SCHIP Coverage for Pregnant Women and Unborn Children

The State Children’s Health Insurance Program (SCHIP) does not include pregnancy status among its eligibility criteria and does not cover individuals over age 18. Under SCHIP, states can cover pregnant women aged 19 and older in one of three ways: (1) states may apply for waivers of program rules to extend coverage to adults such as pregnant women (§1115 waiver authority); (2) states may provide health benefits coverage, including prenatal care and delivery services, to unborn children through an SCHIP state plan amendment (SPA) as permitted through regulation (Federal Register, vol. 67, no. 191, Wednesday, October 2, 2002, Rules and Regulations); or (3) states may offer a “family coverage option” that allows them to provide coverage under a group health plan that may include maternity care to adult females in eligible families. Section 2105(c)(3) of the Social Security Act allows states to cover entire families including parents if the purchase of family coverage is cost-effective when compared with the cost of covering only the targeted low-income children in the families involved, and would not substitute for other health insurance coverage. E-mail correspondence (from June 7, 2007) with Kathleen Farrell, the CMS Director of the SCHIP program, indicates that New Jersey and Massachusetts are the only states with operational family coverage variance programs. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 6 states used the §1115 waiver authority and 12 states extended coverage through unborn child SPAs (Rhode Island extends coverage to pregnant women through both authorities). This report summarizes the variation in pregnancy coverage and the financing streams associated with such coverage among these states. This report will be updated as state activity warrants.

SCHIP Coverage for Pregnant Women and Unborn Children

January 8, 2008 (RS22785)

Summary

The State Children's Health Insurance Program (SCHIP) does not include pregnancy status among its eligibility criteria and does not cover individuals over age 18. Under SCHIP, states can cover pregnant women aged 19 and older in one of three ways: (1) states may apply for waivers of program rules to extend coverage to adults such as pregnant women (§1115 waiver authority); (2) states may provide health benefits coverage, including prenatal care and delivery services, to unborn children through an SCHIP state plan amendment (SPA) as permitted through regulation (Federal Register, vol. 67, no. 191, Wednesday, October 2, 2002, Rules and Regulations); or (3) states may offer a "family coverage option" that allows them to provide coverage under a group health plan that may include maternity care to adult females in eligible families. Section 2105(c)(3) of the Social Security Act allows states to cover entire families including parents if the purchase of family coverage is cost-effective when compared with the cost of covering only the targeted low-income children in the families involved, and would not substitute for other health insurance coverage. E-mail correspondence (from June 7, 2007) with Kathleen Farrell, the CMS Director of the SCHIP program, indicates that New Jersey and Massachusetts are the only states with operational family coverage variance programs. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 6 states used the §1115 waiver authority and 12 states extended coverage through unborn child SPAs (Rhode Island extends coverage to pregnant women through both authorities). This report summarizes the variation in pregnancy coverage and the financing streams associated with such coverage among these states. This report will be updated as state activity warrants.


SCHIP Coverage for Pregnant Women and Unborn Children

Background

States that choose to cover pregnant women through the §1115 waiver authority must submit a proposal to the Centers for Medicare and Medicaid Services (CMS) for approval. States with approved §1115 demonstration programs define the available pregnancy-related services in their waiver terms and conditions agreements.

States that opt to extend SCHIP coverage to unborn children must submit an SPA to CMS for approval specifying the pregnancy-related services. Under the SCHIP SPA option, covered services must be related to the pregnancy or to conditions that could complicate the pregnancy, including those for diagnosis or treatment of illnesses or medical conditions that might threaten the health of the unborn child. Care after delivery for the mother, such as postpartum services, is generally not covered as part of the title XXI SPA option. Although CMS requires the care to be directed at the unborn child, the SCHIP unborn child SPA option effectively enables states to provide prenatal care to pregnant women including those with incomes at or above the Medicaid income eligibility thresholds and for individuals who do not qualify for Medicaid (or SCHIP) for other reasons, such as immigration status1 or incarceration.2 Finally, for the family coverage option, pregnancy-related benefits are those offered by participating private health plans.

Summary of State Variation in Pregnancy Coverage Under SCHIP

Table 1 summarizes the variation in pregnancy coverage among states with §1115 waivers and those using the SCHIP unborn child SPA option. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 12 states extended coverage through unborn child SCHIP SPAs and 6 states used the §1115 waiver authority (Rhode Island extends coverage to pregnant women through both authorities). The highest upper-income eligibility thresholds for pregnant women and/or unborn children under SCHIP was 300% FPL in California. Seven states established upper-income limits at 200% FPL. Four states exceeded 200% FPL, and six states set maximum income levels below 200% FPL.

Of the 12 states that offer pregnancy-related services to unborn children under the SCHIP SPAs, all but Tennessee extended coverage to the unborn children of undocumented aliens who otherwise would not have access to federally funded pregnancy-related services, except through emergency Medicaid.3 Two states used SCHIP SPAs to extend coverage to the unborn children of incarcerated women who are otherwise ineligible for SCHIP coverage.

Covered services under the §1115 waiver programs and the SCHIP SPAs generally consisted of comprehensive pregnancy-related services including prenatal care, labor and delivery services, and access to some form of coverage during the postpartum period. However, the length of coverage (e.g., prenatal period through labor and delivery, or prenatal period through 60 days postpartum period) and financing streams for the care associated with each of these pregnancy phases varied across states. For example, some states offered coverage from conception through 60 days postpartum care (financed with SCHIP funds), whereas others segmented the coverage to include prenatal care (financed with SCHIP funds), labor and delivery (financed with emergency Medicaid funds), and postpartum care (financed with state-only funds). In these states, program specialists pointed out that the pregnancy-related care is seamless to the mother despite the administrative complexities required of the state to submit claims under multiple funding streams. Three states indicated that the coverage offered to pregnant women and/or unborn children was comprehensive and not limited to pregnancy-related services. An additional four states specified that the available care included pregnancy-related care and associated health services including, for example, medically necessary dental or mental health benefits as long as the care was necessary to promote the health of the unborn child.

Postpartum care differs among states that chose to extend pregnancy coverage under the §1115 waiver authority as compared with those that offered coverage to unborn children under the SCHIP unborn child SPAs. There were 15 states that offered 60 days of postpartum care to at least some of their eligible populations, including each of the 6 states that offered pregnancy coverage under the §1115 waiver authority. Among the SCHIP SPA states, five states financed 60 days of postpartum care with state-only funds. Four SCHIP SPA states extended 60 days of postpartum care using SCHIP funds. CMS permitted this financing arrangement despite the fact that the unborn child regulation clearly states that federal SCHIP-financed care ends with the birth of the child. The reason CMS permits this is because the state has a global rate for their pregnancy services that includes the cost of prenatal care, labor and delivery, and 60 days of postpartum care. One SCHIP SPA state provided SCHIP-financed postpartum care through the end of the month that the child was delivered because those services have already been paid for under the monthly managed care capitation payment. Two SCHIP SPA states did not offer any form of care for the mother after the birth of the child except in the case of an emergency during which the mother would have access to emergency Medicaid services. Finally, two states (one §1115 waiver state and one SCHIP SPA state) provided access to extended family planning services and supplies as a part of their postnatal care benefit.

Table 1. SCHIP Pregnancy Coverage for States with Section 1115 Waivers and SCHIP Unborn Child State Plan Amendments (as of October 2007)

State (Award Date)

Authority

Upper-
Income Threshold
(% FPL)

Benefit Coverage

Mother's Coverage After Delivery

Financing Stream

Covered Services

Length of Coverage

Financing Stream

Arkansas (6/30/04)

Unborn Child SPA

200% FPL undoc. aliens

Separate SCHIP program (SSP) includes prenatal care, and delivery services

Conception to birth

SCHIP

No coverage except under emergency Medicaid

Emergency Medicaid

Colorado (9/27/02)

SCHIP §1115 HIFA

200% FPL

Prenatal care, labor and delivery, and 60 days postpartum care (excludes dental care)

Date of application through 60 days postpartum

SCHIP

60 days postpartum care

SCHIP

California (3/28/06)

Unborn Child SPA

0%-200% undoc. aliens

Prenatal care, labor and delivery, and 60 days postpartum care

Conception through 60 days postpartum

SCHIP

60 days postpartum care

SCHIP (treated as a bundled service)

300% uninsured

AIM program offers comprehensive care not just pregnancy related care

Conception through 60 days postpartum

SCHIP

Illinois (6/11/03)

Unborn Child SPA

0%-200% undoc. aliens and incarcerated women

SSP Medicaid look alike benefits includes prenatal care and associated health services (excludes HCBS waiver services and abortion services)

Confirmed pregnancy and through start of labor

SCHIP

60 days postpartum care

State-only funds

Labor and delivery services

Labor through delivery

Emergency Medicaid

Idaho (6/21/05)

SCHIP §1115 HIFA

up to 185% workers in small businesses

Premium assistance for private insurance (must cover postpartum care)

Confirmed pregnancy through 60 days postpartum

SCHIP pays for premiums only

Defined in participating private coverage plans

SCHIP pays for premiums only

Louisiana (4/5/07)

Unborn Child SPA

0%-200% undoc. aliens

SSP to provide prenatal care, care related to the pregnancy, and delivery services

Confirmed pregnancy through delivery

SCHIP

No coverage except emergency services under Medicaid

Medicaid

Massachusetts (9/15/03)

Unborn Child SPA

200% undoc. aliens

SSP prenatal care, associated health services, labor and delivery

Conception through birth

SCHIP

60 days postpartum care

State funded program and free care pool

Michigan (4/17/03)

Unborn Child SPA

185% FPL undoc. aliens

SSP includes prenatal care, pregnancy-related care, and non-pregnancy related care (up to birth of child) labor and delivery, and 60 days postpartum care

Conception through 60 days postpartum

SCHIP

Labor and delivery and 60 days postpartum care

SCHIP (treated as a bundled service)

Other health coverage (e.g., broken arms)

Emergency Medicaid

Minnesota (8/6/03)

Unborn Child SPA

275% undoc. aliens

SSP Medicaid look-a-like program covers pregnancy-related services, prenatal care, labor and delivery, and limited postpartum care

Conception through end of the month in which the child was born

SCHIP

60 days postpartum care

State-funded

Nevada (11/2/06)

SCHIP §1115 HIFA

133%-185%

Medicaid pregnancy -related benefits including prenatal care, related health care, labor and delivery, and 60 days postpartum care

Conception through 60 days postpartum

SCHIP

60 days postpartum care

SCHIP

New Jersey (1/18/01)

Medicaid and SCHIP §1115 HIFA

0%-200%

Presumptive eligibility program includes prenatal care, labor, and delivery

Temporary eligibility until determined eligible for Medicaid

Medicaid

Emergency Medicaid for labor and delivery services only

Emergency Medicaid

0%-185%

New Jersey Medicaid package includes prenatal care, labor and delivery, and 60 days of full Medicaid coverage

Conception through 60 days postpartum

Medicaid

60 days full comprehensive Medicaid

Medicaid

186%-200%

Conception through 60 days postpartum

SCHIP

SCHIP

Rhode Island (4/17/03)

Unborn Child SPA

185%-250% undoc. aliens

Medicaid benefit package includes prenatal care, labor and delivery

Conception through labor and delivery

SCHIP

Extended family planning family services and supplies for 24 months

SCHIP

60 days postpartum care

State-only funds

Rhode Island (1/18/01)

SCHIP §1115

185%-250%

Medicaid benefit package (i.e., prenatal care, labor and delivery, and 60 days postpartum care)

Conception through 60 days postpartum

SCHIP

60 days postpartum care and extended family planning family services and supplies for 24 months

SCHIP

Virginia (6/21/05)

SCHIP §1115 HIFA

133%-185% (approved up to 200%)

Full Medicaid benefits (not pregnancy only benefits)

Conception through labor and delivery

SCHIP

Coverage for the remainder of the birth month plus 60 days postpartum coverage.

SCHIP

Tennessee (10/3/07)

Unborn Child State Plan Option

185%-250%

SSP Pregnancy-related services including prenatal care, labor and delivery, and 60 days postpartum care

Conception through 60 days post partum

SCHIP

Coverage through the last day of the month that 60 day post partum period occurs

SCHIP (treated as a bundled service)

Texas (6/2/06)

Unborn Child SPA

200% undoc. aliens

SSP to provide prenatal care, labor and delivery, and 2 postpartum visits

Care ends at the end of the month during which the child is born. There are no public benefits after that except if the mother qualifies for emergency Medicaid services.

SCHIP

Washington (9/22/03)

Unborn Child SPA

185% undoc. aliens

SSP, Benefits includes prenatal care and associated health services

Conception and through start of labor and delivery

SCHIP

60 days postpartum care

state-only funds

Labor and delivery

Labor and delivery

Emergency Medicaid

Wisconsin (5/7/07)

Unborn Child SPA

185% undoc. aliens, and uninsured and/or incarcerated women

SSP Badger Care prenatal program provides for prenatal coverage including cost of labor and delivery and 60 days postpartum care

Conception through 60 days postpartum

SCHIP

60 days postpartum care allowed for all but undocumented aliens

SCHIP (treated as a bundled service)

Undocumented aliens emergency Medicaid only

Emergency Medicaid

Sources: Section 1115 waiver terms and conditions documents, SCHIP unborn child state plan amendments, and conversations with state officials.

Notes: SPA means State Plan Amendment, HIFA means Section 1115 Health Insurance Flexibility and Accountability Waiver, AIM stands for Access for Infants and Mothers program, HCBS stands for Medicaid Section 1915(c) Home and Community-Based Waiver, SSP means SCHIP Separate State Program, and a Medicaid look-a-like program is a Separate SCHIP Program with a benefit package that looks like Medicaid, but may exclude, for example, certain services.

Footnotes

1.

Section 1903(v) of the Social Security Act.

2.

Section 2110(b)(2)(A) of the Social Security Act.

3.

Illegal immigrants are barred from Medicaid and SCHIP eligibility; legal immigrants who have not been granted lawful permanent residency status are ineligible for Medicaid or SCHIP for five years. Such women who otherwise qualify but for their documentation status have access to emergency care under Medicaid, which includes labor and delivery costs (Section 1903(v) of the Social Security Act).