On April 1, 2022, the Centers for Medicare & Medicaid Services (“CMS”) announced states may seek to extend Medicaid postpartum coverage from 60 days to one year through a new state plan option offered by the American Rescue Plan Act (“ARPA”). The new state plan option allows state Medicaid and Children’s Health Insurance Program (“CHIP”) agencies to provide 12 months of continuous postpartum coverage, regardless of any changes in circumstances, through a state plan amendment (“SPA”). This option is available for five years and ends on March 31, 2027.

States that choose to extend postpartum coverage must elect this option in both their Medicaid and CHIP programs. The extended coverage period begins on the final day of pregnancy and lasts through the end of month in which the 12-month postpartum period ends. Individuals are entitled to extended postpartum coverage regardless of the reason the pregnancy ends.

Coverage must be provided to all eligible individuals who were enrolled in Medicaid or CHIP while pregnant. Postpartum coverage extends to current beneficiaries who enrolled in Medicaid or CHIP while pregnant and are within their 12-month postpartum period when their state implements the option, even if they are no longer pregnant. Individuals who were pregnant at some time within the three months prior to applying for Medicaid, and met the eligibility requirements at that time, also qualify for the extended coverage period.

Louisiana was the first state-approved by CMS for the extended coverage period and began offering enhanced coverage to approximately 14,000 pregnant and postpartum women. CMS has announced it is working closely with nine other states to extend postpartum coverage.

Under current federal law, Medicaid beneficiaries are entitled to continuous coverage through the last day of the month in which the 60-day postpartum period ends. At the end of the 60-day period, some postpartum women have continued pathways to coverage. Mothers with incomes up to 138% of the federal poverty level (“FPL”) in states which have expanded Medicaid under the Affordable Care Act (“ACA”) are eligible to remain covered by Medicaid and those with incomes above 138% FPL may be eligible to qualify for subsidized coverage through the ACA marketplace. In states that have not expanded Medicaid, however, many postpartum women lose coverage.

Prior to the option provided by ARPA, states could use a Section 1115 waiver or state funds to extend coverage. Section 1115 waivers, which require CMS approval, provide states with flexibility to design and improve their Medicaid program by implementing state-specific policy approaches that better serve their specific Medicaid populations. Almost three-quarters of states and the District of Columbia have taken actions to extend postpartum Medicaid eligibility, including through approved and pending Section 1115 waivers, legislation which requires the state to seek federal approval through an SPA or Section 1115 waiver, submission and approval of SPAs, and coverage financed only with state funds.^[1] However, states vary in the terms of their postpartum coverage expansion. Some states, such as Georgia and Texas, only provide an additional six months of postpartum coverage. Missouri’s extended postpartum coverage is limited only to women with a substance use disorder.

The COVID-19 pandemic has also affected Medicaid postpartum coverage. The Families First Coronavirus Recovery Act, passed on March 18, 2020, includes increased federal funding for state Medicaid agencies to provide care during the national public health emergency. One condition of the enhanced federal matching funds is the requirement for states to provide continuous coverage for Medicaid enrollees until the end of the month in which the public health emergency ends. Women whose coverage would otherwise have been terminated at the end of the 60-day postpartum period have remained enrolled in Medicaid until the end of the public health emergency. However, the pending expiration of the public health emergency later this month means many new mothers could be left without coverage and care.

The expansion of postpartum coverage is an important opportunity for states and the federal government to improve maternal and postpartum health outcomes as well as address racial healthcare disparities. Approximately 33% of maternal deaths occur more than seven days after delivery and 12% occur more than six weeks after birth.^[2] Black women have a maternal mortality rate 3.3 times that of White women and American Indian or Alaska Native women are 2.5 times more likely to die from pregnancy-related causes than White women.^[3]

While the expansion of postpartum coverage alone does not provide a solution to these issues, it is a step in the right direction. Expansion of postpartum coverage has been demonstrated to increase the use of postpartum outpatient care and stability of postpartum coverage.^[4] Given the significant role Medicaid plays in this area, as it is the largest single-payer of pregnancy-related services and covers 42% of births, this policy represents a critical move towards improving maternal health.^[5]

Arushi Pandya,  a law clerk in the Firm’s Dallas office, authored this article.

ENDNOTES

[1] Kaiser Family Foundation, Medicaid Postpartum Coverage Extension Tracker (Mar. 31, 2022).

[2] Emily E. Peterson, et. al., Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017, 68 Morbidity and Mortality Weekly Report 423–29 (2019).

[3] Madeline Y. Sutton, et. al., Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020, 137 Obstetrics & Gynecology 225 – 233 (Feb. 2021).

[4] Sarah H. Gordon, et. al., Effects of Medicaid Expansion on Postpartum Coverage and Outpatient Utilization, 39 Health Aff. 77-84 (2020).

[5] National Center for Health Statistics, Birth Data (June 14, 2021).