In This Report:
Introduction
Medicaid and CHIP provide coverage for millions of pregnant people to access essential prenatal, birth-related, and postpartum care each year.[1] Policymakers are taking a fresh look at Medicaid and CHIP options to support better maternal health outcomes in response to the nation’s worsening maternal mortality crisis, the 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization allowing states to ban abortion, and the phase out of the federal continuous coverage protection that kept postpartum people – and everyone else covered by Medicaid – enrolled in coverage during the COVID-19 public health emergency.[2]
States can use their significant flexibility to harness the potential of Medicaid to advance maternal health given the program’s unparalleled reach to pregnant people and their families. Medicaid and CHIP finance nearly half of all births each year, including a disproportionate share of births to women of color, women living in rural areas and younger women.[3] An earlier brief detailed the potential for state Medicaid policy levers to drive systemic changes that promote improved maternal health outcomes for enrolled beneficiaries: benefits, quality improvement and greater accountability for maternal health data and outcomes in Medicaid managed care.[4]
This brief highlights state Medicaid and CHIP eligibility options, including income eligibility expansions, extending the duration of postpartum Medicaid coverage to 12 months following the end of pregnancy, and removing immigration-related barriers to health coverage. The evolution of federal minimum eligibility standards and state options has led to a patchwork of available coverage pathways for pregnant individuals. States can leverage these federal coverage options detailed below to broaden access to care during the perinatal period and draw down generous federal matching funds.
1. Expand Medicaid for all low-income adults
Research shows that having stable health coverage before, during and after pregnancy improves both maternal and infant health outcomes throughout their lives.[5] Data from 2021 shows that women age 18-44 living in states that have expanded Medicaid coverage to all low-income adults earning up to 138% of the federal poverty level (FPL), or about $30,000 per year for a family of three, were nearly twice as likely to have coverage as women age 18-44 living in non-expansion states (note that the data only reflects states that had expanded Medicaid as of January 1, 2021). This trend extended across all racial and ethnic groups, the analysis shows.[6]
In addition to stabilizing coverage for women of childbearing age, Medicaid expansion is associated with lower rates of maternal and infant mortality, with the greatest benefits for Black women and infants[7]. Expansion has also been associated with improvements in preconception health and utilization of preventive care, reduction in postpartum hospitalizations, and supporting healthy development of parents and children together.[8]
In March 2023, North Carolina became the 40th state to expand Medicaid to all low-income adults earning up to 138% FPL, with the support of significant federal matching funds.[9]
2. Elect 12-months postpartum coverage option in Medicaid and CHIP
The American Rescue Plan Act of 2021 (ARPA) created a now-permanent Medicaid and CHIP state plan option to lengthen the postpartum coverage period from the required 60-day postpartum period to 12 months after the end of pregnancy.[10] So far, 37 states and Washington D.C. have lengthened the postpartum coverage period to receive federal matching funds for the longer period of coverage.[11] Most states have elected to extend the postpartum coverage period using the ARPA option through a state plan amendment; a small number of states used section 1115 Medicaid waiver authority to extend the postpartum coverage period.[12]
States are lengthening the postpartum coverage period in response to growing evidence of the harms of the 60-day postpartum coverage cutoff and the alarming rates of preventable deaths among new mothers in the year after birth.[13] If all states were to adopt the coverage extension, an estimated 720,000 additional people each year would gain access to a full year of postpartum health coverage who might have otherwise lost coverage just two months after the end of pregnancy.[14] Successfully implementing the option to extend 12 months of postpartum coverage could affect nearly all of the roughly 1.5 million births financed by Medicaid each year.[15]
3. Increase income eligibility for pregnancy coverage in Medicaid and CHIP
States are required to cover any pregnant woman in Medicaid who has a household income up to 138% FPL and meets certain immigration requirements.[16] While most states have increased eligibility beyond the federal minimum, three states—Idaho, Louisiana, and South Dakota—had a Medicaid pregnancy coverage eligibility level at 138% FPL in January 2023.[17] There are also several states with income eligibility limits under the national Medicaid median of 200% FPL, leaving many pregnant women whose incomes are just slightly over the poverty line exposed to medical debt from high out-of-pocket costs during pregnancy, even if they have private insurance.[18]
States can increase Medicaid income eligibility levels for pregnancy-related coverage and continue to receive their Medicaid matching rate for covering additional people. States can also elect to offer coverage to targeted low-income pregnant women in CHIP, as described in detail in the section titled “Targeted low-income pregnant women option”. A state can only use CHIP to cover targeted low-income pregnant women at higher income levels—and receive the enhanced CHIP federal matching rate—once it sets its Medicaid eligibility for pregnant women to at least 185% FPL.[19]
4. Increasing Income Eligibility for Pregnant Women through Medicaid or CHIP Can Minimize Time-Sensitive Barriers to Marketplace Enrollment
State-based health insurance marketplaces offer another avenue to broaden access to perinatal insurance coverage for uninsured pregnant individuals whose incomes are too high to qualify them for Medicaid or CHIP. The birth of a child qualifies for a special enrollment period for the new parents outside of the annual open enrollment period, but the federal marketplace does not recognize pregnancy as a qualifying event for a special enrollment period.[20] In effect, this means that people who are uninsured and become pregnant outside of the federally-facilitated marketplace’s annual open enrollment period must wait until the next open enrollment period, or until after their child is born, to enroll in marketplace coverage. This can leave pregnant people facing significant medical debt for accessing prenatal and birth care.[21]
States that run their own state-based health insurance marketplace have the ability to create a special enrollment period for pregnancy. As of April 2023, Washington, D.C. and eight states (Colorado, Connecticut, Maine, Maryland, New Jersey, New York, Rhode Island and Vermont) had elected to create a special enrollment period for pregnancy in their state-based marketplace.[22]
Unlike in the marketplace, people who become pregnant can enroll in Medicaid or CHIP at any time during the year as long as they meet eligibility criteria set by the state. Absent federal marketplace changes, states that use the federally-facilitated marketplace can increase their income eligibility levels for pregnancy-related Medicaid or CHIP coverage to mitigate time-sensitive marketplace enrollment barriers that undermine access to timely prenatal care.
5. Expand income eligibility through the Children’s Health Insurance Program (CHIP)
States may build on Medicaid pregnancy coverage by using CHIP to extend coverage to uninsured pregnant individuals with slightly higher income levels. This allows states to leverage a higher matching rate for beneficiaries’ services, but unlike Medicaid, a state’s overall CHIP allotment is capped.[23] CHIP allows states two primary pathways to finance services for pregnant women: the “targeted low-income pregnant women” option and the “unborn child” option.
Targeted low-income pregnant women option
The CHIP Reauthorization Act of 2009 created a new option for states to use CHIP to offer full-benefit coverage for the prenatal, birth and postpartum period for targeted low-income pregnant women. This option is only available to states once they have raised their pregnancy Medicaid income eligibility level of at least 185% FPL (see Table 2 for state-specific eligibility levels in Medicaid and CHIP).[24] States may then set CHIP income eligibility limits for pregnancy coverage up to, but not above, the state’s CHIP income eligibility limit for children’s coverage.[25]
As of January 2023, seven states offer CHIP pregnancy coverage to otherwise uninsured targeted low-income pregnant women through this option.[26]
CHIP-funded “unborn child” option
This CHIP pathway allows states to use CHIP to offer pregnancy-related coverage from conception to birth when the mother is not eligible for Medicaid.[27] The so-called “unborn child” option permits states to consider the fetus a “targeted low-income child” for purposes of CHIP coverage, which allows the pregnant person, regardless of their immigration status, to receive coverage for prenatal care and labor and delivery services.[28] As of January 2023, there are 20 states that have elected to cover some segment of pregnant women using this option.[29]
Perinatal Benefit Considerations in CHIP
States can choose to offer a comprehensive benefit package to pregnant people covered in these optional CHIP categories, or limit benefits only to services related to the pregnancy or conditions that may complicate the pregnancy. [30]
The two options vary significantly in addressing the postpartum period. The targeted low-income pregnant women option includes a minimum 60-day postpartum period, and states that elect to extend the postpartum period to 12 months in Medicaid must also extend the coverage duration and offer a full benefit package to pregnant people enrolled in this CHIP option.[31] With the exception of Missouri, all of the states that have elected the targeted low-income pregnant women option in CHIP have also elected to extend 12 months of postpartum coverage in Medicaid.
In contrast, the 12 months postpartum coverage extension option does not apply to people covered in the CHIP “unborn child” category. Coverage under this option ends for the pregnant mother after the birth of the child and does not include postpartum care, unless the postpartum services are included in a payment bundle that includes prenatal, labor and delivery, and postpartum care.[32] States can draw down federal matching funds for some postpartum coverage for this group using a CHIP Health Services Initiative (HSI), which allows states to use a limited amount of CHIP administrative funds to implement programs focused on improving the health of low-income children.[33] See Table 3 for the states that use this financing option.
6. Remove immigration-related barriers to Medicaid and CHIP coverage for pregnancy
Pregnant people who are not citizens may be eligible for full-benefit Medicaid or CHIP if they have a qualified immigration status (e.g., lawful permanent resident, refugee, asylee, etc.). [34] However, under federal law, some of these groups must wait for at least five years before becoming eligible for pregnancy-related coverage, unless their state opts to waive this waiting period. [35]
States can choose to remove the five-year waiting period for lawfully-residing immigrants so that they can become eligible for pregnancy and postpartum coverage in Medicaid and CHIP, even if they’ve had such status for fewer than five years when they become pregnant. [36] States electing this option continue to receive their regular Medicaid and CHIP federal matching funds for covering these populations. A similar option exists for waiving the five-year waiting period for children.
Removing this waiting period for pregnant women ensures better access to prenatal care and supports healthy birth outcomes for mother and child. Recent research suggests that exclusions from Medicaid eligibility based on immigration status may be associated with increased maternal health disparities and reduced access to timely prenatal care for immigrant pregnant women. [37]
As of January 2023, there are 25 states and Washington D.C. that cover lawfully-residing immigrant pregnant women without a five-year waiting period in Medicaid and CHIP, including five states that have also removed the waiting period for pregnant women in CHIP. [38]
For pregnant people without documentation, the “unborn child” option described above is the only way to pull down federal matching funds for pregnancy-related coverage for them, and benefits are limited to prenatal and birth care. Some states use state-only funds to finance low or no-cost care for new mothers without proper documentation. Massachusetts, New Jersey and Vermont use state-only funds to cover prenatal and postpartum care for some pregnant immigrants without documentation. [39]
Conclusion
The U.S. is facing a worsening maternal mortality crisis that disproportionately affects pregnant people of color, and research suggests that the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturning the constitutional protection of access to safe and legal abortions could further exacerbate current racial, economic, and social inequities in maternal and infant health. [40]
Due to its unmatched role in financing nearly half of all births each year, Medicaid has a significant role to play in responding to these challenges. States can expand income eligibility, remove immigration-related restrictions, and ensure as many pregnant women as possible access full benefits as a first step toward improving maternal health outcomes and eliminating racial health inequities.
| Acknowledgements: The author would like to thank Elisabeth Burak, Kelly Whitener, Aubrianna Osorio, Cathy Hope and Hannah Green for their contributions to this brief. |
[1] Editor’s note: To maintain accuracy, Georgetown CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women.
[2] M. Clark and M. Millette, “New Brief: States Focus on Improving Maternal Health Outcomes Amid Worsening Maternal Mortality Crisis,” (Georgetown University Cetner for Children and Families, March 21, 2023), available at https://ccf.georgetown.edu/2023/03/21/new-brief-states-focus-on-improving-maternal-health-outcomes-amid-worsening-maternal-mortality-crisis/.
[3] Medicaid and CHIP Payment and Access Commission, “Medicaid’s Role in Financing Maternity Care,” (January 2020), available at https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf
[4] M. Clark, “State Trends to Leverage Medicaid Extended Postpartum Coverage, Benefits and Payment Policies to Improve Maternal Health,” (Georgetown University Center for Children and Families, March 20, 2023) available at https://ccf.georgetown.edu/2023/03/20/state-trends-to-leverage-medicaid-extended-postpartum-coverage-benefits-and-payment-policies-to-improve-maternal-health/.
[5] M. Clark, E. Bargeron & A. Corcoran, “Medicaid Expansion Narrows Maternal Health Coverage Gaps, But Racial Disparities Persist,” (Georgetown University Center for Children and Families, September 13, 2021), available at https://ccf.georgetown.edu/2021/09/13/medicaid-expansion-narrows-maternal-health-coverage-gaps-but-racial-disparities-persist/.
[6] Research methods note: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2021 American Community Survey (ACS) Public Use Microdata Sample (PUMS). Estimates with coefficients of variation greater than 25 percent are suppressed due to poor reliability. Data reflect a “point-in-time” estimate of a person’s insurance status, and those who indicate that IHS is their only source of coverage are designated as uninsured. CCF uses “women” for consistency with ACS data; the Survey offers male and female sex response options. CCF combines data for “Asian alone” and “Native Hawaiian or other Pacific Islander alone,” as well as combines “some other race alone” and “two or more races.” Except for “Other,” all racial categories refer to respondents who indicated belonging only to one race. CCF uses “Latina” to refer to those who self-identified as Hispanic or Latino and as a woman. Latina and Non-Latina individuals may be of any race.
[7] E. Eliason, “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality,” Women’s Health Issues, 30: 147-152 (2020), available at https://www.sciencedirect.com/science/article/abs/pii/S1049386720300050.
[8] R. Myerson, S. Crawford, & L.R. Wherry, “Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, and Postpartum Contraception,” Health Affairs, 39: 1883-1890 (2020), available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00106.
[9] E. Park & A. Searing, “Fact Sheet: State Fiscal Incentives for Medicaid Expansion Continue After End of Public Health Emergency,” (Georgetown University Center for Children and Families, February 24, 2023), available at https://ccf.georgetown.edu/2023/02/24/fact-sheet-state-fiscal-incentives-for-medicaid-expansion-continue-after-end-of-public-health-emergency/.
[10] M. Clark, “Permanent Medicaid Postpartum Coverage Option, Maternal Health Infrastructure Investments in 2022 Year-End Omnibus Bill,” (Georgetown University Center for Children and Families, January 2, 2023), available at https://ccf.georgetown.edu/2023/01/04/permanent-medicaid-postpartum-coverage-option-maternal-health-infrastructure-investments-in-2022-year-end-omnibus-bill/.
[11] Kaiser Family Foundation, “Medicaid Postpartum Coverage Extension Tracker,” (April 18, 2023), available at https://www.kff.org/medicaid/issuebrief/medicaid-postpartum-coverage-extension-tracker/.
[12] M. Clark & E. Burak, “Opportunities to Support Maternal and Child Health Through Medicaid’s New Postpartum Coverage Extension,” (Georgetown University Center for Children and Families, July 15, 2022), available at
[13] J. Beauregard, et al., “Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019” (Centers for Disease Control and Prevention, September 2022), available at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html#table3
[14] S. Gordon, et. al. “Medicaid After Pregnancy: State-Level Implications of Extending Postpartum Coverage (2023 Update).” (Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, April 2023). Available at: https://aspe.hhs.gov/reports/extendingmedicaid-postpartum-coverage-2023-updatehttps://aspe.hhs.gov/reports/extending-medicaid-postpartum-coverage-2023-update
[15] Kaiser Family Foundation, “State Health Facts: Births Financed By Medicaid, 2020,” available at https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[16] States are required to cover any income-eligible citizen or refugee/ asylee pregnant woman with incomes at or below 138 percent FPL in Medicaid. Women with other immigration statuses can receive Medicaid and CHIP benefits at state option or have their labor and delivery services covered by emergency Medicaid. See also “Noncitizens,” Medicaid and CHIP Payment and Access Commission, available at https://www.macpac.gov/subtopic/noncitizens/ (accessed January 26, 2023).
[17] T. Brooks, et. al., “Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision,” (Georgetown University Center for Children and Families and the Kaiser Family Foundation, April 4, 2023) available at https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-renewal-policies-as-states-prepare-for-the-unwinding-of-the-pandemic-era-continuous-enrollment-provision/
[18] Medicaid can provide a secondary source of coverage for pregnancy in some circumstances.; J. Peterson, et. al. “Catastrophic Health Expenditures With Pregnancy and Delivery in the United States.” Obstetrics and gynecology, 2022, 139(4), 509–520, available at https://pubmed.ncbi.nlm.nih.gov/35271537/
[19] Center for Medicare & Medicaid Services, State Health Official Letter #09-006 (May 11, 2009), available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho051109.pdf.
[20] “Special enrollment opportunities,” HealthCare.gov, available at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/.
[21] Op. cit. (18)
[22] Links to all the SEP states: Colorado HB1289; Access Health CT Special Enrollment Period; DC special enrollment period criteria; Maine special enrollment period criteria; Maryland Special Enrollment; New Jersey Special Enrollment Period (SEP) Overview; New York Special Enrollment Periods; Rhode Island press release on passage of legislation to create pregnancy SEP; Vermont Qualifying Events Chart 2022
[23] J. Alker & A. Dwyer, “ Next Steps for the Children’s Health Insurance Program,” (Georgetown University Center for Children and Families, August 2021), available at https://ccf.georgetown.edu/wp-content/uploads/2021/08/CHIP-Next-Steps_fix_10-8.pdf.
[24] Op. cit. (19)
[25] Op. cit. (19)
[26] Op. cit. (17)
[27] 42 C.F.R. § 457.10 (2019)
[28] P. Boozang, et. al., Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: CHIP Coverage Option for Pregnant Immigrants and their Children,” (Manatt Health and State Health and Value Strategies, January 2022), available at “https://www.shvs.org/resource/supporting-health-equity-and-affordable-health-coverage-for-immigrant-populations-chip-coverage-option-for-pregnant-immigrants-and-their-children/.
[29] Op. cit. (17)
[30] 42 C.F.R § 440.210 (2021)
[31] Centers for Medicaid and CHIP Services, “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP),” (December, 7, 2021), available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf
[32] Centers for Medicare & Medicaid Services, State Health Official Letter #020-004 (November 12, 2002), available at https://healthlaw. org/wp-content/uploads/2018/09/cms_release_on_prenatal_care_for_ fetuses.pdf
[33] M. Clark, “ CMS Issues Guidance on New Postpartum Coverage State Option in Medicaid and CHIP,” (Georgetown University Center for Children and Families, December 7, 2021), available at https://ccf.georgetown.edu/2021/12/07/cms-issues-guidance-on-new-postpartum-coverage-state-option-in-medicaid-and-chip/.
[34] “Noncitizens,” Medicaid and CHIP Payment and Access Commission, available at https://www.macpac.gov/subtopic/noncitizens/
[35] Known as the Immigrant Children’s Health Improvement Act (ICHIA) option, this is the same pathway used to remove the five year bar for immigrant children’s eligibility for Medicaid and CHIP. See Georgetown Center for Children and Families, “Health Coverage for Lawfully Residing Children,” (May 2018), available at https://ccf.georgetown.edu/wp-content/uploads/2018/05/ichia_fact_sheet.pdf
[36] “Medicaid and CHIP Coverage of Lawfully Residing Children & Pregnant Women” Centers for Medicare and Medicaid, available at https://www.medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip-coverage-lawfully-residing-children-pregnant-women.
[37] T. Janevic, et. al. Analysis of State Medicaid Expansion and Access to Timely Prenatal Care Among Women Who Were Immigrant vs US Born. JAMA Netw Open. 2022;5(10):e2239264, available at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797905?resultClick=3
[38] Op. cit. (17)
[39] Op. cit. (17)
[40] C. Daniel, et al., “State Abortion Policies and Maternal Death in the United States, 2015-2018” (National Institutes of Health, August 2019), available at https://pubmed.ncbi.nlm.nih.gov/34410825/; M. Aswani et al., “Racial/Ethnic and Educational Inequities in Restrictive Abortion Policy Variation and Adverse Birth Outcomes in the United States” (BMC Health Services Research, October 2021), available at https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-07165-x
