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States Act on Postpartum Medicaid Coverage

By Kate Bradford, Khanh Nguyen and Emily Blanford  |  March 29, 2022

High—and rising—rates of preventable maternal mortality and pregnancy-related complications have caught the attention of state and federal policymakers. Now many states are taking steps to leverage available pathways—including a new federal option—to extend Medicaid coverage and improve care for mothers during the crucial postpartum period.

As the largest single payer of pregnancy-related services, Medicaid plays an important role in maternity care.

The Importance of Postpartum Care

Pregnancy-related deaths in the United States have increased over the last several decades alongside persistent and stark racial disparities. “Maternal health in the United States lags behind other nations in terms of quality, and communities of color experience higher risk of poor outcomes due to structural inequities,” says Colorado Sen. Janet Buckner (D).

About 1 in 3 pregnancy-related deaths occurs within one year after childbirth, and another 50,000 women experience pregnancy complications that can have serious implications for lifelong health.

Still, most pregnancy-related deaths are preventable. Experts point to the “fourth trimester” following birth as an essential time for early recognition and management of potential complications before they may become more difficult and costly to treat. “Cutting off care 42 days after delivery does not provide time to adequately treat issues such as heart disease or complications of diabetes that may present due to the stress of pregnancy and delivery,” Georgia Rep. Sharon Cooper (R) says.

Medicaid’s Role

Medicaid is the single largest payer of maternity care in the United States, financing about 42% of all births and a greater proportion of births among populations with higher rates of pregnancy complications. Federal law requires state Medicaid programs to cover pregnant individuals with incomes at or below 133% of the federal poverty level, plus a mandatory income disregard of 5%, making the minimum eligibility level effectively 138%. Some states chose to provide coverage at 185% and are required to maintain that level. Other states that cover pregnant individuals in their Children’s Health Insurance Program are also required to provide Medicaid pregnancy eligibility up to 185% of the federal poverty level.

This Medicaid coverage pathway for pregnant individuals is required to continue through 60 days postpartum. After that, individuals who are not eligible to remain covered under their state’s Medicaid eligibility requirement for parents or low-income adults must obtain coverage from another source.

New Federal Option

The American Rescue Plan Act of 2021 provided a new option for states to extend Medicaid coverage up to one year postpartum through a state plan amendment. This policy will take effect April 1 and is available for the next five years.

The Centers for Medicare and Medicaid Services provides guidance for implementing this option. To participate, among other components, states must:

  • Submit a state plan amendment through the centers’ portal.
  • Provide continuous coverage through the end of a 12-month period following delivery.
  • Provide full Medicaid benefits to pregnant and postpartum individuals.

Pending federal legislation would further extend coverage. The Build Back Better Act, which the House of Representatives passed in November 2021, includes a provision that would permanently require all states to extend continuous Medicaid coverage for one year postpartum.

Extending Postpartum Medicaid Coverage

At least 25 states and the District of Columbia have taken steps to extend postpartum coverage. Most states initiated the process through legislation, requiring their Medicaid agencies to seek federal approval, or by setting aside parts of their state budgets for extended coverage, as in Virginia and Tennessee.

Before the new, streamlined ARPA pathway, several states leveraged 1115 Medicaid waivers. As of March 2022, CMS had approved postpartum coverage extensions in 1115 waivers for five states. Illinois was the first state to receive federal approval in early 2021, followed shortly by Georgia, which requested coverage through six months postpartum.

As the lead sponsor of the Georgia bill, Cooper says the state is “working hard to reduce maternal mortality and to prevent infant deaths. This extension of coverage is one essential part of that strategy.”

A new bill currently moving through the Georgia General Assembly would extend the six months of coverage previously approved to 12 months.

During the 2021 sessions, ColoradoOhio and West Virginia were among the latest states to enact laws initiating the 1115 waiver process or state plan amendment submission preparation.

After the passage of ARPA, some states also adjusted their plans to take advantage of the new state plan option. For example, Indiana’s Medicaid director withdrew the state’s pending 1115 application, planning instead to move forward with the new option in April 2022. Pennsylvania also recently announced its intent to pursue the ARPA option.

States seeking to extend postpartum Medicaid for a narrower set of benefits or for fewer than 12 months may continue to use the 1115 waiver process.

medicaid postpartum coverage map

Source: Medicaid Postpartum Extension Tracker (KFF March 2022)

The federal government estimates that extending Medicaid coverage to one year postpartum for all beneficiaries may affect 720,000 additional individuals each year, particularly among groups with higher rates of pregnancy-related complications.

The Congressional Budget Office estimates the additional 10 months of coverage to average about $1,500 per person, per year in combined federal and state dollars. Potential savings from averted medical conditions and more efficient administrative action might offset some of the cost.

As states look for ways to support families and combat disparities in maternal health outcomes, Medicaid offers one potential point of intervention. It’s up to states to decide which pathway is best for them. The Centers for Medicare and Medicaid Services offers guidance and technical assistance for states, as do state Medicaid agencies.

“We hope to see more people accessing more services postpartum and getting the care they need, whether that be support for a postpartum mood disorder, physical therapy, lactation support or any number of things,” says Buckner, who co-sponsored the Colorado bill. “We hope this will support the long-term health and wellness of the whole family.”

Kate Bradford is a former NCSL staffer. Khanh Nguyen and Emily Blanford track health issues for NCSL.

This resource is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31659 totaling $400,000. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. government.

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