Editor’s Note: Support for this article was provided by the State Health and Value Strategies Program, a grantee of the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Introduction
The American Rescue Plan Act of 2021 (ARP) establishes a new state option to extend Medicaid and Children’s Health Insurance Program (CHIP) coverage for pregnant women for one year following the baby’s birth.1 Under current law, Medicaid and CHIP pregnant women’s coverage extends only through 60 days postpartum. A woman loses her Medicaid or CHIP coverage at the end of her 60-day postpartum period if she is not eligible for coverage under another Medicaid eligibility category (e.g., the new adult or parent group). ARP’s new state option to extend continuous coverage for one year postpartum enables states to take a major step toward improving health outcomes for postpartum women and their babies by mitigating coverage loss, providing comprehensive coverage in the postpartum period to address maternal mortality and morbidity, and advancing health equity.
There is considerable evidence supporting the policy decision to extend postpartum coverage; about 12 percent of pregnancy-related deaths occur between six weeks and one year postpartum.2 Despite approximately 60 percent of all maternal deaths in the United States being preventable, an estimated 700 women die each year as a result of pregnancy or delivery complications, and women of color are disproportionately affected.3 Black women in 2018, for example, were about 2.5 times more likely to suffer a pregnancy-related death than white women.4
Policy and Operational Considerations for States
Eligible Populations. Under this new option, states may extend postpartum coverage to 12 months for individuals who are currently enrolled in a Medicaid or CHIP pregnant women eligibility group. If a state elects to apply 12 months of postpartum coverage to the Medicaid pregnant women eligibility group, the state must also extend that option to its CHIP pregnant women eligibility group.5 The postpartum extension option is also available to states that cover “lawfully residing” pregnant women who otherwise would not be eligible during their five-year waiting period under Section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA).6 While the Centers for Medicare & Medicaid Services (CMS) guidance on eligible populations is still pending, ARP also appears to extend postpartum coverage to individuals who have been previously enrolled in Medicaid or CHIP. For example, an uninsured woman who is four months postpartum could apply for and be enrolled through the end of her 12 months postpartum period if she previously had Medicaid or CHIP coverage. The extension of postpartum coverage under ARP does not appear to apply to undocumented individuals who receive services under the CHIP “unborn child option,” which provides pregnancy-related services (and, at the option of the state, postpartum care if services are included in a payment bundle arrangement) to pregnant individuals, regardless of immigration status.7, 8, 9 It is also unlikely that the postpartum coverage extension would apply to emergency Medicaid, as this coverage is limited to “emergency labor and delivery” and other emergency services.10
Covered Benefits. States that extend postpartum coverage must provide comprehensive Medicaid State Plan benefits throughout the 12-month postpartum period.
Postpartum Coverage Timelines. The visual below provides an illustrative example of the differences in coverage timelines for a pregnant woman if a state takes up the option to extend postpartum coverage to 12 months.
Financing. States will receive their regular matching rate for the postpartum coverage extension; ARP does not provide states with an enhanced matching rate for the postpartum coverage extension, as was recently recommended by the Medicaid and CHIP Payment and Access Commission (MACPAC).11 In the meantime, states can work with their legislatures to ensure adequate state dollars are appropriated to access the federal match when they implement the state option.
State Plan Amendment (SPA). To take advantage of the new state option, states will need to submit a SPA, and will likely need to submit separate SPAs to reflect the postpartum coverage extension for their Medicaid and CHIP pregnant women eligibility groups. It is possible, and states may consider advocating, for CMS to release a template to facilitate a streamlined, single SPA process, as it has done for some emergency authorities throughout the COVID-19 pandemic.
Effective Date. Provisions to extend Medicaid and CHIP coverage postpartum are set to take effect on April 1, 2022, and will remain in effect for five years thereafter.12, 13
Section 1115 Postpartum Coverage Extension Considerations
Prior to ARP providing the state option to extend postpartum coverage, several states had pursued this authority through Section 1115 demonstration requests. Under the previous administration, CMS was reluctant to approve broad postpartum coverage extensions. In South Carolina, CMS approved a partial coverage expansion for postpartum women requiring substance use disorder (SUD) or mental health treatment—falling well short of the state’s original request. The Biden administration, however, is already moving to approve Section 1115 demonstration proposals to expand postpartum coverage. On April 12, 2021, CMS approved Illinois’s demonstration that provides 12 months postpartum continuous coverage for: (1) individuals enrolled in the Medicaid pregnant women group whose 60-day postpartum period is ending and (2) individuals enrolled in any Medicaid eligibility group (other than the pregnant women group) whose 60-day postpartum period is ending, with income up to 208 percent of the federal poverty level (FPL).
Shortly thereafter, on April 16, 2021, CMS approved Georgia’s six month postpartum extension and Missouri’s request to provide targeted SUD and mental health benefits for 12 months to certain postpartum women.
Three other states—Indiana, New Jersey and Virginia—have pending postpartum extension waiver requests at CMS, and Massachusetts just finished its state public comment period for its postpartum extension request before submitting the waiver amendment request to CMS. While Indiana and New Jersey submitted their postpartum extension requests to CMS before ARP’s passage, Virginia and Massachusetts forged ahead with their postpartum expansion waiver requests after ARP’s passage, and other states will likely follow suit for a number of reasons.
First, states may be required to submit an 1115 waiver consistent with state statutory requirements (as is the case in Virginia).14 Many states are also eager to address the maternal mortality and morbidity crisis and are seeking to implement the postpartum coverage extension sooner than April 2022. States may pursue 1115 waiver authority to go above and beyond the SPA option, such as seeking a longer postpartum period or extending the postpartum period for populations not otherwise eligible under the SPA option (e.g., individuals who apply for coverage past the 60 days postpartum period who were not previously enrolled in Medicaid or CHIP).
Looking Ahead
CMS has acknowledged that it will need to issue clarification and additional detail on the ARP state option to extend postpartum coverage, but it does not plan to release such guidance in the near term, given the April 2022 effective date of the provisions.15 While states await further direction from CMS, they can proactively begin their policy and financing planning for their postpartum coverage extensions, which will enable them to take full advantage of the state option once it becomes available.
1 American Rescue Plan Act of 2021, H.R.1319, § 9812 and § 9822.
2 Centers for Disease Control and Prevention (CDC), Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017.
3 CDC, Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017.
4 CDC, 2018 Maternal Mortality Statistics Highlight Wide Racial and Ethnic Gaps.
5 CMS, Tuesday, April 13, 2021, All State Call.
6 CMS, State Health Officer (SHO) Letter #10-006 & CHIPRA #17.
7 42 CFR 457.10.
8 CMS, SHO Letter #09-010.
9 Because eligibility is tied to the “unborn child” that the mother is carrying, the ARP postpartum coverage extension (for targeted low-income children who are pregnant or targeted low-income pregnant women) would likely not apply.
10 Social Security Act, § 1903(v)(3).
11 MACPAC, Advancing Maternal and Infant Health by Extending the Postpartum Coverage Period.
12 American Rescue Plan Act of 2021, H.R.1319, § 9812 and § 9822.
13 The statutory effective date is the first day of the quarter beginning one year after the bill’s enactment.
14 2020 Special Session I Virginia Acts of Assembly, Chapter 56.
15 CMS, Tuesday, March 16, 2021 All State Call.