Postpartum Individuals Are at Risk of Losing Medicaid During the Unwinding of the Medicaid Continuous Enrollment Provision, Especially in Certain States
Usha Ranji , Jennifer Tolbert , and Ivette Gomez May 26, 2023
With the end of the Medicaid continuous enrollment provision that was implemented during the pandemic health emergency, states are resuming Medicaid disenrollments. Many individuals who originally qualified for Medicaid through pregnancy eligibility may be at risk of losing coverage. During the pandemic, people who obtained Medicaid coverage because they were pregnant were able to remain on the program even after the traditional 60-day postpartum coverage period ended. CMS data show that from February 2020 to July 2022 there was a 75% increase in enrollment in the pregnancy eligibility group. States could have moved people to other eligibility groups, but many did not.
While the Medicaid continuous enrollment was in place, Congress took additional steps to improve postpartum coverage by giving states the option to extend that coverage from 60 days to 12 months starting in April 2022. Because this coverage option has not been uniformly adopted by states, some postpartum individuals may now be disenrolled after 60 days as states return to pre-pandemic enrollment and eligibility operations.
State policies on postpartum coverage
Medicaid offers coverage to pregnant women and others with state established income eligibility levels that range from 138% to 380% of poverty (ranging from approximately $34,000 to $94,000 annually for a family of 3), and as a result, covers four in ten births nationally. States must cover pregnant people through 60 days postpartum, and now have the option to extend that coverage to 12 months. In addition to state choices to implement the postpartum extension, states’ policies on full Medicaid expansion affect coverage in the postpartum period. Prior to the pandemic, in expansion states, most women and people eligible for postpartum coverage who had incomes up to 138% FPL could stay on the program, and many with higher incomes could qualify for subsidized coverage through the Affordable Care Act (ACA) Marketplace. However, in states that had not adopted Medicaid expansion, eligibility levels for parents are much lower than for pregnancy, so many people would lose coverage after 60 days because their incomes exceeded the lower income thresholds for parents. Those with incomes below poverty – which is the minimum income required to qualify for ACA subsidies – were caught in the “Medicaid coverage gap” in non-expansion states.
It is well accepted that the postpartum period extends beyond 60 days. Many common pregnancy-related complications, such as cardiovascular conditions, hypertension, and postpartum depression require care over a longer-term. Providing coverage for a longer period after pregnancy also promotes continuity of care and access to preventive services such as contraception and intrapartum care. Since the pandemic’s onset, there has been a sea change in postpartum coverage as 37 states and DC have adopted the 12-month extension and another 4 states have legislation to adopt the extension pending (Figure 1).
Over the coming months, across the states that have not adopted the 12-month postpartum extension, people who qualified for Medicaid through the pregnancy pathway risk losing Medicaid coverage before the end of their postpartum year because pregnancy-related income eligibility levels are higher than those for parents. However, the risk is greater in some non-expansion states. Texas, for example, has not expanded Medicaid under the ACA and does not have an approved postpartum extension (state legislators are considering a bill). A single mother with a newborn in Texas may lose Medicaid coverage two months after giving birth if she has an annual income above $4,000 (~16% of the poverty level). Furthermore, she may fall into the coverage gap if her income is below the poverty line ($24,860), the minimum eligibility for assistance through the ACA marketplace.
Considerations for Unwinding
As states resume Medicaid disenrollments, many who qualified for Medicaid through the pregnancy pathway during the pandemic are at risk of losing Medicaid coverage. Some will qualify for subsidized ACA Marketplace plans. Some parents, particularly in non-expansion states, are likely to become uninsured, but their children will remain eligible for Medicaid or CHIP.
Some postpartum individuals may also lose coverage despite remaining eligible because they face barriers to completing the renewal process. Not receiving or understanding renewal notices or not knowing how to respond to state requests for information are some of the reasons why people may not complete the renewal process.
Monitoring how the Medicaid unwinding is proceeding in states can help ensure continuity of coverage for eligible postpartum individuals by identifying potential enrollment problems early in the process. States are required to report monthly on the number of individuals with pregnancy-related coverage who are terminated and whether it is for procedural reasons; however, data collection, quality and timing may be a challenge.
The demands of caring for a newborn can exacerbate challenges in completing the renewal process, which is further complicated because infants born during the pandemic will need to transition to eligibility for children, another procedural hurdle for parents of young children. State approaches to the unwinding process, particularly policies to streamline renewals and to follow up with enrollees who have not completed the renewal process, can facilitate the ability of eligible individuals to retain coverage.