Medicaid Coverage for Pregnant Women

Current Medicaid Access and Barriers

Women of reproductive age and pregnant women often rely on Medicaid to access health services ranging from prenatal to postpartum care. Only pregnant women with extremely low incomes—approximately $9,000 annually for a 4-person household—can access Medicaid with all of its benefits. This “full” Medicaid coverage has the strictest qualifications of any form of Medicaid coverage in the state, limiting eligibility by income, family size, additional resource availability, citizenship status, and residency. If a woman's finances improve, coverage can and often is revoked through the process of redetermination.

North Carolina also offers Medicaid for Pregnant Women (MPW), a full-coverage program with benefits limited solely to pregnancy-related care. Although key decision-makers in North Carolina decide which specific services to cover under MPW, federal statute requires coverage of “prenatal care, delivery, postpartum care, and family planning, as well as services for conditions that may threaten carrying the fetus to full term or the fetus' safe delivery” [4]. MPW allows more access to Medicaid, as women enrolled in the program can have annual incomes up to 196% of the federal poverty guidelines ($50,472 for a family of 4) (see Table 1) [5, 6]. The benefits of broader access are limited by the pregnancy-dependent coverage of the MPW program; services become available with positive proof of conception and income eligibility, but they end just 60 days postpartum. Unlike traditional Medicaid coverage, women enrolled in MPW benefit from consistency of care regardless of any changes to their income within their period of enrollment. That time period is so limited, however, that those struggling with postpartum health conditions or chronic ailments quickly lose access to health coverage after giving birth, regardless of the potential impact on their ability to properly care for their newborn or themselves.

Pregnancy coverage options are especially limited for North Carolina's undocumented immigrant women, who are often low-income but do not qualify for either full Medicaid coverage or MPW. Many of these women must seek care at free clinics or Federally Qualified Health Centers. Understandably, this creates barriers to pre- and post-natal care. The Emergency Medicaid program covers the cost of births for undocumented immigrants, but program benefits do not extend to prenatal coverage or postpartum health care. Claims data for these services point to a significant level of unmet need. Nearly all of North Carolina's Emergency Medicaid claims are to undocumented immigrants, and 4 in every 5 claims paid by the program are for obstetric diagnoses [7].

North Carolina's Medicaid program is undergoing significant changes, further complicating the landscape of options for pregnant women in the state. The North Carolina Medicaid program has begun the implementation phase of transformation from mostly fee-for-service to mostly managed care. Although the various Medicaid coverage eligibility criteria are not changing, pregnant women will soon have a new Medicaid system to navigate in North Carolina. Certain maternity-related services and even care management programs for high-risk pregnant women are still being prioritized, but the North Carolina Department of Health and Human services has noted that there will be a transition period for the services and programs [8]. While the initial phases of transformation take place, it is likely that many women who rely on Medicaid and MPW could be confused about how to navigate the new system or access the vital services they need before, during, and after their pregnancies.

Policy Options

Considering the importance of health coverage before and after a woman becomes pregnant, North Carolina has the opportunity to develop many policy options to ensure women of reproductive age gain access to high-quality and affordable health coverage. The Affordable Care Act (ACA) is one federal policy that has allowed many more women to gain not only coverage, but also important health services. The ACA requires a minimum Alternative Benefit Plan (ABP) in states that receive federal funding under the policy to expand Medicaid eligibility. The ABP includes 10 essential health benefits that states must provide to Medicaid beneficiaries at no cost to the patient. These benefits include several preventive and maternity care services that North Carolina is currently not required to provide or to continue providing through either MPW or the full Medicaid program (see Table 2) [9].

North Carolina is one of 14 states that has not adopted one key provision of the ACA—Medicaid expansion. Given the restrictive income eligibility for adults and the limited MPW services and duration, extending Medicaid coverage to childless adults would help ensure that women of reproductive age have ongoing health coverage [10]. As Medicaid expansion covers adults up to 138% of the federal poverty guidelines, women with incomes between 139% and 196% would still rely on MPW until those benefits end. Afterward, they would rely on private coverage subsidized by the ACA's premium tax credits for households with incomes between 100% and 400% of the federal poverty guidelines.

States that have expanded Medicaid access report improvement in infant mortality and maternal mortality as well as progress in reducing racial and ethnic disparities in these outcomes. A 2018 analysis published in the American Journal of Public Health found that infant mortality had the greatest decline in states that expanded Medicaid access under the ACA [11]. In fact, expansion states experienced a 50% higher reduction in their infant mortality rates than non-expansion states [11]. The decline in the study was greatest among Black (non-Hispanic) infants, a population currently dying at nearly twice the statewide rate in North Carolina [12]. Medicaid expansion also addresses the uninsured rate; in 2017 North Carolina's uninsured rate for women of reproductive age was 15.7%. For the 37 states (and Washington, DC) that have implemented Medicaid expansion, the average uninsured rate is 9% [10].

Unfortunately, Medicaid expansion has become quite a political issue, and continued debate within the North Carolina legislature may further delay adoption of the policy. A second policy option is to extend MPW for 1 year or at least through the so-called fourth trimester, covering the 12-week transition period after childbirth [13]. This would ensure new moms continue to receive the critical health care they need to promote their health and, by extension, the health of their child(ren). Currently, one-third of mothers with Medicaid-financed births in North Carolina do not have a postpartum care visit within 8 weeks of delivery [14]. Mothers often face unique health challenges during this period that can be best managed with the assistance of health professionals, including: perinatal depression; difficulty feeding or appropriately caring for an infant; a lack of information about contraception, birth spacing and sexuality; sleep and fatigue concerns; and complications with physical recovery from childbirth.

Extending MPW coverage through the fourth trimester, which is an additional 30 days, would help to balance the frequency and coordination of prenatal care with that available to mothers after delivery. Extending MPW to 12 months postpartum would be an even better option to improve health outcomes for mothers and children.

North Carolina must also consider how federal policies and regulations impact access to health coverage and services. In August 2019, the federal government sent notification of substantial changes to the Public Charge Rule, which would affect how adults, families, and children access services and benefits. For the first time, participation in key health programs like Medicaid would be viewed negatively in a test of circumstances determining whether immigrants seeking lawful permanent residency are likely to become a “public charge” and could therefore be denied [15]. Implementation of this test was stalled by federal litigation in October 2019, but the potential chilling effect on benefits use and application within immigrant communities is significant. Immigrant mothers concerned about maintaining their lawful immigration status may now be afraid to claim public benefits to which they are entitled. It is critical to note that pregnant women and children under age 21 were excluded from proposed changes to the Public Charge Rule and should continue to seek Medicaid coverage to meet their basic health needs regardless of implementation. Given the potential legal complications and confusion individuals and families are experiencing with the Public Charge Rule changes, the North Carolina Department of Health and Human Services should consider increased outreach and education. This would ensure that pregnant women—no matter their immigration status—remain enrolled in Medicaid and MPW to increase their likelihood of experiencing a healthy pregnancy and positive outcomes for their children.