y N/A Y N/A New York 223% Y N/A Y N/A North Carolina 201% Y N/A Y N/A North Dakota 162% N/A N/A Ohio 205% Y N/A Y N/A Oklahoma 138% 210% N/A N/A Oregon 190% 190% N/A N/A Pennsylvania 220% Y N/A Y N/A Rhode Island 195% 258% 258% South Carolina 199% Y N/A Not reported Not reported South Dakota 138% 138% N/A N/A Tennessee 200% 255% N/A Y N/A Texas 203% 207% N/A Y N/A Utah 144% N/A Y N/A Vermont 213% Y N/A N/A Virginia 148% 205% Y Y Washington 198% 198% Y N/A N/A West Virginia 190% 305% Y Y Y N/A Wisconsin 306% 306% Y N/A Y N/A Wyoming 159% Y N/A Y N/A Source: T. Brooks, et al., “Medicaid and CHIP Eligibility, Enrollment and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey,” Georgetown University Center for Children and Families and the Kaiser Family Foundation (March 2020), available at http://files.kff.org/attachment/Report-Medicaid-and-CHIP- Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of-January-2020.pdf. 8 Medicaid and chip coverage for pregnant women CCF.GEORGETOWN.EDU November 2020 Endnotes 1 Female pronouns are used throughout the paper, but the policies 13 Known as the Immigrant Children’s Health Improvement Act (ICHIA) apply to all birthing people enrolled in coverage programs, regardless option, this is the same pathway used to remove the five year bar for of gender. immigrant children’s eligibility for Medicaid and CHIP. See Georgetown 2 Medicaid and CHIP Payment and Access Commission, “Medicaid’s Center for Children and Families, “Health Coverage for Lawfully Role in Financing Maternity Care,” (January 2020), available Residing Children,” (May 2018), available at https://ccf.georgetown. at https://www.macpac.gov/wp-content/uploads/2020/01/ edu/wp-content/uploads/2018/05/ichia_fact_sheet.pdf (accessed Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf October 16, 2020). (accessed October 20, 2020). 14 Op. cit. (12) 3 Unpublished Georgetown University Center for Children and 15 42 C.F.R. § 440.255 (2019). Families analysis of the 2008-2018 Integrated Public Use Microdata 16 42 C.F.R. § 440.255(c) (2019). Series (IPUMS) American Community Survey data. Note: Change 17 42 C.F.R. § 435.406(b) (2019). is significant at the 90 pecent confidence level. See Georgetown University Center for Children and Families, “Rate of Uninsured Infants 18 D.C., Massachusetts, New Jersey, New York, Oregon, Tennessee, and Toddlers on the Rise,” (March 2020), available at https://ccf. and Washington. For more information, see K. Gifford, et.al., “Medicaid georgetown.edu/wp-content/uploads/2020/04/Under-3-Increase-in- Coverage of Pregnancy and Perinatal Benefits: Results from a State Uninsured-v4.pdf (accessed October 16, 2020). Survey,” Kaiser Family Foundation (April 2017), available at https:// www.kff.org/womens-health-policy/report/medicaid-coverage- 4 Y. J. Taylor, T. L. Liu, and E. A. Howell, “Insurance Differences in of-pregnancy-and-perinatal-benefits-results-from-a-state-survey/ Preventive Care Use and Adverse Birth Outcomes Among Pregnant (accessed October 16, 2020). Women in a Medicaid Nonexpansion State: A Retrospective Cohort Study,” Journal of Women’s Health, 1: 29-37 (2020), available at 19 Center for Medicare & Medicaid Services, State Health Official Letter https://pubmed.ncbi.nlm.nih.gov/31397625/ (accessed October 19, #09-010 (September 3, 2009), available at https://www.medicaid.gov/ 2020). sites/default/files/Federal-Policy-Guidance/downloads/SHO090309.pdf (accessed October 16, 2020). 5 M. A. Clapp, et al., “Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women,” Obstetrics and 20 States also must cover children under age 19 in Medicaid and CHIP Gynecology, 134(5): 1066-1074 (2019), available at https://pubmed. up to at least 200 percent FPL before expanding CHIP coverage to ncbi.nlm.nih.gov/31599841/ (accessed October 19, 2020). pregnant women. Only North Dakota and Idaho have eligibility lower than 200 percent FPL for children in Medicaid and CHIP. See Op. cit. 6 States are required to cover any income-eligible citizen or refugee/ (12), Table 1. asylee pregnant woman with incomes at or below 138 percent FPL in Medicaid. Women with other immigration statuses can receive 21 Center for Medicare & Medicaid Services, “Questions and Answers Medicaid and CHIP benefits at state option or have their labor and Related to Coverage of Pregnant Women in the Children’s Health delivery services covered by emergency Medicaid. See also “Non- Insurance Program (CHIP)” (September 3, 2009), available at https:// citizens,” Medicaid and CHIP Payment and Access Commission, www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/ available at https://www.macpac.gov/subtopic/noncitizens/ (accessed downloads/SHO090309.pdf (accessed October 16, 2020). October 16, 2020). 22 Op. cit. (12). 7 In some states, pregnant women must be covered up to 185 percent 23 42 C.F.R. § 457.10 (2019). FPL because the state had already expanded to these levels when 24 Op. cit. (19). legislation was enacted in 1989 to mandate coverage up to at least 133 percent FPL. States are required to maintain these higher preexisting 25 Centers for Medicare & Medicaid Services, State Health Official thresholds. See also “Pregnant women,” Medicaid and CHIP Payment Letter #020-004 (November 12, 2002), available at https://healthlaw. and Access Commission, available at https://www.macpac.govs/ org/wp-content/uploads/2018/09/cms_release_on_prenatal_care_for_ subtopic/pregnant-women/ (accessed October 16, 2020). fetuses.pdf (accessed October 19, 2020). 8 Throughout the paper, when we refer to pregnancy coverage, we are 26 Op. cit. (12). being inclusive of the 60 days postpartum period, unless otherwise 27 National Academy for State Health Policy, “View Each State’s Efforts stated. to Extend Medicaid Coverage to Postpartum Women,” (September 29, 9 42 C.F.R § 435.17 (2016). 2020), available at https://www.nashp.org/view-each-states-efforts-to- extend-medicaid-coverage-to-postpartum-women/ (accessed October 10 A. Chen and E. Hayes, “Q&A on Pregnant Women’s Coverage Under 16, 2020). Medicaid and the ACA,” National Health Law Program, available at https://healthlaw.org/resource/qa-on-pregnant-womens-coverage- 28 Centers for Disease Control and Prevention, “Pregnancy-Related under-medicaid-and-the-aca/ (accessed October 16 2020). Deaths Happen Before, During, and Up to a Year After Delivery,” Press Release (May 7, 2019), available at https://www.cdc.gov/media/ 11 42 C.F.R. § 435.916 (2019) and 435.1200(e) (2019). releases/2019/p0507-pregnancy-related-deaths.html (accessed 12 Idaho, Louisiana, Oklahoma, and South Dakota only cover pregnant October 26, 2020). women to 138 percent. See Table 3, T. Brooks, et al., “Medicaid and 29 Centers for Disease Control and Prevention, “Racial/Ethnic CHIP Eligibility, Enrollment and Cost Sharing Policies as of January Disparities in Pregnancy-Related Deaths—United States, 2007–2016,” 2020: Findings from a 50-State Survey,” Georgetown University Center available at https://www.cdc.gov/reproductivehealth/maternal- for Children and Families and the Kaiser Family Foundation (March mortality/disparities-pregnancy-related-deaths/infographic.html 2020), available at http://files.kff.org/attachment/Report-Medicaid- (accessed October 26, 2020). and-CHIP-Eligibility,-Enrollment-and-Cost-Sharing-Policies-as-of- January-2020.pdf (accessed October 16, 2020). November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 9 30 N. L. Davis, A. N. Smoots, and D. A. Goodman, “Pregnancy-Related “Pregnant women,” Medicaid and CHIP Payment Access 43 Deaths: Data from 14 U.S. Maternal Mortality Review Committees, Commission, available at https://www.macpac.gov/subtopic/pregnant- 2008-2017,” Centers for Disease Control, available at https://www.cdc. women/ (accessed October 16, 2020). gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief. 44 T. Brooks, “Hospital Presumptive Eligibility,” Health Affairs, (January html#table2 (accessed October 20, 2020). 2014), available at https://www.healthaffairs.org/do/10.1377/ 31 E. L. Eliason, “Adoption of Medicaid Expansion is Associated with hpb20140109.508614/full/ (accessed October 20, 2020). Lower Maternal Mortality,” Women’s Health Issues, 30: 147-152 (2020), 45 Op. cit. (12), Table 12. available at https://www.whijournal.com/article/S1049-3867(20)30005- 46 “Health coverage if you’re pregnant, plan to get pregnant, or recently 0/abstract (accessed October 16, 2020). gave birth,” HealthCare.gov, https://www.healthcare.gov/what-if- 32 S. McMorrow et al., “Extending Postpartum Medicaid Coverage im-pregnant-or-plan-to-get-pregnant/#:~:text=All%20Health%20 Beyond 60 Days Could Benefit Over 200,000 Low-Income Uninsured Insurance%20Marketplace%C2%AE,born%20%E2%80%94%20 Citizen New Mothers,” available at https://theincidentaleconomist.com/ are%20essential%20health%20benefits (accessed October 16, 2020). wordpress/extending-postpartum-medicaid/ (accessed October 15, 47 Center on Budget and Policy Priorities, “Special Enrollment 2020). Period Reference Chart,” (July 2020), available at http://www. 33 K. Johnson, S. Rosenbaum, & M. Handley, “The Next Steps to healthreformbeyondthebasics.org/wp-content/uploads/2020/07/ Advance Maternal and Child Health in Medicaid: Filling Gaps in REFERENCE-CHART_Special-Enrollment-Periods-7.6.20.pdf (accessed Postpartum Coverage and Newborn Enrollment,” Health Affairs October 16, 2020). (January 2020), available at https://www.healthaffairs.org/do/10.1377/ hblog20191230.967912/full/ (accessed October 15 2020). 48 Op. cit. (44). 49 Op. cit. (10). 34 Medicaid and CHIP Payment and Access Commission, “Medicaid’s Role in Maternal Health,” (June 2020), available at https://www.macpac. 50 “Special Enrollment Period,” NYC Health Insurance Link, available gov/wp-content/uploads/2020/06/Chapter-5-Medicaid%E2%80%99s- at https://www1.nyc.gov/site/ochia/coverage-care/special-enrollment- Role-in-Maternal-Health.pdf (accessed October 20, 2020). period.page (accessed October 16, 2020). 35 California DHCS Medi-Cal, “Provisional Postpartum Care Extension,” 51 “Welcome to Access Health CT,” Access Health CT, available at Press Release (July 31, 2020), available at https://files.medi-cal.ca.gov/ https://learn.accesshealthct.com/ (accessed October 16, 2020). pubsdoco/newsroom/newsroom_30223_01.aspx (accessed October 15, 52 “Qualifying Events,” Vermont Health Connect, available at https:// 2020). info.healthconnect.vermont.gov/QualifyingEvents#:~:text=Due%20 36 U.S. Congress, House, Helping MOMS Act of 2020, H.R. 4996, 116th to%20the%20COVID%2D19,financial%20help%20paying%20for%20 Congress, 2nd Session (November 8, 2019), available at https://www. coverage (accessed October 16, 2020). congress.gov/bill/116th-congress/house-bill/4996 (accessed October 53 “Are you pregnant? Enroll in a health plan with Maryland Health 26, 2020). Connection!” Maryland Health Connection, available at https://www. 37 Office of Management and Budget “A Budget for America’s Future: marylandhealthconnection.gov/pregnancy-sep/#:~:text=Last%20 Budget of the U.S. Government,” See Table S-4, (February 10, 2020), year%20the%20Maryland%20Legislature,(SEP)%20for%20 available at https://www.whitehouse.gov/wp-content/uploads/2020/02/ pregnant%20women.&text=1%2C%202020%2C%20becoming%20 budget_fy21.pdf (accessed October 19, 2020). pregnant%20means,the%20uninsured%20rate%20in%20Maryland (accessed October 16, 2020). 38 S. McMorrow, et al., “Uninsured New Mothers’ Health and Health Care Challenges Highlight the Benefits of Increasing Postpartum 54 “DC Health Link to Offer Even More Opportunities for Residents to Medicaid Coverage,” Urban Institute (May 2020), available at https:// Get Covered,” DC Health Link, available at https://dchealthlink.com/ www.urban.org/sites/default/files/publication/102296/uninsured-new- node/3413 (accessed October 16, 2020). mothers-health-and-health-care-challenges-highlight-the-benefits-of- 55 “Medicaid Program; Eligibility Changes Under the Affordable Care increasing-postpartum-medicaid-coverage_0.pdf (accessed October Act of 2010,” Federal Register, 77: 17144-17145 (March 23, 2012), 20, 2020). available at https://www.govinfo.gov/content/pkg/FR-2012-03-23/pdf/ 39 Op. cit. (22). FR-2012-03-23.pdf (accessed October 19, 2020). See Op. cit. (12). 40 “Status of State Action on the Medicaid Expansion Decision,” Kaiser 56 Center for Medicare & Medicaid Services, “Special Populations: Family Foundation, available at https://www.kff.org/health-reform/ Pregnant Women,” available at https://marketplace.cms.gov/technical- state-indicator/state-activity-around-expanding-medicaid-under-the- assistance-resources/special-populations-pregnant-women.pdf affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colI (accessed October 16, 2020). d%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 57 Op. cit. (12). October 15 2020). 58 “Medicaid Program; Eligibility Changes Under the Affordable Care 41 E. Eckert, “It’s Past Time to Provide Continuous Medicaid Coverage Act of 2010,” Federal Register, 77: 17144-17145 (March 23, 2012), for One Year Postpartum,” Health Affairs (February 2020), available at available at https://www.govinfo.gov/content/pkg/FR-2012-03-23/pdf/ https://www.healthaffairs.org/do/10.1377/hblog20200203.639479/full/ FR-2012-03-23.pdf (accessed October 19, 2020). (accessed October 15 2020). 59 Op. cit. (18). 42 A. Searing, and D.C. Ross, “Medicaid Expansion Fills Gaps in 60 Op. cit. (17). Maternal Health Coverage Leading to Healthier Mothers and Babies,” Georgetown University Center for Children and Families (May 2019), 61 Medicaid and CHIP Payment and Access Commission, “Chapter available at https://ccf.georgetown.edu/wp-content/uploads/2019/05/ 1. Maternity Services: Examining Eligibility and Coverage in Medicaid Maternal-Health-3a.pdf (accessed October 15 2020). 10 Medicaid and chip coverage for pregnant women CCF.GEORGETOWN.EDU November 2020 and CHIP,” (June 2013), available at https://www.macpac.gov/wp- available at https://www.macpac.gov/wp-content/uploads/2019/07/ content/uploads/2013/06/Maternity-Services-Examining-Eligibility-and- CHIP-Health-Services-Initiatives.pdf (accessed October 16, 2020). Coverage-in-Medicaid-and-CHIP.pdf (accessed October 16, 2020). 66 Center for Medicare & Medicaid Services, “Access to Mental Health 62 42 C.F.R. § 457.450 (2019). and Substance Use Disorder Services for Children and Pregnant 63 Medicaid and CHIP Access and Payment Commission, “EXHIBIT Women in the Children’s Health Insurance Program,” (March 2, 2020), 35: Medicaid and CHIP Income Eligibility Levels as a Percentage available at https://www.medicaid.gov/sites/default/files/Federal-Policy- of the FPL for Children and Pregnant Women by State, April 2019,” Guidance/Downloads/sho20001.pdf (accessed October 16, 2020). (December 2019), available at https://www.macpac.gov/wp-content/ 67 E. W. Burak, “Behavioral Health Services in Separate State CHIP uploads/2015/01/EXHIBIT-35.-Medicaid-and-CHIP-Income-Eligibility- Programs: Is Your State in Compliance?” Georgetown University Center Levels-as-a-Percentage-of-the-FPL-for-Children-and-Pregnant-Women- for Children and Families (May 29, 2020), available at https://ccf. by-State-April-2019.pdf (accessed October 16, 2020). georgetown.edu/2020/05/29/behavioral-health-services-in-separate- 64 Op. cit. (12). state-chip-programs-is-your-state-in-compliance/ (accessed October 16, 2020). 65 Illinois and Minnesota use HSI funds to cover post-partum services for women covered under the CHIP unborn child option. See Medicaid and CHIP Payment and Access Commission, “CHIP Health Service Initiatives: What They Are and How States Use Them,” (July 2019), Georgetown University Center for Children and Families McCourt School of Public Policy 600 New Jersey Avenue, NW Washington, DC 20001 Phone: (202) 687-0880 Email: childhealth@georgetown.edu ccf.georgetown.edu/blog/ facebook.com/georgetownccf twitter.com/georgetownccf November 2020 CCF.GEORGETOWN.EDU Medicaid and chip coverage for pregnant women 11