Ensuring comprehensive health care coverage to one year postpartum for all birthing people in the U.S. is one among many policy proposals that are part of ongoing national dialogues around improving maternal health and eliminating inequities in maternal health outcomes. One particularly busy policy space over the last few years has been proposals by federal and state lawmakers and advocates to extend postpartum Medicaid coverage beyond the historical federal cut-off of 60 days from the end of pregnancy. To help make sense of all that activity, this blog post will:
- Give you an overview of where things stand on federal and state proposals to extend postpartum Medicaid coverage;
- Point you to resources and tools to dig deeper and stay up-to-date; and
- Discuss what to keep an eye on in the coming months on the postpartum Medicaid extension front.
But first, why does this policy approach matter? I suggest the following resources for a run-down on why postpartum Medicaid extension is an important policy approach among many for improving maternal health and eliminating racial and ethnic disparities in maternal health outcomes:
- Ranji, U., Gomez, I., & Salganicoff, A. (2021, March 9). Expanding postpartum Medicaid coverage. Kaiser Family Foundation.
- Taylor, J. (2020, November 16). Promoting better maternal health outcomes by closing the Medicaid postpartum coverage gap. The Century Foundation.
- American College of Obstetricians & Gynecologists, Association of Maternal & Child Health Programs, March of Dimes, & Society for Maternal-Fetal Medicine (2020). Making the case for extending Medicaid coverage beyond 60 days postpartum: A toolkit for state advocates[White paper].
The Latest Federal and State Activity to Extend Postpartum Medicaid Coverage
1. The American Rescue Plan Act Added a New State Option to Extend Postpartum Medicaid Coverage
In March 2021, Congress passed and President Biden signed into law the American Rescue Plan Act (H.R.1319), which included two sections (Sections 9812 & 9822) to support state efforts to extend postpartum Medicaid and Children’s Health Insurance Program (CHIP) coverage. Specifically, the bill created a new option under Medicaid that allows a state to apply for a State Plan Amendment (SPA) to their Medicaid program to extend the postpartum coverage period under Medicaid and CHIP from 60 days to 12 months from the end of pregnancy.
For an in-depth summary of the American Rescue Plan Act state option provisions, see “Postpartum coverage extension in the American Rescue by Plan Act of 2021” (2021) by Usha Ranji, Alina Salganicoff, and Ivette Gomez from the Kaiser Family Foundation.
2. States Are Already Taking Action to Pursue the New Medicaid State Option
The new state option to extend postpartum Medicaid coverage becomes available to states on April 1, 2022. Several state legislatures have already allocated the state funding needed to implement the new coverage provision and directed their state Medicaid agency to apply for the new state option. For the latest information on which states plan to pursue the state option, see “Where states stand on postpartum Medicaid coverage” (2021) by Maggie Clark and Ema Bargeron from the Georgetown University Health Policy Institute Center for Children and Families.
For more information on what states and the Centers for Medicare and Medicaid Services (CMS) can be doing right now to prepare for implementation of the new state option, see “Implementing American Rescue Plan’s 12-month postpartum Medicaid coverage: Federal and state actions” (2021) by Elisabeth Wright Burak and Maggie Clark from the Georgetown University Health Policy Institute Center for Children and Families.
Keep an eye out for forthcoming guidance from CMS to states on the new state plan amendment option. The American College of Obstetricians & Gynecologists recently reiterated its request for CMS to issue such guidance in a timely manner to assist states in implementing the American Rescue Plan Act provisions.
3. States May Still Pursue Other Pathways to Extend Postpartum Medicaid Coverage
Prior to the passage of the American Rescue Plan Act, which gave states the option to extend postpartum Medicaid coverage by applying for a State Plan Amendment, many states opted to pursue this policy goal through other means: section 1115 waivers and state-only funds.
Section 1115 waivers allow states to carry out demonstration projects that promote the objectives of the Medicaid program. Several states have applied for section 1115 waivers to extend postpartum Medicaid coverage. CMS approved the first such waiver in April 2021 for Illinois. Subsequently, CMS approved waivers for Georgia and Missouri to extend postpartum Medicaid; these demonstration projects provide more limited coverage than the Illinois project.
States also have the option to pay for the coverage extension with state-only dollars. In this case, a state does not use federal dollars, and therefore, the state does not need federal approval through either a section 1115 waiver or a SPA. With clear pathways now for states to receive federal matching funds for extending postpartum Medicaid coverage, it seems unlikely that states will continue to pursue state-only funding approaches.
4. Why Would a State Pursue a SPA vs. a Waiver vs. State-only Funds?
Joan Alker with Georgetown University’s Center for Children and Families breaks down the question of why a state might pursue a waiver vs. a SPA in her June 2021 blog, “Advancing Postpartum Coverage in Medicaid: Waiver or SPA?” Spoiler alert: she ultimately favors a SPA.
Table 1. compares aspects of all three pathways for states to extend postpartum Medicaid coverage: State Plan Amendment, section 1115 waiver, and state-only funds.
Table 1. Comparison of Key Aspects of Pathways for States to Extend Postpartum Medicaid Coverage
|State Plan Amendment||Section 1115 Waiver||State-Only Funds|
|Process for approval||Streamlined federal approval process||Slower, more cumbersome federal approval process||No federal approval process|
|Coverage requirements||Strong federal requirements for coverage population and benefits||Flexibility in coverage population and benefits||Maximum flexibility in coverage population and benefits|
|Federal funding||Standard federal matching rate for Medicaid funding||Standard federal matching rate for Medicaid funding||No federal matching funds|
|Budget neutrality||No requirement for “budget neutrality”||Requires “budget neutrality”||No requirement for “budget neutrality”|
|Timeframe||Becomes available April 1, 2022||Available now with CMS approval||Available now|
5. How to Stay Up-to-Date on All State Activity to Extend Postpartum Medicaid Coverage
At least three national organizations currently track all state activity to extend postpartum Medicaid coverage, including legislative and administrative actions via all three pathways: 1. Section 1115 waiver; 2. State Plan Amendment (SPA); and 3. State-only funds. Identify your favorite of the following trackers and bookmark it in your internet browser:
- Kaiser Family Foundation tracker;
- American College of Obstetricians & Gynecologists tracker; and
- National Academy for State Health Policy tracker.
You can also access the section 1115 waivers directly from CMS.
6. On the Horizon for Postpartum Medicaid Extension: More Congressional Action?
In addition to continued state activity, we could see Congress pass additional federal legislation in the future – and as early as this year – to strengthen the postpartum Medicaid extension provisions included in the American Rescue Plan Act. There are five bills pending before Congress that would build on the new Medicaid state option by pursuing one or more of the following policy changes:
- Making the state option permanent. (It currently expires after 5 years);
- Providing additional federal funding (an enhanced Federal Medical Assistance Percentage or “FMAP”) to states for the coverage extension; and
- Requiring states to provide coverage to 12 months postpartum.
To view the details of each of the federal bills related to postpartum Medicaid coverage extensions, visit the Maternal Health Bill Tracker published and updated weekly by the Association of Maternal & Child Health Programs and select “Medicaid/CHIP postpartum coverage extension” from the “Topics” drop-down menu.
The most likely vehicle for Congress to pass additional postpartum Medicaid extension provisions this year is as part of the budget reconciliation process. Budget reconciliation is the mechanism that Democrats in Congress will use this fall to try to pass President Biden’s American Families Plan, which includes a proposal to invest $3 billion in improving maternal health.
The budget reconciliation instructions for the Senate Finance Committee, which holds jurisdiction in the Senate for Medicaid policy, includes a direction to invest in “health equity (maternal, behavioral, and racial justice health investments).” We will likely see some version of postpartum Medicaid extension policy included here among other provisions related to maternal health. Members of Congress and advocates are pushing congressional leadership to pass a robust postpartum Medicaid extension policy in addition to the Black Maternal Health Momnibus Act as part of the reconciliation legislative package.
If postpartum Medicaid extension policy makes it into budget reconciliation, it stands a good chance of passing Congress and being signed into law this year. That’s because reconciliation bills need only a simple majority to pass and Democrats have effective majorities in both the House and Senate.
Stay tuned for a busy Fall 2021 of federal and state activity to extend postpartum Medicaid coverage.