As Say Ahh readers know, there have been bursts of Section 1115 demonstration activity since the start of the year. April was no different, bringing another flurry of actions from CMS. This time, however, there were some new demonstration approvals that promote coverage, albeit in a more limited way than we would have liked to see in a few instances.
It all started with the approval of Illinois’s waiver which extends postpartum coverage to 12 months – the first of its kind. As our colleague Maggie Clark wrote about, Secretary Becerra announced the waiver approval during a press conference as part of Black Maternal Health Week. Later that week, two additional 1115 demonstrations were approved in Georgia and Missouri, both extending postpartum benefits beyond 60 days. The week also brought some drama related to Texas’s 1115 Medicaid demonstration. For more on this, read Anne Dunkelberg’s from Every Texan blog.
While the Illinois approval was undoubtedly positive news, the Georgia and Missouri approvals are more mixed. Let’s start with the good news: both demonstrations promote coverage for postpartum people. (A welcome change after the last four years). The less great news is that these two postpartum extensions are much more limited than the American Rescue Plan state plan amendment (SPA) option that extends coverage for all pregnant people to twelve months, especially in the case of Missouri. The approvals are also complicated by the dynamics of Medicaid expansion in the states.
Georgia’s demonstration extends full Medicaid state plan benefits from 60 days to six months (an additional four months of coverage) for postpartum people with income at or below 225% FPL. Individuals that receive this extended coverage will be continuously eligible throughout the six-month period, regardless of changes in income. In Missouri, the approved demonstration provides limited postpartum benefits – for substance use disorder (SUD) and mental health services – up to 12 months postpartum for people with incomes up to 201% FPL but only for those who have been diagnosed with an SUD and are in need of treatment.
We will unpack the policies in both states’ approvals in another blog. The bottom line though is both demonstrations are more restrictive than the new state plan option. In a recent letter to CMS, Georgetown CCF and the Center on Budget and Policy Priorities requested that any 1115 waiver approvals for postpartum coverage extensions should be as expansive as the federally authorized option – a standard which Georgia and Missouri’s approvals do not meet.
There are other complicating factors to consider with these demonstrations as well.
Both Georgia and Missouri have not implemented Medicaid expansion and are two of the fourteen states that could receive the new federal financial incentives to do so. Missouri has adopted expansion, but the implementation has turned into a complex situation (more on that in a second). While extending postpartum coverage is a positive step, thousands will fall back into the coverage gap once the postpartum coverage period is over. As the American College of Obstetricians and Gynecologists have noted, expansion and postpartum extension should be paired together to ensure continuous coverage before, during, and after pregnancy.
Georgia is one of the twelve states that has not adopted Medicaid expansion for adults with incomes up to 138% FPL. In fact, the state only covers parents with incomes up to 35% FPL ($641 per month for a family of three). That means after the six months of postpartum coverage ends, there are limited, affordable options for individuals to receive coverage for the remaining six months of their postpartum period despite needs that persist throughout the first year after delivery. While Georgia’s demonstration moves the needle forward, it should not be a replacement for fully expanding Medicaid and the state should consider adopting the twelve month adoption when the SPA becomes available next year. Today, the Medicaid disenrollment freeze is protecting these women from losing coverage but when that is lifted (likely sometime in 2022) the loss of coverage will become clear….
In Missouri, the approval leaves the majority of postpartum people without reliable coverage in the first year after birth once the disenrollment freeze is lifted. According to its initial application, Missouri’s demonstration would only cover around 800 people per demonstration year. Receiving the extended benefits is not simple; individuals have to be diagnosed and assessed as having an SUD by certain providers and be in need of treatment to be eligible. Currently there is some uncertainty about the voter approved Medicaid expansion being implemented as the legislature didn’t budget for it – but even if expansion is implemented, women with incomes between 138% FPL and 201% FPL would have few affordable coverage options once their 60-day postpartum period ends.
Several states still have pending Medicaid section 1115 requests to extend postpartum coverage (NJ, IN), which are more restrictive than the SPA option. Policymakers at both the federal and state levels should take another look at this issue and move in the 12-month direction – especially given that an estimated 123,000 uninsured postpartum individuals annually would be newly eligible for Medicaid and CHIP coverage if the policy was adopted across the country.