Medicaid for more Moms

Yesterday, Illinois got some good news from the Center for Medicare and Medicaid Services (CMS).  CMS approved a Section 1115 waiver.  Illinois will be allowed to extend eligibility for income qualified mothers who had a live birth covered by Medicaid from the current 60 days post-partum to a full year.

Approval of this demonstration amendment will enable the state to test the effects of providing full Medicaid state plan benefits to postpartum women with incomes up to 208 percent of the federal poverty level (FPL) for 12 months inclusive of the 60-day postpartum period under the state plan. The state will also provide continuous eligibility for a woman during the entire postpartum period, ensuring continuity of coverage. This amendment aims to increase and strengthen overall coverage and improve the health of certain mothers in Illinois, as well as reduce the rate of maternal morbidity and mortality in the state by addressing continuity of care for women postpartum. This approval is effective April 12, 2021 through December 31, 2025, upon which date, unless extended or otherwise amended, all authorities granted to operate this demonstration will expire.

Johnston et al in Health Affairs this month showed that insurance disruptions are still wicked common for women who either are pregnant or had recently been pregnant and who had been covered by Medicaid.

We used data for new mothers with Medicaid-covered prenatal care in 2015–18 from forty-three states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) to describe patterns of perinatal uninsurance and health outcomes of women experiencing uninsurance. We found that 26.8 percent of new mothers with Medicaid-covered prenatal care were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period, with higher perinatal uninsurance rates in nonexpansion states and for Hispanic women who completed the PRAMS survey in Spanish.

We have very strong reason to believe that the 60 day window is a cliff.  Eligibility for Medicaid for post-partum women goes from about 2 times the federal poverty level  (FPL) (varies by state) to other redeterminations.  ACA expansion eligibility is to 138% FPL.  Some states have higher FPLs.  Other states, like North Carolina have much lower qualifying FPLs for an otherwise healthy adult with a child (41% FPL).  There is a huge gap for women who had been covered by Medicaid to attempt to jump over.  Some succeed in either getting redetermined into another flavor of Medicaid or enrolling in an ACA plan, and some fail.  The COVID pandemic has actually reduced insurance loss for post-partum women as the CARES ACT and FFCRA had a maitenance of effort requirement that disallows redeterminations that could lead to coverage loss.

This is a moment of administrative burden when the cognitive budget of a parent of a young child is extraordinarily depleted.  California will soon be attempting to automatically crosswalk women who have been on pregnancy Medicaid for sixty days and who do not qualify for another Medicaid program into the ACA marketplace.  The new ARA subsidies will lower administrative burden of setting up payments.  A BFD in the ARA is an allowance for states to use a state plan amendment to cover women post-partum for a full year at the standard federal financing rate.  That will start next spring.

These types of waivers will be fairly common over the summer.  They will be approved for Blue States.  They will be approved for Red States.  These waivers will meaningful reduce insurance churn and likely improve both maternal and early childhood incomes by reducing familial household stress.