It’s critical that expectant mothers have access to comprehensive, affordable coverage and continuity of care during this critical time of life. The Affordable Care Act expanded coverage options for pregnant women but the intersection of these changes to the law with other state and federal policies is a bit confusing to untangle. Recent federal guidance has impacted the coverage options in 2015 and beyond for pregnant women. To help us explain the important health coverage issues facing expectant mothers, Sonya Schwartz interviewed Dipti Singh with the National Health Law Program (NHeLP) to share her expertise with Say Ahhh! readers.

Q&A with Dipti Singh and Sonya Schwartz:

Sonya: Dipti – you know more about pregnancy coverage options than anyone I know so on behalf of Say Ahhh! readers, I want to thank you for walking us through all the nuances of health coverage for pregnant women.

Let’s start with eligibility. If a woman is pregnant when she applies for coverage, what are her options?

Dipti: It really depends on her household income, where she lives and whether she satisfies other eligibility requirements. Depending on her income and immigration status, a pregnant woman could be eligible for Medicaid, CHIP or private health insurance with subsidies.

Sonya: So can you explain various options that may be available depending on income and immigration status?

Dipti: Sure. There are several ways a pregnant woman could get coverage: Full Scope Medicaid Coverage, Pregnancy-Related Medicaid Coverage, Medicaid Expansion Coverage, CHIP coverage options for pregnant women, Basic Health Plan and Marketplace Plans are the main options. For more background information on the various sources of coverage for pregnant women, see this Q&A by NHeLP, which focuses on Medicaid and Marketplace plan options.

Sonya: On November 7th, CMS issued guidance to clarify whether or not types of pregnancy-related Medicaid coverage count as Minimum Essential Coverage (MEC) and whether or not people enrolled in such coverage can get a hardship exemption, so that they don’t have to pay a tax penalty. The guidance lays out a more definitive policy than what has been in place until now. Can you explain how this will impact pregnant women?

Dipti: As you know, whether or not coverage is determined to be MEC has significant implications for consumers. Individuals eligible for Medicaid coverage that is considered to be MEC are not eligible for Advanced Premium Tax Credits (APTC) or Cost Sharing Reductions (CSR) for Qualified Health Plans (QHPs) purchased through the Marketplace. The November 7th guidance addresses whether or not pregnancy-related Medicaid and CHIP coverage is considered MEC, which depends on whether coverage provided under that category is comprehensive. Under federal law, states have the option of providing pregnant women enrolled in the pregnancy-related category full Medicaid benefits or potentially something less than comprehensive coverage.

All states were required to submit a new state plan amendment (SPA) to the Centers for Medicare & Medicaid outline coverage for pregnant women under MAGI. States must indicate whether they cover full Medicaid benefits for all pregnant women or whether they only provide “pregnancy-related services.” All states have submitted theirs SPAs and the vast majority have checked the box stating they provide full Medicaid benefits to pregnant women. For states that did not check the box, HHS will review the benefits covered to determine whether “pregnancy-related services” are equivalent to full Medicaid benefits and thus whether the coverage is MEC.

Sonya: Since Medicaid or CHIP coverage as a result of pregnancy applies only for the duration of the pregnancy plus a period of up to the end of the month in which the 60-day postpartum period ends does this create any potential problems with the mandate?

Dipti: If, after the birth of the child, the individual is not eligible for Medicaid or CHIP coverage on another basis, she would be required to enroll in a QHP or another private health insurance option to maintain coverage. (Note: The loss of Medicaid or CHIP coverage generally qualifies the individual for a special enrollment period. This is true even if the pregnancy-related coverage isn’t considered MEC.)

Sonya: If a low-income woman is enrolled in a QHP then becomes pregnant and eligible for Medicaid, does she have to switch plans?

Dipti: That’s a good question. The benefits package, cost, plan choice, provider networks, and likelihood of having to transition to another program all bear upon a woman’s best choice of coverage. Medicaid might be the lowest-cost and most comprehensive option for a lot of women. But, forcing a low-income pregnant woman who is already enrolled in a QHP to go to Medicaid could interrupt her continuity of care (for example, by requiring her to switch providers).. CMS recognized that this would be problematic and the guidance allows women who become pregnant while enrolled in a QHP the choice to either remain in their marketplace plan or transfer to Medicaid. The guidance states: “An individual enrolled in a qualified health plan who becomes eligible for Medicaid coverage for pregnancy-related services that is minimum essential coverage, or for CHIP coverage based on pregnancy, is treated as eligible for minimum essential coverage under the Medicaid or CHIP coverage for purposes of the premium tax credit only if the individual enrolls in the coverage.”

Sonya: If a woman is only eligible for coverage because of the CHIP fetal regulation option (sometimes also referred to as the “unborn child option” whereby states have the option to cover the fetus of a woman who is herself ineligible for CHIP because of her immigration status), what are her choices?

Dipti: CHIP coverage under the unborn child provision does NOT result in a woman becoming ineligible for premium tax credits. She can likely even enroll in both as long as state policy doesn’t pre-empt it (and IT systems permit it). She can also qualify for a hardship exemption from the tax penalty if she is enrolled just in CHIP fetus coverage, which isn’t considered MEC for her, and doesn’t have other minimum essential coverage.

Sonya: Thanks Dipti. If readers have further questions, do you have any suggested resources?

Dipti: Thanks for the opportunity. Readers can feel free to contact me with any questions at singh@healthlaw.org. Here are also a few resources for Say Ahhh! readers who want to learn more about pregnancy coverage:

CMS Nov 7 Guidance
Association of Maternal and Child Health Programs fact sheet