In a little-noticed but important action, CMS recently notified the Utah Medicaid agency that it should proceed with extending postpartum coverage from 60 days to 12 months under the state plan amendment (SPA) option rather than continuing to pursue its Section 1115 waiver request. At first blush, this seems like a distinction only the most serious Medicaid wonks would care about. CMS has been strongly supportive of state Medicaid programs extending such coverage, and for all the right reasons: extended postpartum coverage is critical to addressing the nation’s maternal mortality crisis. And states have been quick to extend Medicaid postpartum coverage since the option became available.
The short of it is that Utah was trying to use the 1115 waiver process to cover postpartum services for all eligible women, except those whose pregnancy ends with an abortion that is not permitted under Utah law. To its great credit, CMS is not allowing the state to do so. Instead, the CMS letter encourages the state to submit a state plan amendment (SPA) to take up the unrestricted 12-month postpartum option, as its own state law directs it to do if CMS has not approved the waiver request by January 1, 2024.
We and others had commented on the Utah proposal urging CMS to say no and we are glad they did. Since the state plan option was made available by the American Rescue Plan as described below, it has been our view that CMS should not allow states to do less – either by limiting the length of coverage – as Wisconsin is currently proposing to do (Wisconsin has applied to CMS for a section 1115 waiver allowing it to extend postpartum coverage by one month, a proposal that is on its face performative) – or restricting the definition as Utah was proposing. Utah is not the only state where this issue has come up; Texas had a restricted eligibility definition and limited six-month waiver amendment request but this became moot when the legislature passed the full 12-month state plan option.
As a result, we’re putting Utah in the “take-up” column, along with 38 states (including the District of Columbia) that, according to the KFF tracker, have implemented the 12-month postpartum option and eight states that are planning to implement. That leaves just four states—Arkansas, Idaho, Iowa, and Wisconsin—that have not taken up the option.
The option to extend postpartum coverage from 60 days to 12 months became available on April 1, 2022, having been enacted in the American Rescue Plan Act (ARPA) a year earlier. In the year and a half since then, all but four states have implemented or taken up the option. In the annals of Medicaid options, the speed at which so many states have taken up the option is remarkable, and perhaps unprecedented. The uptake is particularly impressive because there is no provision for increased federal matching payments to incentivize states to take up the option. Prior to the option being enacted in 2022, a handful of states, including Georgia and Missouri, had received section 1115 approval to explore extended postpartum coverage for certain groups in the pregnant women eligibility category and in some cases for less than twelve months. However once the state option became available, all of these states moved to provide a full year of postpartum coverage without restrictions on the definition of who is eligible.
By way of comparison, another state option enacted in ARPA, allowing states to cover community-based mobile crisis intervention services, was also available to states starting in April 2022, but was accompanied by an increased federal matching rate of 85 percent for a three-year period. The first state to take up this option was Oregon, approved by CMS in September 2022. A May 2023 KFF survey found that 8 states reported implementing the option in FY 2022, 11 states reported planning to implement it in FY 2023, and 9 in FY 2024. Very respectable (and encouraging), but not nearly as dramatic as the state response to the postpartum option.
Given this overwhelming state consensus on the logic of extending postpartum coverage for a full 12 months—states of all political stripes are on board— the pathway to adoption is clear: submission of a state plan amendment reflecting the option enacted in ARPA and made permanent in the Consolidated Appropriations Act of 2022. By making the option permanent, Congress underscored that the objective of the Medicaid program is coverage of the full 12 months of the postpartum period, for all postpartum women, regardless of how their pregnancy ended. The CMS letter to Utah recognizes what we’ve argued: that the use of section 1115 authority to limit these provisions is inappropriate. Congress has established (and reaffirmed) Medicaid’s postpartum coverage policy. If a state wants to go above and beyond what Congress approved that would be section 1115 territory, offering less is not.