Since the American Rescue Plan passed in March, we’ve been closely following state decisions to take up the important new Medicaid state plan option that allows states to extend postpartum Medicaid and CHIP coverage for 12 months after the end of the pregnancy, well beyond the current federal cutoff of just 60 days postpartum. Because the ARP was enacted while many state legislatures were in session this spring, we saw lawmakers take quick action to allocate money to make sure their state could submit the necessary state plan amendment (SPA) to be ready to implement the longer postpartum coverage period as soon as federal matching funds become available on April 1, 2022. [See below for a map of state activity]
What Compelled States to Act?
The ARP option provided a streamlined path for action amidst the unacceptably high U.S. maternal mortality rates and the persistently wide racial disparities in maternal mortality within states. Specific to Medicaid, coverage churn in throughout the perinatal period is a major factor behind gaps in coverage during postpartum months, and women of color are more likely to lose coverage during their pregnancy and postpartum period.* In case these realities weren’t enough, the added stress and harm to families caused by the COVID-19 pandemic drove lawmakers across the political spectrum to advance longer postpartum Medicaid and CHIP coverage.
The Policy Weeds
The ARP option allows states to provide 12 months of full benefits to all postpartum people who were covered by Medicaid for pregnancy. The benefits must extend for 12 months postpartum and be available to all postpartum people–not just for a subgroup of postpartum people or for a shorter period of time. States receive their regular Medicaid matching rate (FMAP) for the extended coverage period and the option sunsets after five years.
As of today, eleven states have allocated state matching funds for the additional coverage period and directed their state Medicaid agency to apply for a state plan amendment when it becomes available.
This list will almost certainly grow before the federal matching funds turn on next spring. There are a few states still in session that may act before the end of the summer, and we expect to see more activity on the postpartum SPAs in the fall as states come back for special sessions on redistricting and allocating COVID relief funds.
The states taking up the SPA option join the six additional states that have applied to CMS for an 1115 waiver to extend postpartum coverage as well. So far, CMS has approved unique extended postpartum coverage waivers in Illinois (for 12 months of postpartum coverage for all pregnant people in Medicaid), Georgia (for six months of extended coverage for all pregnant people in Medicaid), and Missouri (for 12 months of limited postpartum benefits for only for postpartum individuals with a substance use disorder diagnosis.) This earlier blog outlines the difference between the waiver and SPA approaches and why states might choose each path.
Will Congress Do More?
More federal action may lie ahead. Say Ahhh! readers will recall some of the strongest recommendations came from MACPAC in January, which recommended that Congress act to guarantee 12 months of postpartum coverage with full benefits for all pregnant individuals in Medicaid, and urged Congress to provide a 100% federal matching rate (FMAP) to all states for the extended postpartum period in Medicaid.
National health advocates seek to move closer to the MACPAC recommendations in the next Senate budget reconciliation package as well. Maternal health advocates and congressional lawmakers alike seek to make 12 months of postpartum coverage mandatory for states, or at a bare minimum make the SPA option permanent with an enhanced FMAP rate.
Non-expansion states leaving billions on the table for more limited, costlier postpartum extension
Creating a new standard of 12 months of postpartum Medicaid coverage is undoubtedly a good first step to provide new mothers with better access to care during a critical period. But extended postpartum coverage does not make up for the fact that low-income adults in states that have not expanded Medicaid do not have access to coverage before or after pregnancy.
Medicaid expansion is essential for new moms and babies before, during, and after pregnancy, and is associated with reductions in maternal and infant mortality, especially for Black women and babies, as well as decreases in uninsured rates for women of childbearing age across all racial and ethnic groups. While extending postpartum coverage will help mothers stabilize after the end of pregnancy, in states that have not expanded Medicaid, the extension only pushes their coverage cliff further down the road.
Unfortunately, in non-expansion states, including Texas, Florida, Georgia, and Tennessee, state lawmakers have taken the extended postpartum coverage extension but did not expand Medicaid to all adults-- a less effective strategy and more costly move overall, since the additional 10 months of postpartum coverage are matched at the state’s regular FMAP rate, compared to Medicaid expansion’s 90% enhanced FMAP.
These states are also rejecting billions more in new federal incentives from the ARP to expand Medicaid. And they continue to deny parents, caregivers, and other adults in their state access to consistent, comprehensive health care coverage throughout their lifetime.
Extending postpartum Medicaid coverage to 12 months so that it is permanent, mandatory for states, and financed at a higher matching rate builds on Medicaid expansion’s foundation to ensure that every family has the health coverage they need for a healthy start. Both of these policy choices are available to states at a moment of great opportunity. By providing access to lifesaving health coverage for low-income families who’ve been disproportionately hard hit by the disease and economic burden of COVID-19, states can build a new foundation for maternal and infant health in Medicaid and CHIP, and bring us closer to achieving health equity and racial justice for the next generation.
* Editor’s Note: To maintain accuracy, CCF uses the term 'pregnant women' when referencing statute, regulations, research, or other data sources that use the term “pregnant women” to define or count people who are pregnant. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women.