High rates of preventable maternal mortality and morbidity and wide racial and ethnic disparities have caught the attention of clinicians, public health practitioners, advocates, and policymakers.¹  In the closing days of the Trump Administration, HHS released an action plan to improve maternal health, and President-elect Biden has cited this topic as a key health care issue. Vice President-elect Harris has been an advocate in the Senate for improving maternal health, particularly stemming the disproportionately high rates of maternal mortality and morbidity among Black women, and may continue to champion this work at the Executive Branch. During the 2019-2020 Congressional session, more than a dozen bills across political lines related to maternal health outcomes, care, and coverage were introduced, and many could be re-introduced when the new Congress is seated. Several federal and state efforts aim to address the postpartum period, the time shortly after the birth of an infant, an important but often neglected element of maternity care. Birthing parents may be dealing with a host of medical conditions, such as complications from childbirth, pain, depression or anxiety, all while caring for a newborn. It can be a medically vulnerable period and many cases of maternal mortality occur in the postpartum period.

While Medicaid pays for more than four in ten births and must cover pregnant women through 60 days postpartum, after that period states can and have made very different choices regarding whether eligibility for Medicaid coverage is continued. In states that have not expanded Medicaid under the Affordable Care Act (ACA), many women are left without a pathway to coverage and become uninsured just two months after giving birth. Recently, there has been growing interest from federal and state policymakers, clinicians, and health advocates in expanding Medicaid’s postpartum coverage from 60 days to one year. This brief discusses Medicaid’s eligibility for pregnancy and postpartum care, describes gaps in coverage particularly for low-income women who live in states that have not expanded Medicaid under the ACA, and highlights several state and federal efforts to extend postpartum coverage for a longer period of time.

What is Medicaid’s role for pregnancy and postpartum care?

Medicaid has long prioritized coverage of pregnant women and now finances more than four in ten births in the United States.²  Federal law requires that all states extend eligibility for pregnant women with incomes up to 138% of the federal poverty level (FPL); however, most states (48 and DC) go beyond this minimum threshold, ranging from 138% to 380% FPL. Pregnancy-related coverage must last through 60 days postpartum and the infant is eligible for Medicaid for the first year after birth. For women who qualify for Medicaid on the basis of pregnancy, all states provide pregnant women with a wide range of Medicaid benefits, including prenatal care, childbirth and delivery services. States have discretion to determine specific maternity care benefits under Medicaid. For example, many states cover substance use treatment and home visiting services but fewer cover other services such as doula care and home births.

For pregnant women who are eligible for Medicaid under the ACA’s Medicaid expansion pathway, states must cover all preventive services recommended by the United States Preventive Services Task Force (USPSTF) including many pregnancy-related services, such as prenatal screening tests and folic acid supplements as well as services in the postpartum period, such as lactation consultation and breastfeeding supplies. Importantly, all states cover family planning services before and after pregnancy. Pregnancy-related services for those enrolled under any Medicaid pathway are exempt from cost-sharing. For low-income people in particular, the lower cost sharing and absence of deductibles under Medicaid can be a major advantage over private insurance.

Where are the gaps in coverage during the postpartum period?

Following the 60 days postpartum period, mothers with incomes up to 138% FPL in the states that have expanded Medicaid under the ACA (38 states and DC) have a continued pathway to coverage. Those with incomes above 138% FPL may qualify for subsidized coverage through the ACA Marketplace. However, in the 12 states that have not adopted the ACA’s Medicaid expansion, postpartum women could qualify for Medicaid as parents to stay on the program, but Medicaid income eligibility levels for parents are much lower than for pregnant people in all of the states (Figure 1). As a result, many women in non-expansion states become uninsured after pregnancy-related coverage ends 60 days postpartum because, even though they are poor, their income is still too high to qualify for Medicaid as parents and too low to qualify for Marketplace subsidies. For example, in Texas, a married mother with a newborn loses Medicaid coverage two months after giving birth if she and her partner have an annual income above $3,733 (17% FPL).

Research shows that Medicaid coverage is higher and uninsured rates are lower among women before and after pregnancy in expansion states compared to non-expansion states (Figure 2). As shown in Figure 2, coverage patterns are similar during pregnancy between expansion and non-expansion states. After pregnancy, however, Medicaid coverage declines and the uninsured rate climbs, with the effect more pronounced in non-expansion states.³ 

Furthermore, many women in non-expansion states who do not qualify for Medicaid after 60 days postpartum may also not qualify for subsidies to assist with the purchase of private insurance in state Marketplaces because they have incomes between the income limit for parents and 100% FPL, leaving them in the “coverage gap” with few options for affordable coverage.

How has the coronavirus affected postpartum coverage?

The Families First Coronavirus Recovery Act (FFCRA) includes an enhanced federal match (FMAP) to states, contingent on meeting maintenance of eligibility (MOE) requirements that include ensuring continuous coverage for enrollees until the end of the month in which the public health emergency (PHE) is in place. Under earlier guidance issued by the Centers for Medicare and Medicaid Services (CMS), someone qualifying on the basis of pregnancy would remain enrolled in that group, even after the 60 days postpartum period. Under a new interim final rule effective on November 2, states can move a pregnant woman from the pregnancy group to another eligibility pathway if eligible for another full benefit group, such as ACA expansion, and the benefit package for the new group is the same or more generous than the pregnant woman benefit package, move to new group. However, if the pregnancy benefit package is more generous than another pathway or the person is ineligible for any other full benefit group, they would remain enrolled in pregnancy group.

In addition to changing eligibility for coverage, the coronavirus pandemic has changed the way pregnancy and postpartum care is provided. New mothers may be more isolated from postpartum support, such as family members or doulas and women may be accessing services such as lactation consultations or postpartum checkups via telehealth. Continuity of coverage may be even more valuable given the other disruptions in care that new parents may be facing during the pandemic.⁴ 

Why is coverage for postpartum care important?

Postpartum care encompasses a range of important health needs, including recovery from childbirth, follow up on pregnancy complications, management of chronic health conditions, access to family planning, and addressing mental health conditions. While postpartum care has traditionally centered around one clinical visit six to eight weeks after delivery, there has been a paradigm shift to emphasize that postpartum care is an ongoing process that typically requires multiple visits and follow up care that may last a year or even longer. This is particularly important for those who experience pregnancy complications or have chronic conditions, such as hypertension or diabetes.

Mental health is a major concern during and after pregnancy. Suicidality among pregnant and postpartum people has risen over the past decade. At least one in ten women experience perinatal depression, and some studies suggest higher rates but poorer access to treatments among some communities of color and low-income women. ACOG recommends screening during the postpartum visit and initiation of treatment or referral to a mental health provider when a woman is identified with depression. This kind of care may be provided over a long duration, often lasting beyond 60 days.

Addressing pregnancy-related deaths (typically defined as death within one year of pregnancy)⁵ , particularly the substantially higher rates among Black and American Indian and Alaska Native (AIAN) women, is an urgent health challenge.⁶  At least one-third of maternal deaths occur in the postpartum period. Identifying the causes of maternal mortality and morbidity is complex, and coverage is only one factor, but research strongly indicates that access to health care throughout a woman’s reproductive years, is essential for prevention, early detection, and treatment of some of the conditions that place women at higher risk for pregnancy-related complications, including cardiovascular disease, diabetes, and chronic hypertension. Coverage disruptions during the perinatal period disproportionately affect Black, AIAN, and Hispanic women. Furthermore, a wide array of conditions that may present or persist through the postpartum period, including mental health challenges, intimate partner violence, and substance use, all play a role in maternal mortality and broader maternal health outcomes.

What can states do to extend postpartum coverage under Medicaid?

Assuring that low-income women have continuous coverage after pregnancy would support improvements in infant and maternal outcomes. States have several main pathways for broadening coverage in the postpartum period to Medicaid beneficiaries. These would all involve some increase in state spending, but with substantial federal matching funds available as well. Potential approaches, in decreasing order of scope and reach, include:

• Expand full scope Medicaid–Expanding Medicaid eligibility under ACA would provide the most comprehensive approach to broadening postpartum coverage, and the federal government would pay 90% of the costs for the expansion population. Postpartum women with incomes up to 138% FPL would be able to retain Medicaid past 60 days postpartum, providing greater continuity of coverage and care. Furthermore, other individuals with incomes up to 138% FPL would also qualify for Medicaid coverage, expanding Medicaid benefits to mothers and fathers as well as people without children, including those who intend to become pregnant and need preconception care. Research demonstrates the impact of Medicaid expansion on pregnancy-related coverage and care to date. One study found that Medicaid expansion was associated with lower maternal mortality rates compared to non-expansion states.⁷  Full Medicaid expansion would also narrow the coverage gap in non-expansion states for poor parents who do not qualify for either Medicaid or subsidies in the Marketplace. Research from the Urban Institute suggests that at least a quarter of uninsured new mothers would likely newly qualify for Medicaid postpartum if their state expanded Medicaid.
• Raise parental income eligibility levels under Medicaid– Short of full expansion, non-expansion states have another tool at their disposal to narrow the postpartum coverage cliff– raising income eligibility thresholds for parents, which is one of the pre-ACA eligibility categories. States set income eligibility levels for Medicaid. Raising the eligibility thresholds for parents could extend Medicaid eligibility to more low-income mothers and fathers and partially close the coverage gap in non-expansion states. Currently, Wisconsin sets eligibility thresholds for parents at 100% FPL and Tennessee is not far behind at 93% FPL (Table 1). The rest of the non-expansion states are much more restrictive however and currently have large gaps in coverage for parents. States would receive their regular federal match rate for any new enrollees who qualify as a result of higher parental eligibility levels.
• Extend pregnancy-related Medicaid coverage beyond 60 days postpartum– A number of states, both expansion and non-expansion, are taking action to try to extend the period of Medicaid postpartum eligibility, but the initiatives vary in scope.^8 ,9  Some states are applying for Section 1115 waivers from CMS to extend Medicaid beyond 60 days postpartum. Georgia, a non-expansion state, enacted legislation to extend postpartum coverage from 60 days to six months for those who had a Medicaid funded birth, and the state has submitted a waiver application to CMS. Even in Medicaid expansion states, postpartum women may lose Medicaid coverage postpartum, particularly if their incomes are above 138% FPL, and need to transition to Marketplace insurance. Even with a premium subsidy, some may find the out of pocket costs unaffordable and they may have to change providers with a coverage transition. Some expansion states, such as Illinois and New Jersey, are also seeking waivers from CMS to extend Medicaid’s postpartum period so that low-income postpartum women at income levels above 138% FPL keep their Medicaid coverage beyond two months postpartum.
• Expand coverage for specific postpartum services or specific populations- There has been some interest in broadening Medicaid postpartum coverage for specific health needs. The HHS maternal health action plan recommends supporting policies that allow states to maintain coverage for pregnant and postpartum people with substance use disorders. The postpartum period can be a particularly susceptible time for substance use relapse, with loss of coverage and access to care considered a potential trigger for relapse. Missouri and Indiana have submitted waiver applications to CMS that propose Medicaid postpartum extension to 12 months for postpartum women in need of services for substance use. Missouri’s waiver would allow postpartum women to continue to receive substance use and mental health services for a year, while Indiana’s proposal would extend full Medicaid coverage for those with opioid use disorder. Additionally, both states participate in CMS’ Maternal Opioid Misuse (MOM) model, a funding initiative that the agency offers for states to develop and improve programs to care for pregnant and postpartum people with opioid use disorder..Some states have used state dollars to extend postpartum coverage to certain populations. California enacted legislation and is using state funds to extend Medicaid coverage to a year for postpartum individuals diagnosed with a maternal mental health condition. Since September 2020, the state of Texas has been using state funds to provide a limited package of postpartum services for one year to those enrolled in the state’s Healthy Texas Women program, which is for uninsured reproductive age women. The state has submitted a Section 1115 waiver application to CMS to draw down federal funds for this program.

• Provide postpartum coverage for family planning services – Outside of lengthening the postpartum period under Medicaid, half of states provide Medicaid coverage for just family planning services to individuals who do not qualify for full Medicaid coverage. While these programs do not provide coverage that is as comprehensive as full scope Medicaid, they provide access to postpartum and intrapartum contraceptive services, which is important for pregnancy planning and healthy birth spacing. Most of the non-expansion states have a Medicaid or state-funded family planning program (Figure 3). However, in three states – Tennessee, Kansas, and South Dakota – postpartum individuals who were covered by Medicaid for pregnancy likely become uninsured after 60 days because the state has not expanded Medicaid under the ACA, and may not even have access to contraceptive services after pregnancy because the state does not have a Medicaid-funded family planning program.

What legislative proposals are currently being considered at the federal level to broaden postpartum coverage and strengthen maternity care?

In the 2019-2020 Congressional session, a number of federal bills related to maternal health care coverage, access, and quality are pending. Major themes across these bills include extension of Medicaid postpartum coverage to 12 months, coverage of doulas, greater support for state maternal mortality review committees, broadening provider networks in rural areas, and training on health equity and implicit bias for providers. Some notable federal bills that have garnered attention include:

• H.R. 4996 Helping Medicaid Offer Maternity Services (MOMS) Act of 2019 (sponsored by Rep. Robin Kelly), would amend the Medicaid program to allow states the option to extend continuous coverage with full benefits for postpartum individuals through one year postpartum. The bill was approved unanimously by voice vote in the House, and while many advocates and policymakers called for the Senate to pass the bill before the end of the 2019-2020 session, it was not passed.
• H.R. 1425, Patient Protection and Affordable Care Act Enhancement Act – This bill focuses on strengthening the ACA, but also includes a change to the postpartum period under Medicaid from 60 days to a full year. This differs from the Helping MOMS Act, which proposes a state option, while this bill requires mandatory 12 months postpartum coverage in all states. There would likely be significant differences in financing and access to care between proposals that create a mandatory expansion versus a state option, which some states would not adopt.¹⁰  A CBO analysis of the coverage extension in HR 1425 estimates a resulting $6 billion increase in the deficit over ten years. The bill passed the full House of Representatives in June 2020.
• H.R. 6142 – The MOMNIBUS is a package of nine bills sponsored by the Black Maternal Health Caucus in the House of Representatives and Vice-President elect Kamala Harris in the Senate. It is intended to improve different aspects of maternal health care for pregnant people, with a focus on health equity. Key components in the package include an extension of WIC benefits for one year postpartum, measures to diversify the perinatal workforce, funding to enhance maternal mortality committees and data collection, and mitigating the impact of social determinants of health. The MOMNIBUS has not yet been heard in a House committee.

Conclusion

As President-elect Biden, Vice President-elect Harris, and a new Congress come into office, maternal health, particularly large and persistent racial and ethnic inequities, continues to be a major health challenge. Coverage changes alone cannot address these issues, but given Medicaid’s large role in maternity financing and health coverage for communities of color, an extension of postpartum coverage for the full year after a Medicaid birth could provide stable coverage and care to more low-income birthing parents in both non-expansion and expansion states. For birthing parents, the need for health care services does not end two months after childbirth.

The ACA offers states the option to extend Medicaid eligibility to low-income parents with incomes up to 138% of the federal poverty level. However, in the 12 states that have not adopted full scope Medicaid expansion, most postpartum women lack a pathway to coverage and are at greater risk of becoming uninsured and losing access to critical health services in the postpartum and intrapartum periods. Some federal and state-level initiatives are in place to provide coverage for family planning or other more limited services to some reproductive age and postpartum people, but they do not provide the same level of coverage afforded by full scope Medicaid. Absent federal action, these decisions will continue to be in the hands of the states to decide whether to choose from among a number of pathways to expand coverage for new parents.

1. Black Mamas Matter Alliance, Policy Working Group. Advancing Holistic Maternal Care for Black Women Through Policy, December 2018. ↩︎
2. Martin, et al. National Center for Health Statistics. “Births in the United States, 2019,” October 2020. ↩︎
3. Daw, et al. High Rates of Perinatal Insurance Churn Persist After the ACA, Health Affairs, September 16, 2019. ↩︎
4. Eckert, E. “Preserving the Momentum to Extend Postpartum Medicaid Coverage,” Women’s Health Issues, September 2020. ↩︎
5. March of Dimes. Maternal Death and Pregnancy-Related Death, September 2019. ↩︎
6. Howell, E. Reducing Disparities in Severe Maternal Morbidity and Mortality, Clinical Obstetrics and Gynecology, June 2018. ↩︎
7. Eliason, E. “Adoption of Medicaid Expansion is Associated with Lower Maternal Mortality,” Women’s Health Issues, February 2020. ↩︎
8. National Academy for State Health Policy (NASHP). States’ Efforts to Extend Medicaid Coverage to Postpartum Women. ↩︎
9. American College of Obstetricians and Gynecologists (ACOG). Extend Postpartum Medicaid Coverage. ↩︎
10. Heberlein, M. MACPAC. “Extending Postpartum Coverage.” December 10, 2020. ↩︎

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

Key Findings

• A little over two months into the U.S. efforts to distribute and administer the COVID-19 vaccine, and as many states and localities ramp up efforts and work out the kinks in their systems, the latest KFF COVID-19 Vaccine Monitor shows that while the scheduling process has been smooth for most of those who got vaccinated, some older adults have had difficulty getting a vaccination appointment and many others have had trouble finding information about where or when they will be able to get the vaccine.
• Among adults ages 65 and over, who are now eligible to be vaccinated in nearly every U.S. state, about half say they have already received at least one dose of the vaccine (44%) or have scheduled an appointment to do so (8%). However, one in six older adults (16%) say they have tried but been unable to make an appointment to get vaccinated. Among older adults who got vaccinated or attempted to get an appointment, about half say the process was easy and about four in ten say it was difficult.
• Among those who have gotten at least one dose of the COVID-19 vaccine, four in ten across age groups say someone else helped them get the appointment. About half of those who helped others try to get an appointment say it was difficult to get an appointment, while a similar share say it was easy.
• Among those who have not been vaccinated, just over four in ten (44%) say they have tried to look for information about when or where to get the COVID-19 vaccine. About six in ten (57%) of this group say the information was easy to find and four in ten (42%) say it was difficult. Overall, nearly two-thirds (63%) of those who haven’t been vaccinated say they don’t have enough information about when they’ll be able to get vaccinated and nearly half (45%) say they don’t have enough information about where they can go to get the vaccine.
• Asked where they would most like to go to get the COVID-19 vaccine, the largest share across demographic groups says they want to get it at their own doctor’s office (75% say they’d be very likely to get it there if it was available, and 38% pick their doctor’s office as the place they would most prefer to go among a range of options). Fifteen percent choose a pharmacy as the place they’d most like to get vaccinated, followed by a hospital (9%) or their workplace (8%). Others say they’d choose locations such as a community health clinic, a local school, a church or other religious site, or a large vaccination site run by the government, suggesting that having multiple distribution avenues will help in reaching different segments of the U.S. population with a trusted place to go to get vaccinated.

Older Adults’ Experiences Getting Vaccine Appointments

While there is variation across states and even counties in terms of who is currently eligible to receive the COVID-19 vaccine, most states have opened up vaccinations to those ages 65 and over. New analysis from the KFF COVID-19 Vaccine Monitor shows that about half of adults in this age range say they have either gotten their first vaccine dose (44%) or have scheduled an appointment to do so (8%). Another one in six (16%) say they tried to make an appointment to get vaccinated but were unable to get one.

Some states started vaccinating adults ages 75 and over before opening up vaccinations to other age groups, and this is reflected in a higher share of this group saying they have received or scheduled their first vaccine dose (67% of those ages 75 and over compared to 43% of those ages 65-74). In addition, older adults with college degrees, who may be better able to navigate the systems for signing up for vaccine appointments, are more likely than those who have not graduated from college to say they have received or scheduled their first dose (65% compared to 46%). About half of both men and women ages 65 and over say they have received or scheduled their first dose of the vaccine.

.Among older adults who either got the COVID-19 vaccine or tried to get an appointment, about half (52%) say it was easy to get an appointment while about four in ten (43%) say it was difficult. Combined with the fact that one in six older adults attempted to get a vaccination appointment but were unable, this suggests that while the process is working well for many of those among the first priority age group for vaccination, others are encountering difficulties and frustration when attempting to sign up.

.Ease Of Finding Information About When And Where To Get Vaccinated

Among adults of all ages who have not yet been vaccinated, just over four in ten (44%) say they have tried to look for information about when or where to get the COVID-19 vaccine. Among all those who were either vaccinated or tried to look for information, just over a third (36%) say that information was difficult to find while most (63%) say it was easy. Those who have gotten at least one dose of the vaccine are somewhat less likely to report difficulty finding information compared to those who looked for information but have not yet been vaccinated (24% vs. 42%).

Among those who are most eager to get the COVID-19 vaccine (those who say they will get it as soon as it’s available to them), about six in ten (63%) say they have looked for information about where or when they can get the vaccine, and nearly half that group (28% overall) say the information was difficult to find.

.Who Got Help? Who Is Helping?

Among those who have gotten at least the first dose of a COVID-19 vaccine, four in ten (39%) say that someone else helped them find or schedule a vaccine appointment while six in ten (59%) completed the process on their own. The share who report getting help signing up is similar among both older and younger adults who have gotten the vaccine (40% of those ages 18-64 and 39% of those ages 65 and over). Those without a college degree (50%) and those with household incomes under $40,000 (55%) are somewhat more likely than their counterparts with higher levels of income and education to report getting help with finding or scheduling a vaccine appointment.

.One third of adults overall say they have helped someone else find information about when and where to get vaccinated and close to a quarter (23%) report helping someone else get a vaccine appointment. While those with lower levels of income and education are more likely to report getting help finding vaccine appointments, the opposite is true when it comes to doing the helping. Nearly half of college graduates (47%) and those with incomes of $90,000 or more (45%) say they have helped someone else find information and about three in ten in these groups say they’ve helped someone get a vaccine appointment (32% and 30%, respectively). Although anecdotes abound about adult children and grandchildren helping older relatives get appointments, those ages 65 and over are in fact more likely than younger adults to report assisting someone else (43% say they’ve helped someone else find information and 32% have helped someone get a vaccine appointment).

.Those helping others report similar levels of difficulty finding information and getting appointments as those who completed these tasks on their own. Among those who helped someone else look for information about when and where to get vaccinated, six in ten (62%) say it was easy and four in ten (38%) say the information was difficult to find. Among those who helped someone else try to get a COVID-19 vaccination appointment, half (49%) say the process was difficult and a similar share (46%) say it was easy.

.Information And Outreach

At this point, a much larger share of the public reports seeing messages in the media urging people to get the COVID-19 vaccine than says they have asked a health care professional for information or received information via targeted outreach. Among those who haven’t been vaccinated, seven in ten (71%) say they’ve seen messages online or in the media, one-quarter have asked a health care provider for information, and about one in five (18%) have been contacted by a health organization or agency with information about how to get the vaccine.

While large shares across demographic groups report seeing messages online and in the media, older adults, women, and those with college degrees are both more likely to say they have asked a health care provider for more information and more likely to say they have been contacted by a health care provider, insurance company, or public health agency with information about how to get vaccinated for COVID-19.

Despite high visibility of outreach campaigns online and in the media, large shares of the public continue to say that they don’t have enough information about the potential side effects of the COVID-19 vaccine, or about when or where they will be able to get vaccinated. Among those who have not yet gotten the vaccine, awareness about where to get vaccinated increased somewhat over the past month; 55% now say they have enough information about this, up from 43% in January. Yet this leaves 45% saying they don’t have enough information about where to get vaccinated. In addition, 63% of those who haven’t been vaccinated say they don’t have enough information about when they’ll be able to get the vaccine and over half (54%) say they don’t know enough about the potential side effects of the vaccine, both essentially unchanged from last month.

.Among those who have not yet been vaccinated, adults with lower incomes are more likely than those with higher incomes to say they don’t have enough information about where they can get vaccinated as well as the potential side effects of the COVID-19 vaccine. In addition, Hispanic adults are more likely than White adults to say they don’t have enough information about where or when they can get the vaccine, and both Black and Hispanic adults are more likely than White adults to say they don’t have enough information about the potential side effects of the vaccine.

.Where People Want To Get Vaccinated

With COVID-19 vaccines increasingly becoming available at different locations across the U.S., we examined which locations people say they’d be willing to visit to get a COVID-19 vaccine, as well as the locations they would most prefer as vaccination sites. Individual doctor’s offices were at the top of both lists, but a range of locations were acceptable and preferred by different individuals.

Three-quarters of adults who are open to getting vaccinated (defined as those who say they will get the vaccine as soon as they can, after waiting to see how it works for others, or if required) say they would be very likely to get the COVID-19 vaccine at their doctor’s office, if it is available there. A majority also say they’d be very likely to get it at a local pharmacy (61%) or a hospital (55%) and around half say the same of a community health clinic (49%) or their workplace (48%). When asked to pick their most preferred place, 38% chose their own doctor’s office, followed by a local pharmacy (15%), a hospital (9%), or their workplace (8%). Fewer people say they’d most prefer to get the vaccine at a large vaccination site run by the government (5%), a community health clinic (4%), a local school (4%), a grocery store (4%), or a local church or religious center (3%).

.As previously reported, majorities of Black and Hispanic adults who are still deciding whether to get vaccinated are concerned that they won’t be able to get the vaccine from a place they trust. Given this, it’s important to understand preferred vaccination locations among Black and Hispanic adults.

Across racial and ethnic groups, the largest share says they would be “very likely” to get vaccinated at their own doctor’s office, though many are open to getting vaccinated at a range of other places as well. Black adults are somewhat less likely than White adults to say they’d be very likely to get vaccinated at work (39%), at a large vaccination site run by the government (31%), or at a local school (32%). However, the top choice three choices across Black, Hispanic, and White adults alike are their own doctor’s office, a local pharmacy, and a hospital.

.Concerns About Vaccine Effectiveness Against New Strains Of The Virus

Over half (53%) of adults are worried that the vaccines currently available against COVID-19 might not be effective against new strains of coronavirus, while another 47% aren’t worried. Adults who say they definitely won’t get the vaccine are the least likely to be worried, with 55% saying they are not worried at all.

The people who want the vaccine as soon as possible and those who are going to wait and see are the most concerned about the new strains, with seven in ten of those who plan to wait and see very or somewhat worried that it might not be effective, and 58% of those who want the vaccine as soon as possible who say the same.

Black and Hispanic adults are among the most concerned that the current vaccines might not be effective against new strains, with two-thirds of Hispanic adults (67%) and around three in five Black adults (61%) saying they are very or somewhat worried.

This KFF COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted February 15-23, 2021, among a nationally representative random digit dial telephone sample of 1,874 adults ages 18 and older (including interviews from 506 Hispanic adults and 507 non-Hispanic Black adults), living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Phone numbers used for this study were randomly generated from cell phone and landline sampling frames, with an overlapping frame design, and disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity subgroups within each frame. Specifically, the cell phone frame was stratified as: (1) High Hispanic: Cell phone numbers associated with rate centers from counties where at least 35% of the population is Hispanic; (2) High Black: Cell phone numbers associated with remaining rate centers from counties where at least 35% of the population is non-Hispanic Black; (3) Else: numbers from all remaining rate centers. The landline frame was stratified as: (1) High Black: landline exchanges associated with Census block groups where at least 35% of the population is Black; (2) Else: all remaining landline exchanges. The sample also included 190 respondents reached by calling back respondents that had previously completed an interview on the KFF Health Tracking poll at least nine months ago. Another 387 interviews were completed with respondents who had previously completed an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n = 180; including 50 in Spanish) or non-Hispanic Black (n=207). Computer-assisted telephone interviews conducted by landline (339) and cell phone (1,535, including 1,143 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2019 U.S. American Community Survey (ACS), on sex, age, education, race, Hispanic origin, and region, within race-groups, along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January- June 2020 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of prepaid cell phones and likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

This work was supported in part by a grant from the Chan Zuckerberg Initiative DAF, an advised fund of Silicon Valley Community Foundation. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

During the coronavirus pandemic, Medicaid has played a key role in providing coverage to millions of people who have lost their jobs or their health coverage. In addition, provisions included in the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security (CARES) Act require states to maintain eligibility standards and provide continuous enrollment in Medicaid until the end of the public health emergency (PHE) in order to qualify for enhanced federal Medicaid funding. This report provides data on state Medicaid and CHIP eligibility levels and presents a snapshot of key aspects of state enrollment and renewal procedures in place during the COVID-19 PHE based on information from the 19th annual survey of Medicaid and CHIP program officials in the 50 states and DC. The report includes policies for children, pregnant women, parents and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial rules. Key findings from the survey include the following.

• In 2021, Medicaid and CHIP eligibility is largely unchanged from 2020 as a result of maintenance of eligibility (MOE) requirements. State eligibility levels across all groups remained steady throughout 2020 due to the FFCRA’s increased FMAP and MOE provisions. Children and pregnant women continue to be covered at higher income levels while the coverage gap for low-income adults persists in the 14 states that have not implemented the expansion. In October 2020, Nebraska became the 37^th state, including the District of Columbia, to implement the Medicaid expansion following its adoption through a ballot initiative in 2018. Voters in Missouri and Oklahoma approved similar initiatives in 2020 and will implement the expansion later in 2021.
• Even with the MOE, most states are renewing coverage when possible and taking other steps to prepare for the end of the PHE. Most states are renewing coverage when they are able to confirm ongoing eligibility through electronic data sources. Two-thirds of states processing renewals also indicate they are sending renewal forms or requests for information when they are unable to renew coverage automatically through other data sources. Although states may not now terminate coverage for lack of response or ineligibility, sending renewal requests enables states to extend coverage for those who respond with proof that they remain eligible. In addition, just over a third of states have established a new 12-month renewal period when processing a change in circumstances that results in a new eligibility pathway. As states prepare for the end of the PHE, more than one-third are continuing or plan to take proactive steps to update enrollee mailing addresses. These actions will help to reduce backlogs and minimize coverage disruptions at the end of the PHE. Only 17 states reported an increase in new applications since the beginning of the COVID-19 PHE.  This could be because of smaller than expected declines in employer-sponsored insurance, drops in applications at the beginning of the pandemic due to office closures, and the elimination of reapplications (where an individual loses coverage, often due to procedural reasons, then reapplies a short time later) due to the MOE requirements.
• Administrative actions and Congressional proposals will have implications for Medicaid coverage and enrollment as well as for state efforts to plan for resuming normal operations after the PHE. In a letter to Governors, the Biden administration noted that the PHE is likely to extend for the entirety of 2021 and promised a 60-day notice before the PHE is terminated or is allowed to expire. In December 2020, CMS released guidance outlining how states are expected to unwind emergency authorities and resume normal eligibility and enrollment processing after the end of the PHE. Although the extension of the PHE gives states more time to prepare for it to end, it is possible CMS will issue additional clarifying guidance, which would affect states’ planning efforts. The administration also recently announced it will revise Medicaid waiver demonstration policy and rescind guidance related to work requirements and may also revise demonstration policy related to capped financing. In addition, the latest COVID relief legislative package includes provisions to provide states the option to extend coverage for pregnant women to 12 months postpartum in both Medicaid and CHIP and to provide financial incentives for non-expansion states to adopt the Medicaid expansion. The eligibility and enrollment policies presented here provide a baseline for assessing changes states may make in response to these federal policy shifts.

Introduction

Since its emergence a year ago, the coronavirus has had implications for the health of the nation and our economy, exposing gaps in the public health infrastructure and further highlighting the importance of health coverage. During this time, enrollment in Medicaid has increased as people sought coverage after losing jobs or income because of the pandemic. Through the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security Act (CARES), states are required to maintain eligibility standards and provide continuous enrollment in Medicaid until the end of the public health emergency (PHE) in order to qualify for a 6.2 percentage point increase in Federal Medical Assistance Percentage (FMAP). The continuous coverage provision, along with new applications, resulted in Medicaid enrollment growth of 6.7% between February and September 2020 (the most recently available data). States were also able to adopt a range of options through temporary changes in their state Medicaid plans (SPAs),through disaster-related waivers, and through other administrative authorities to streamline processes and connect individuals to coverage more quickly, such as expanding use of presumptive eligibility and allowing self-attestation of certain eligibility criteria.

This 19th annual survey of the 50 states and the District of Columbia (DC), provides data on state Medicaid and CHIP eligibility levels and presents a snapshot of key aspects of state enrollment and renewal procedures in place during the COVID-19 public health emergency. In light of the ongoing COVID-19 pandemic, the survey was scaled back in length and scope and focuses on state actions taken or planned in response to the pandemic. The report is based on a survey of state Medicaid and CHIP program officials conducted by the Kaiser Family Foundation (KFF) and the Georgetown University Center for Children and Families during January 2021. The report includes policies for children, pregnant women, parents and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules; it does not include policies for groups eligible through Medicaid pathways for adults over the age of 65 or on the basis of disability.

Medicaid and CHIP Eligibility

As of January 2021, Medicaid and CHIP eligibility is largely unchanged from 2020 due to maintenance of eligibility (MOE) requirements tied to enhanced federal funding. To help support states and promote stability of coverage amidst the COVID-19 pandemic, the FFCRA provides a 6.2 percentage point increase in the federal share (FMAP) of certain Medicaid spending if states meet certain MOE requirements. The MOE provisions prohibit states from tightening eligibility and enrollment standards beyond policies in place as of January 1, 2020 and require states to provide continuous coverage and to cover COVID-19 testing and treatment for Medicaid enrollees. The MOE continuous coverage requirement remains in place until the end of the month when the public health emergency (PHE) expires or is terminated. The MOE does not apply to CHIP programs, but other MOE requirements remain in place for CHIP.¹  While states continue to have the flexibility to increase eligibility or implement new enrollment and renewal processes, the impact of the COVID-19 pandemic and the economic recession have limited states’ ability to do so, resulting in few changes in eligibility outside of temporary emergency authorities.

In October 2020, Nebraska implemented the ACA Medicaid expansion, the only major eligibility policy change in 2020. As of January 2021, 37 states extend coverage to adults without dependent children with incomes up to 138% FPL ($30,305 for a family of 3) (Figure 1). Also, in 2020, Missouri and Oklahoma voters approved ballot initiatives to implement Medicaid expansion in their states. When Medicaid expansion was first launched in January 2014, 26 states (including DC), participated. Since then, an additional 13 states have adopted the Medicaid expansion, six via state ballot initiatives. Following implementation in Missouri and Oklahoma, planned for mid-2021, the total number of expansion states will increase to 39.

In states that have not implemented the Medicaid expansion, eligibility for parents and other adults remains extremely low (Figures 2 and 3). The median eligibility level for parents and caretakers in the 14 non-expansion states remains at 40% FPL ($8,784 annually for a family of three), ranging from a low of 17% FPL in Texas to 100% FPL in Wisconsin. Ten non-expansion states base eligibility on a fixed dollar threshold that is converted to the equivalent federal poverty level for comparison purposes. Over time, the equivalent eligibility level will decrease when annual updates adjust federal poverty levels upward to account for inflation. Wisconsin remains the only non-expansion state to cover adults without dependent children, extending eligibility up to 100% FPL for these adults through a waiver.

Children’s upper income eligibility in Medicaid and CHIP continues to be the highest of all eligibility groups with 49 states covering children at or above 200% FPL (Figure 4). In 2020, the median eligibility level for children held steady at 255% FPL, ranging from a low of 175% FPL in North Dakota to a high of 405% FPL in New York. More than a third of the states (19) cover children at or above 300% FPL. The only change in eligibility levels for children’s coverage was in Kansas, where CHIP eligibility is linked to a dollar-based income level tied to the 2008 FPL. While the dollar value remains the same, over time, the equivalent eligibility level will decrease when the federal poverty level is adjusted upward to account for inflation.

The median eligibility limit for coverage for pregnant women in Medicaid and CHIP is stable at 205% FPL (Figure 5). Across states, eligibility levels for pregnant women in Medicaid and CHIP range from a low of 138% FPL (the federal minimum level) in Idaho and South Dakota to a high of 380% FPL in Iowa. A total of 35 states cover pregnant women at or above 200% FPL. Six states have expanded coverage for pregnant women through CHIP, an option for states that cover pregnant women in Medicaid up to at least 185% FPL.

As of January 2021, 41 states have adopted federal options or use state-only funds to extend coverage or limited benefits to some immigrant children, pregnant women, or non-elderly adults. CHIP’s enactment in 1997 included the unborn child option that allows states to provide coverage from conception to birth, thereby extending coverage to pregnant women regardless of immigration status. A total of 17 states have adopted this option. Then, the 2009 CHIP Reauthorization Act (CHIPRA) offered a new option for states to receive federal funding to cover lawfully-residing children and pregnant women in Medicaid and CHIP without the five-year waiting period. Since then, two-thirds of states (35) have implemented the option for children in Medicaid and all of those states with separate CHIP programs (24 states) cover lawfully-residing children in CHIP (Figure 6). Twenty-five states have adopted the CHIPRA option to cover lawfully-residing pregnant women. Additionally, eight states use state-funds to cover children who are ineligible for federal funding due to immigration status, five states provide pre-natal or postpartum services to some immigrant pregnant women, and eight states cover other immigrant adults.

The median eligibility level for family planning services is 206% FPL, but eligibility levels range from 138% FPL in Louisiana and Oklahoma to a high of 306% FPL in Wisconsin. In 2020, Texas became the 30^th state to provide family planning services using federal funds. Texas offers family planning services through a Section 1115 demonstration waiver, Healthy Texas Women, which includes restrictions on free choice of family planning providers.

Enrollment and Renewal Processes During the PHE

One third of states have experienced an increase in new applications since the beginning of the COVID-19 PHE (Figure 7) and few states reported application backlogs. Seventeen states report that the volume of new applications increased during the COVID-19 PHE compared to the same period in 2019. Seven of these states (Delaware, Hawaii, Illinois, Nebraska, New York, Nevada, and Tennessee) report increases of greater than 10%. Despite overall Medicaid enrollment growth, states may not be experiencing large increases in applications for a variety of reasons, including smaller than expected declines in employer-sponsored insurance, a drop in applications early in the pandemic due to office closures and the elimination of reapplications (where an individual loses coverage, often due to procedural reasons, then reapplies a short time later) due to the MOE requirements. Only five states report current delays in processing new applications beyond the current timeliness standards. Two of the five states with backlogs indicated their current backlogs were lower than in the prior year, while one state indicated that the backlog was the result of decreased administrative capacity due to the pandemic. CMS expects that states will resume timely processing of all applications within four months of the end of the PHE. Since most states are not currently experiencing application backlogs, they can potentially focus resources on processing renewals or changes in circumstances before the end of the PHE.

Just over half of states (28) report a shift in how individuals are applying for Medicaid coverage, largely driven by an increase in online applications (Figure 8). The ACA required states to create a single streamlined application for Medicaid, CHIP, and Marketplace coverage and to provide options for individuals to apply for and renew coverage through multiple modes, including online and phone. Most states reporting a change in the primary mode of application experienced an increase in online applications, likely driven by limited access to in-person application assistance at state and local eligibility offices or through community-based assisters due to COVID-19.

CMS has recommended that states take steps to increase the share of online applications in a planning tool it developed to help states prepare for the end of the PHE. Electronic applications can expedite determinations and reduce both administrative costs and errors associated with manual data entry. As reported in the 2020 survey, the share of applications received online varies considerably among states, ranging from less than 10% to more than 90%. Both states that reported high and low shares of online applications in 2020 reported experiencing an increase in online applications. States can use a variety of strategies to increase the volume of online applications, including actively promoting the weblink in all outreach and marketing efforts and developing mobile-based apps and creating portals for assisters to facilitate applications.² 

As of January 2021, most states (41) report processing ex parte (automated) renewals to extend coverage for individuals during the PHE (Figure 9) and two-thirds of those states (28 of 41) are sending renewal forms or requests for documentation when they are unable to confirm ongoing eligibility through electronic data sources. Under the ACA, states must seek to complete automated or ex parte renewals by verifying ongoing eligibility through available data sources, such as state wage databases, before sending a renewal form or requesting documentation from an enrollee. While some states suspended renewals as they implemented the MOE continuous coverage requirements and made other COVID-related adjustments to operations, most states are now actively processing renewals. Other states will likely restart the renewal process in response to CMS guidance that outlines actions states should take during the PHE to resume normal operations to the extent possible. When states are able to confirm ongoing eligibility on an ex parte basis, including the 41 states currently processing automated or ex parte renewals, they have the option to extend the renewal date out to 12 months from the original renewal date or 12 months from when the renewal was processed to stagger renewal dates, but this may result in renewal periods for enrollees that are shorter than 12 months. If an enrollee submits documentation to verify ongoing eligibility at renewal, the state must extend coverage for a full 12 months.

Slightly more than a third of states (19) have established a new 12-month renewal period when processing a change in circumstances that results in a new eligibility pathway. In November 2020, CMS published an interim final rule that provided options for states to transition enrollees determined ineligible for their current coverage to different coverage pathways for which they are eligible if such a transition is in the same tier of coverage (though it may cover fewer benefits or have higher patient cost-sharing). States may then retain the original renewal date or extend a new 12-month eligibility period if they have information needed to confirm ongoing eligibility. Some states report that pregnant women and children aging out of coverage are most likely to be given a new 12-month renewal period, while other states say enrollees in all MAGI-based eligibility groups are given a new 12-month renewal period.

Just over one third of states (19) proactively take steps to update mailing addresses or plan to do so before the end of the PHE (Figure 10). Once the PHE expires and states resume normal operations under current federal rules, states may automatically terminate coverage without the advance ten-day notice when an enrollee cannot be located.³  Prior to the COVID-19 pandemic, a number of states terminated coverage when mail was returned as undeliverable, potentially contributing to enrollment declines. Ongoing issues with the United States Postal Service (USPS) and the impact of the COVID-19 economic crisis on housing may exacerbate difficulties in reaching enrollees by mail. In 2020, states that took proactive steps to keep mailing addresses current reported using the USPS National Change of Address Database or contracting with vendors to facilitate the process. States may also check other public programs for more updated information or engage Medicaid managed care organizations in updating addresses. Additionally, as of 2020, 43 states offered online accounts, which make it easier for enrollees to update addresses among other features. A few states also reported taking additional action, such as attempting to contact enrollees via telephone.

Most states are not planning changes to eligibility or enrollment that are currently disallowed when the PHE ends. While all states will phase out the continuous coverage requirement, five states are planning to make other changes. Two states reported plans to move forward with implementing work requirements and three states plan to charge premiums for some adults. The Biden Administration has announced it intends to rescind work requirements demonstration waivers and may take additional action to revise waiver guidance, impacting states’ ability to implement these policies.

Looking Ahead

State eligibility and enrollment policies in place as of January 2021 provide a baseline for assessing state actions after the PHE ends and in response to new Medicaid policy options that may be adopted at the federal level. Currently, states cannot implement more restrictive eligibility policies than those in place as of January 1, 2020 and must provide continuous coverage to Medicaid enrollees until the PHE ends in order to receive enhanced federal funding. Their policy choices at the end of the PHE and decisions around adopting potential coverage options will have coverage implications for those who are currently enrolled and those who may become eligible.

The Biden Administration’s recent announcement regarding the likely extension of the PHE gives states more time to prepare for the end the PHE. In a letter to Governors, the Biden administration noted that the PHE is likely to extend for the entirety of 2021 and promised a 60-day notice before the PHE is terminated or is allowed to expire. Advance notice before the end of the PHE was one of the top responses when states were asked what additional guidance they need from CMS to plan for resuming normal operations.

States are taking steps now to prepare for the end of the PHE, but some indicate additional guidance would be helpful to reduce backlogs and minimize coverage disruptions. While most states are processing automated renewals when possible, states will still have a backlog of renewals that were not able to be completed. Some states noted the need for additional guidance to avoid unevenly distributed workloads due to large numbers of renewals and other changes occurring in a short period of time. When the PHE ends, CMS guidance issued under the Trump administration allows states to send coverage termination notices to individuals who did not respond to requests for information, did not return renewal forms, or lost eligibility for other reasons within six months of the end of the PHE. This approach may result in coverage losses at the end of the PHE for individuals who remain eligible. CMS guidance also gives states six months to catch up on pending renewals and other changes once the PHE ends; however, several states indicated that 12 months would allow for a smoother resumption of operations. While states can use this guidance to help plan for the end of the PHE, it is possible the Biden administration could revise the guidance, which would affect states’ planning efforts.

As states prepare to return to normal operations at the end of the PHE, there are additional considerations beyond resuming routine eligibility and enrollment procedures. In addition to the MOE requirements, states implemented a variety of temporary strategies to deal with the pandemic including, but not limited to eligibility, enrollment or renewal. These changes were wide ranging, impacting all aspects of Medicaid from improving access to telehealth and easing prior authorization requirements to waiving premiums or cost-sharing and modifying appeals and fair hearing requirements. CMS has developed two planning tools to aid states in preparing for the end of the PHE. The first focuses on eligibility and enrollment pending actions and the second provides assistance in general planning to restore regular Medicaid and CHIP operations. Together, the tools prompt states to consider actions that will aid in a smooth return to normal operations, including how they communicate with beneficiaries and stakeholders and how to extend or permanently implement flexibilities adopted through Section 1135 emergency waivers or disaster-related temporary state plan amendments.

Administration actions and Congressional proposals would reduce some barriers to Medicaid enrollment and support targeted Medicaid coverage expansions. The Biden administration has already reopened the marketplace and will restore funding for outreach, marketing and consumer assistance that will help connect uninsured individuals with Medicaid and CHIP. The administration also recently announced it will revise waiver demonstration policy and rescind guidance related to work requirements and may also revise demonstration policy related to capped financing. In addition, the latest COVID relief legislative package includes provisions to provide states the option to extend coverage for pregnant women to 12 months postpartum in both Medicaid and CHIP and to provide financial incentives for non-expansion states to adopt the Medicaid expansion.

Table A: Trends in State Medicaid and CHIP Eligibility Policies, July 2000-January 2021

Table 1: Income Eligibility Limits for Children’s Health Coverage as a Percent of the Federal Poverty Level, January 2021

Table 2: Medicaid and CHIP Coverage for Pregnant Women and Medicaid Family Planning Expansion Programs, January 2021

Table 3: State Adoption of Options to Cover Immigrant Populations, January 2021

Table 4: Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level, January 2021

Table 5: Medicaid and CHIP Applications During the COVID-19 Public Health Emergency, January 2021

Table 6: Renewals, Changes in Circumstances, and Returned Mail, January 2021

1. Medicaid and CHIP Payment Advisory Commission, CHIP Eligibility. https://www.macpac.gov/subtopic/eligibility-2/ ↩︎
2. Maximizing Enrollment, Consumer Assistance in the Digital Age: New Tools to Help People Enroll in Medicaid, CHIP and Exchange, (July 2012). http://www.maxenroll.org/files/maxenroll/resources/Maximizing%20Enrollment%20-%20Consumer%20Assistance%20-%20July%202012.pdf ↩︎
3. 42 CFR §431.213 – Exception from advance notice. The agency may send a notice not later than the date of action if: (d) The beneficiary’s whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the beneficiary’s whereabouts become known). ↩︎