By Tricia Brooks and Sophia Duong,

Maryland and Ohio are considering rolling back Medicaid coverage for pregnant women. Currently, Maryland’s eligibility level is at 259% FPL, and Ohio’s eligibility threshold rests at 200% FPL (not including the standard 5 percentage point disregard). Governors Hogan and Kasich’s proposed budgets cut these eligible income levels, but how far can states roll back Medicaid for pregnant women?

The answer varies by state and depends on what eligibility level was in effect or approved in 1989. Federal law requires states to minimally provide Medicaid coverage to pregnant women whose household income is the higher of:

• 133% FPL, or
• A higher income standard, up to 185% FPL, the state had established as of December 19, 1989, or as of July 1, 1989, had authorizing legislation to do so.

Maryland’s income threshold was 185% FPL in 1989, so that’s as far as the state can cut back. In Ohio, pregnant women eligibility was 100% FPL in 1989. But given the new minimum eligibility level today, the lowest that any state, including Ohio, can roll back eligibility is 133% FPL.

More importantly, does cutting Medicaid eligibility for pregnant women make sense? While states may consider cutting eligibility under the assumption that these women can receive coverage through the Marketplaces, there are a number of reasons why rolling back Medicaid coverage for pregnant women is not a strategic solution for trying to fix state budgets:

Women who fall into the family glitch are not eligible for premium tax credits on the Marketplace. Eligibility for Marketplace subsidies is determined not only by income but by access to “affordable” coverage. The definition of “affordable” – for both an individual employee and a family – does not take into account the cost of a family plan. Thus, the family glitch locks a family out of access to premium tax credits and cost-sharing reductions when the cost of individual or spouse’s self-only coverage (not family coverage) is less than 9.56% of household income.

Pregnancy does not trigger a Special Enrollment Period. Unlike marriage or the birth of a child, pregnancy is not one of those life changes that qualify for a special enrollment period. If an uninsured woman becomes pregnant outside of an open enrollment period, she will not be able to enroll in Marketplace coverage. This will leave low-to-middle income pregnant women with few, if any, options for health coverage if Medicaid eligibility is cut back.

Newborn babies may miss out on comprehensive, low-cost coverage during that first crucial year of life. Babies born to mothers covered by Medicaid are automatically eligible for Medicaid coverage for one year, regardless of changes in circumstances that may impact the baby’s eligibility as a new applicant. The deemed newborn provision ensures that these infants have access to the full EPSDT services to promote healthy growth and development. By cutting Medicaid for pregnant women, coverage for babies born to women in this income range will no longer be protected during that first defining year of life.

Low-income pregnant women may not be able to afford QHP coverage. Beyond the family glitch and not being able to enroll outside of open enrollment, many low-to-middle income women may not be able to afford QHP coverage. For example, a pregnant woman with income at 150% FPL ($31,960 for a family of three) is expected to pay 4% of her household income for coverage, plus cost-sharing when she accesses services.

If low-income pregnant women remain uninsured, they may not get the prenatal care they need to promote a safe, full-term delivery and healthy child. Research has shown that prenatal care is effective in reducing low-weight and premature births. Moreover, it saves money. The cost of hospitalizing a premature baby in a neonatal intensive care unit is around $5,000 per day; 100 days in a NICU can cost upwards of a half million dollars. States are likely to bear these costs given the current levels of children’s eligibility.

Guidance from CMS states that a woman who is enrolled in a QHP and becomes pregnant has the choice to stay in the QHP or switch to Medicaid. At one point there was concern that a pregnant woman enrolled in a QHP would have to switch doctors if she had to enroll in Medicaid. But federal guidance has addressed that issue and now gives pregnant women a choice that assures continuity of care and access to their current providers. However, for many low-to-middle income women, Medicaid remains the lowest-cost and more comprehensive option. Read more about this guidance here.

In the end, states should take a closer look at the impact of cutting back pregnant women’s coverage. Doing so could be penny wise and pound-foolish.