CMS Issues Guidance on New Postpartum Coverage State Option in Medicaid and CHIP

Today CMS released highly anticipated guidance to states implementing the new Medicaid and CHIP state plan option to provide 12 months of extended postpartum coverage to pregnant individuals enrolled in Medicaid beginning April 1, 2022.

Created by the American Rescue Plan Act passed earlier this year, this policy option has been widely embraced by states already: there are 15 states that have so far passed legislation to take up the option when it becomes available in April 2022, and five states have received waiver approval from CMS to begin extended postpartum coverage beyond the current cutoff at 60 days postpartum – although two of these states (GA and MO) are providing more limited coverage.

The guidance was released as part of the Biden administration’s “White House Maternal Health Day of Action” on December 7, which included a White House summit on reducing maternal mortality morbidity and racial disparities in maternal health, an announcement from CMS on the creation of a new “birthing-friendly” hospital quality metric, and the release of a report from the HHS Assistant Secretary for Planning and Evaluation which found that if all states adopted 12 months of postpartum coverage, that 720,000 people per year would have extended postpartum coverage.

We will continue to unpack the guidance in the coming weeks, but below are some highlights. As a reminder, states can take up the extended coverage option at any point, although pending further legislative action the option sunsets on May 31, 2027. The Build Back Better Act currently under consideration in Congress would make 12 months of postpartum coverage permanent and mandatory for all states regardless of whether the state had picked up the option. 

Eligibility: The guidance makes clear that the following groups must be covered for 12 months postpartum:

  • Beneficiaries eligible and enrolled in any Medicaid eligibility category while pregnant;
  • Beneficiaries enrolled in separate CHIP programs as “targeted low income children” while pregnant, and “targeted low-income pregnant women” if a state has elected to take up this option in CHIP

The guidance also clarifies that pregnant people who are covered in the CHIP “unborn child” category, which covers limited prenatal care, may not receive extended coverage under the ARPA option. However, the guidance encourages states interested in coverage for this group to reach out to their CHIP program officer. This is promising, as CMS has recently approved requests from Illinois and California to use CHIP Health Services Initiative funds to extend postpartum coverage for people in this category, so this may signal a new opportunity for states to close coverage gaps for undocumented persons who are primarily those receiving coverage through this option.

The guidance also highlights recently approved Medicaid section 1115 waivers in states to extend postpartum coverage in Medicaid and CHIP and says that states “may choose” to transition this authority to the new SPA option. My colleagues have explored this issue in depth here.

Continuous eligibility for 12 months postpartum: Continuous eligibility for postpartum people ensures that they will receive 12 months of uninterrupted coverage despite any changes in circumstances they experience during this year (i.e. household size, income, age), not just income changes. This is similar to the 12-month continuous eligibility policy option already available for children.

States must ensure that eligible pregnant and postpartum people remain enrolled in Medicaid and CHIP unless they request a voluntary termination, move out of state, the agency determines they were improperly enrolled due to agency error, fraud, abuse or perjury by the individual, or the eligible person dies.

The continuous eligibility requirement protects postpartum beneficiaries from losing coverage even if they become eligible for Medicaid or CHIP through other pathways (like the adult expansion group for example) – an important step that will reduce coverage churn that leaves many postpartum people with coverage during a critical time. The 12 months of postpartum continuous eligibility, “renders any regular renewal scheduled before the end of the 12-month postpartum period unnecessary,” the guidance states. Postpartum people will stay enrolled in the eligibility group they were enrolled in for pregnancy, and renewals must wait until after the individual’s 12 months of postpartum coverage ends. 

Benefits: States must provide the full Medicaid and CHIP benefit package to people covered in the extended postpartum option, as most states already do in their pregnancy coverage programs. However, states that elect the option and do not currently offer full benefits through their pregnancy coverage programs– (Arkansas, New Mexico, North Carolina, and South Dakota) – must submit a SPA to lift this coverage limitation while the option is in effect.

Federal matching rates: Consistent with recent 1115 waiver approvals for extended postpartum coverage in Virginia and New Jersey, CMS is offering states the opportunity to create a “proxy methodology” to receive the enhanced 90% match for postpartum people who would otherwise be eligible for Medicaid expansion because their income is less than 138% FPL. This ensures that states do not lose the enhanced expansion match for these postpartum people which could create a disincentive for states to pick up the new postpartum option. Creating a formula for this funding also avoids requiring any new income or eligibility information from new mothers which would add administrative burdens for both new parents and state agencies. We will unpack this further in future blogs, so stay tuned!

Outreach: The guidance encourages states that have elected the postpartum coverage option to educate beneficiaries and providers about the extended coverage period. States may use Medicaid and CHIP administrative matching funds for beneficiary and provider outreach. CMS also encourages states to update notices to beneficiaries to let them know they are eligible for extended postpartum coverage, and make information accessible to people with limited English proficiency and people with disabilities.

This can be a place where state advocates can leverage federal/state investment to broaden outreach campaigns to reach community-based child-and-family serving providers, including home visitors, doulas, child care centers, WIC and SNAP agencies, and other community partners who serve pregnant and postpartum people and young families.

Leveraging extended postpartum coverage to improve maternal health: The guidance encourages states to think about how adopting the extended postpartum coverage option can be an opportunity to improve the quality of care in Medicaid, and integrate with a child’s coverage as well. CMS highlights opportunities to focus on improving rates of postpartum visits–the national median rate for postpartum visits was 72 percent in 2020– and increasing the number and quality of well-child visits too. It is noted that existing Medicaid authority can be used to cover doula care and home visiting services for postpartum people and their families.

Importantly, CMS also encourages states to measure utilization and quality of care for postpartum people, such as reporting of the Maternity Core Set, and disaggregate quality metrics by race, ethnicity, geography, and other indicators to help identify disparities and take targeted steps to improve maternal health equity. Managed care plans should also play a role.

As states move closer to the April 1, 2022 implementation date for this important new coverage option, CMS has outlined a clear vision of the opportunity that lies ahead to make meaningful improvements in maternal health and reduce racial disparities in maternal health across the country.

Maggie Clark is a Program Director at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.