Department of Health and Human Services

OFFICE 
INSPECTOR GENERAL

MEDICAID EXPANSIONS FOR

PRENATAL CARE: STATE AND LOCAL

IMPLEMENTATION

7f. 
Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-06-90-00160  EXECUTIVE SUMMARY

Ths inspection descnoes State and loca effort to implement eligtoilty expansions 
for Medicaid-covered prenata cae and to overcome barers to accssibilty and 
avaiabilty of prenatal cae. 
BACKGROUN 
Aimed at reducing the incidence of inant mortality and low birweight, Federal 
legislation allows more women to meet the income criteria for Medicaid-covered 
prenatal care. States are now mandated to set income eligIoilty at 
133 percent of 
the Federal povert level, guarantee contiuous eligtoilty unti 60 days post partum 
extend the presumptive eligtoilty period up to 60 days for States choosing ths 
option, use special pregnancy-related application form, use application sites other 
than where Aid to Famies with Dependent Chidren applications are processed, and
eliate 
paternty establihment as a precondition to receive Medicaid-covered 
prenatal care. Additional Federal options allow States fleXloilty to set an income 
standard up to 185 percent of the Federal povert level, use of presumptive eligibilty 
to provide temporary ambulatory care while formal Medicaid determations are 
being made, and to disregard assets when makig eligibilty determinations. 
MEODOLOY 
We conducted site visits in 19 communties withi eight states (Alabama, Arkansas 
Colorado, Florida, Maryland, New Jersey, New Hampshie, and Pennylvania). 
Providers, eligtoilty supervsors and workers, and prenatal clients were intervewed 
and a number of implementation issues were identifed. We also conducted a 
national telephone survey of 51.State and Distrct of Columbia offcials responsible 
for implementig the eligtoilty expansions. Along with self-reported inormation, we 
analyzed applicable Federal and State laws, policies and procedures, plus reviewed 
outreach materials and application forms. 
FIINGS 
Jan 
figs ar 
(All  info17tin as of  1991)
based  on 
Al State Have Set Their Income Stadad at 133 Percent of the Federa 
Povert Leel. In Addition, Man Oters Have Endors Optiona ElgIoilty 
Exanions. 
. 46 States waive the asset/resource test.  Some State Are Takg Positie Steps to Addres Problems with Acc and 
Awibilty of Medcad-Cered Prnata Cae. 
. Comprehensive client outreach materials 
. Streamled and simplied application processes 
Provider participation incentives 
Alternative health care providers

. Case managers and enhanced prenatal care packages 
Integrated data collection 
Potential Cost Reductons Wil Exce $97 Mion if Neonata Intensive Cae Is 
Reduce by 
Just 1 Percent. 
RECOMMATIONS 
Deelop A Comprehee Oueach Strteg. 
Pres 
Simplif and Streaml th Applitin 
Prvi Parttin. 
Develop Incenes to Inceae 
Impletin 
Clri Poli and Monior  of Medid Exnsns. 
Deelop Data Collctn Syst and Evalutin Preses to Mease Pres
th Eligiil Exnsns  Fut Prm 
and  Effect 
Esblih a Celied Authori wi Ful Resnsil  Impleg

for 
Exansns.
 .....y.. .......................................................................................................................
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. . ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ...   ...   ...   ....    ....    ....    ....    ....    ....  .  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .  .. ..  .  ... .   . ... .   . ... .   . ... .   . ... .   . ... .   . ....     ....    ....    ...   ...   ...   ...   ...   ...   ...   ...   ...   ....    ....    ....    ....    .....     .....     ... .. . .    .....     .....     ....    ....    ....  ....   . 
TABLE OF CONTENTS 
INODUCTON 
Purpse. .. . . . 

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

FIINGS 
fi 
It1 
infom 
(Al  as of  1991) 
lI baed  Of 
Le 
Al States Have Set Thei Inmme Stada at 133 Pert of the Federa Pov 
Adtion, Ma Oth Ha 
Endors OptiDB Elgibilty  ions . . . . . . . . . . . . . . . . . .. 
Howr, Signcat Prble Prnt New Elgible Women frm Recivg
RdPn 
cUd  .............................................. 5 
Client Outreach Is Inadequate 
Women Are Not Completing the Cumbersome Application Proces. . . . . . . . . . . . . . . 

States Have Difculty Reciting Prenatal Care Providers. . . . . . 

Adintrative Complexties Discourage Broader Use of Presumptive Eligibilty

Lack of Staffg Hiders Procing of New Elgibles in Most States

States Request More Timely Inormation and Tring from HCFA . . . . . . . . . . . . . . . . .. 

Prgr 
HCFA and !dost State Caot !deaur the  and Impa of the &pions 
...... .. 11 
Aa 
Some State Ar TackUg Pdo-sCiti  Steps to ACdad r Prblem with  and
Avabilty of  Prnata 
Several States Have Develope Comprehensive Clent Outreach Materials

Several States Have Streamlined and Simplified Their Application Proces. . . . . . . . 

Some States Offer Provider Incentives to Increae Panicipation . . . . . . . . . . . . . . . . . 

Many States Use Alternative Providers

Some States Use Cae Managers and Provide Enhanced Prenatal Care Packages. . . 
Some States Have Integrted Data Collecion Points to Evaluate Future Outcomes. . . . . .. 16 
Ex 
Potenti Cot Reductons Wi  $9 Mion if Neonata Intensiv 
Pernt. 
Is Reduce by Just 1  INTRODUCTION

PUROSE 
Ths 
inspection describes State and local effort to implemnt eligibilty expansions for 
Medicaid-covered prenatal care and to overcome barrers to accessibilty and 
availabilty of prenatal care. 
BACKGROUN 
Congressional concern about the health status of pregnant women has led to 
signcant Federal and State Medicaid eligibilty expansions in recent years. (See
Appendix B.) The impetus for these reforms stems from 1) the United States' poor
showing among other nations in regard to infant mortalityl; 2) concern over the 
excessive health care costs to maintain low birhweight babies vis-a-vis the low cost of 
providing prenatal care%; 3) growig numbers of low income women who are 
uninsured for pregnancy-related health care ; and 4) unsatisfactory progress in

achievig the 1990 Health Objectives for the Nation

Today, states are Federally mandated to extend 
pregnancy-related care to women
who have incomes up to 
133 percent of the Federal povert level, with an option to
use 185 percent of the Federal povert 
level. (See Appendix C.) Other Federal
mandates affecting ths group are: 
eliminating paternty establishment as a precondition to receive Medicaid-
covered prenatal care; 
guaranteeing continuous eligtoilty throughout pregnancy until the end of the 
month in which 60 days postpartum occurs
, regardless of income changes; 
applying at sites other than where Aid to 
Family with Dependent Children
(AFDC) applications are normally processed (effective July 1
, 1991); 
using specific application forms for Medicaid-covered prenatal care (effective 
July 1, 1991); and 
extending the time period for presumptive eligibilty if a State 
chooses this 
option to provide temporary ambulatory care while a formal Medicaid 
application is being processed 
(effective July 1, 1991). 
States also have the option to waive an asset test when determining a pregnant 
woman s income.  5) offerig traing and techncal assistance to states wishig to unplement 
presumptive eligibilty, targeted case management, servces for pregnant 
teenagers 
using EPSDT, additional care to high-risk mothers and inants through freedom-of
choice waivers, as well as other available options. 
Durg 1990, HCFA developed a marketig gude for HCFA Regional Offces to use 
with State legislative, governent, and fiance staff; held thee multi-regional/tate
maternal and inant health conferences; and entered into a contract with the 
American College of Gyecologists and Obstetricians (ACOG) and the Public Health 
Servce (PHS) to develop gudes to promote provider recrutment and retention. 
Healthy Start 
The Healthy Start program targets 10 project areas with 
exceptionally high rates of
infant mortality. Some of the specifc  enrollg
objectives of this intiative are: 1) 
more women in prenatal care durig their fist trimester; 2) decreasing the number
of low birhweight babies; and 3) decreasing the infant 
mortality rate. 
The  Secretary s Task Force on Minori Health 
The Task Force on Minority Health 
was created to 1) identif and coordinate HHS

programs that serve minority populations ; 2) address barrers to improved health

among minority populations; 3) identify successfu models of health interventions in 
specific minority populations; and 4) recommend actions to 
increase the number of

minorities served by HHS, plus ways to improve the quality of servces aleady

delivered to these groups'. One of the major areas of Task Force concern is the

delivery of servces to pregnant women. 
Recent Ofce of Inspector Genera (OJQeport 
A recent management 
advisory report "Access to Medicaid-Covered Prenatal Care 
preliar 
(OEI, October 1990), presents  fidigs 
regarding barrers to State and
local implementation of Medicaid prenatal care expansions. Effective techniques
used by states to implement these expansions were also highlighted. Another study
assessed the implementation of the 
Comprehensive Perinatal Care Program (CPCP), 
an intiative of the PHS (OEI, May 1990). The OIG recommended that the PHS 
reexamine its method of allocating 
CPCP funds to assure community and migrant 
health centers in areas with high inant mortality rates receive this support. Finaly,
another study examined a local program to reduce infant 
mortality. Findings 
indicated that successful implementation strategies should include targeting client 
outreach, conducting risk assessments, ensuring adequate clinical servces, and
fostering indigenous community leadership (OEI, July 1989).  FINDINGS

ba 
Th  an  Douuati u of JanUl 
1991.
fo  on 
1H 
~ AI STATE HAVE SE  LINEroM E STANAR AT 133 PERCE 
TH FEER  MA 
OF  POVETY  IN ADDmON, 
EIGmll 
ENRSED 
HAVE  OPTONAL  EXANSIONS. 
St 
Overheg 
An  CoMnajotr iE of lil. Have Waived th Aset/Resour Tes an Ar 
Guaranteig 
waived the asset/resource test and 45 States guarantee 
Fort-six States have 
contiuous eligtoilty unti the end of the month in which 60 days postpartum 
occurs. (Since the tie of our data collection, States are now mandated to 
contiue benefits unti the end of the month in which 60 days postpartum 
occurs. ) 
Voluri Ered th 
Twen10ur States  Mandte Fedl Incme 
Standrd Used 
Deter Eligiil. 
to 
Eighteen States use an income standard up to 185 percent of the Federal

povert  determe 
level to  eligibilty; one State is using 155 percent of the 
Federal povert level; four at 150 percent of the Federal povert level; and one 
at 140 percent of the Federal povert level. 
Elil 
Twen- Ar Usig Presptie  Prvi 
Prtas i State  to  Temporary Amultory
thd 
(Over one- of the States without presumptive eligtoilty 
Care 
report expedited formal eligtoilty determinations. 
Appendi E compares States' implementation of the eligtoilty expansions 
, as of
January 1991. Shown are implementation dates for presumptive eligtoilty, asset
test waiver, contiuous eligibilty, and Federal income standards used to 
determne eligtoilty, plus an  reportg 
indication of States  expedited eligtoilty
determations. 
~ HOWEVE SIGNICA PROBLE PREVE 
MEICAVEN EWLY EUGmLE
WOME FROM RECEIVG  PREATAL 
Cl  Inate 
Oueach Is 
Few States have coordinated. ongoing. and targeted client outreach. 
Although
the majority of State respondents (84 percent) report some efforts to 
heighten
awareness of the eligtoilty expansions, it is neither intensive nor extensive. Most 
States rely on the 'welfare grapevie" (81 percent) as a primary means of  ; "
want(ing) to disclose their income  (not) really want(ing) prenatal care anyway 
and women  tending to be afraid of anything offial 
Lengthy. complex forms . Only 17 States use an application form tailored for 
ca 
Medicaid-covered prenata care. Formal applications  vary in length from 
one page to over 30 pages. One respondent from a State using a 34-page 
application form described it as  somewhat complex 

In several local welfare offces, some women only wanting Medicaid-covered 
prenatal care felt coerced into applyig for additional public assistance programs. 
Their frstrations are exemplified by such statements  (1) wasn t sure what to 
as: 
all I wanted was Medicaid for prenatal care.  t want Food 
fil out because  I didn 
Stamps or AFDC. I didn t even start filing (the applicatin form) out. I looked 
through it and said '  GADS  II or
 We knew we weren t going to need this 
(Medicaid-covered prenatal care) once my husband had a job. The social worker at 
social services kept pushing us to sign up for other programs and all we wanted was 
(Medicaid-covered prenatal care). All this pushing made me not want to go back; 
they didn t seem to understand all we wanted was (Medicaid-covered prenatal 
care). 
Multiple application sites and appointments
. During our local visits, 87 percent
of the presumptively eligible women reported changing sites to reapply 
for 
continued Medicaid-covered prenatal care, with 91 percent of this group going to
a local welfare agency. In most caes, these women were not able to complete
this task on the same day they were determined presumptively eligtole. Before 
an intervew with a formal application intake worker, they either made an 
appointment and returned another day or first attended an orientation. 
As pointed out by one State 
respondent,  Appointments for formal applicatin are 
set arbitrarily and the women do not get to choose their appointment tie. 
This 
additional step is especially burdensome for working women and parents who 
must rearrange their work schedules. Over half of 92 local supervsors
, eligibilty
workers, and providers confied ths delay as a problem for women seeking 
prenatal care. Even though most local sample States (6 out of 8) report
outstationing eligibilty workers in places where women are more 
likely to seek 
prenatal care, we did not observe its widespread use. The majority of eligibilty
workers (31 out of 41) and supervsors (9 out of 
15) confirmed this finding. 
Also, while over hal of the State respondents report outstationing 
eligibilty
workers, it is usually at selected sites. 
Welfare stigma " Qosely associated with requiring women to go to the local 
welfare office to formally apply for 
Medicaid-covered prenatal care is the fear 
of being thought of as a welfare recipient. Such comments by State respondents 
The welfare stigma is a big problem. Underemployed
, intact families don t want  ; "
concern is expressed in such statements as: 
 OB's are settg quotas on the

number of Medicaid clients they will acceptll 
percent

partipatin  Iwe have) less than a
 25
physician 
rate lin our State)";  and  'Doctors claim they have plenty of 
paying customers so they don t need Medicaid patients. " 
Several State respondents think providers' attitudes toward IIwelfare women" limit 
their acceptance of Medicaid patients. They believe 
providers view women as 
enterig prenatal care later in their pregnancy than non-welfare patients, not 
being as cooperative, and not keeping their appointments as well. 
Some providers have problems with presumptive eligibilty
. Eight of the 26 State
respondents from presumptive eligibilty States report problems with some 
providers not making presumptive eligibilty determinations; 10 of these 26 say 
some providers are not willng to accept presumptive eligibilty cards. 
During the site visits, we found that restricting presumptive eligibilty 
coverage to
ambulatory care was a problem in some instances. If the need 
arises for hospital
inpatient care (for such complications as miscarrage, premature delivery, or an 
ultrasound), a presumptively eligible woman is not covered. 
As pointed out by
one provider affected by this situation and who no longer accepts 
presumptively
eligible women  'Most providers feel morally obligated to offer the full-range of

services for women once they are in (his/her) care. My fit 
three presumptively

eligible patients all had to be admited to the hospital: one delivered, one needed a

dilatin and curettage); and one miscarrd. 
& C 

Limited access to eligtoilty verification systems !tampers provicter partfcipation

and creates biling problems
. Although 92 percent of the States have an

automated verication system, only 53 percent allow provider access. One-third

of the States report ths is a problem 
for providers. Also, restricting provider

lieliood of 
access increases the  bilg errors, especially for servces rendered
durig the presumptive eligibilty period. 
Reimbursement rates are low and reimbursement turnaround is slow 
. Eighty-two 
percent of State respondents say low reimbursement rates contribute to provider
dissatisfaction; over 50 percent say slow turnaround for reimbursements is also a 
disincentive. 
Liabilty issues hinder participation. Six-nine percent of the State respondents
think providers don t participate in Medicaid-covered prenatal care because of
the high cost of liabilty 
insurance. Also, 61 percent of the State offcials say
providers' perception that Medicaid clients are more likely to sue makes it 
diffcult to recrut providers.
 workers must identify rejected cases and redetermine 
eligtoilty incorrectly so that 

eligibilit. "

Despite these complaints about slow policy communcation and lack of trainng,
80 percent of the State respondents do fid HCF A helpful in providing technical 
assistance. Also, when policy guidance is issued, 71 percent of State respondents
report it is usually clearly wrtten. 
However, when asked how HCF A could be even more helpfu, the State offcials 
request clearer and less complicated policy statements; pre-printed State Plan 
amendments; and, as one administrator indicated  'HCFA should coordinate the 
sharing of informatin among States. 
HCFA AN MOST STATE CANOT MEUR TH PROGRE 
IMACf OF TH EXANSIONS. 
Stte-Reported Data on Prm Parttin Appers Incomple and of
Qunable Acccy. 
Respondents from 22 States could not or did not estimate 
the number of new 
eligibles served, or to be served, in 1990 and/or 1991. (See Appendix G.
) Only
17 State representatives could report the total number 
of formal applications
made by new eligibles for any (or all) of the past four years. Additionally, 10 of
the 26 respondents from presumptive eligibilty States do not keep 
data on the 
number of women currently presumptively eligible. Also
, just 11 representatives
from presumptive eligtoilty States submitted the number of 
presumptively
eligible women who were subsequently denied formal eligtoilty. 
Along with some of the State respondents
, we question the accuracy of this
incomplete program participation data. A cursory examination of Appendix G
raises several concerns about the validity of the provided data. 
Several of the States with large populations do not report data
, and
in other States some of the estimates do not seem to be consistent 
with the size of their Medicaid populations. 
We are concerned that the reported increases in non-AFC 
women may include not only new eligibles but also signifcant 
numbers of AFC-eligible women who are being enrolled more 
rapidly under the new, less restrictive eligibilty requirements. This 
concern was supported by the four State representatives who 
submitted data on the number of new eligibles who later qualified
AFC. 
for  For example, in one State over two-thirds of the new  postparum cae (Ginsburg, Lewis-Idema, and Pettigrew 1989), it is not surprising 
th 
they cannot report  inormation. Even when they can, only 16 State 
respondents could identi the agency collectig the number of prenatal visits. 
Only 20 State representatives claim they can provide information about the 
trester a newly eligible woman enrolls in prenatal care. Of these, only three 
States actually submitted this requested data. Also, almost one-fourth of the 
State respondents say they do not capture race/ethcity for the new eligibles. 
(See Appendix F. 
Local sites also reflect problems with collecting data. Almost two-thirds of 
51 local supervsors and providers do not have access to completely 
computeried data collection systems. Even when they do, new eligibles are not 
usually distinguished from AFC-eligible pregnant women. 
AR TAKG POSIT STS TO ADDRE 
PSOMRE  OBSTLATE E  ACC AN AVAIIL  MEICAI-CVE 
OF  OF 
PREATAL CAR12

Cl 
Severl States Have Deelope Comprehe  Oueach Materls. 
Unique logos are being used to heighten awareness of the benefits of receiYi 
early and continuous prenatal care. Distictive logos used to identify a State 
outreach campaign are "HealthStart" (New Jersey), "Healthy Start" (Ohio 
Wisconsin, and Massachusetts), "Baby Your Baby" (Utah); "MICHcare 
(Michigan); and "Baby Care" (Colorado). These themes are found throughout all 
their outreach materials.

Materials descnoe the benefits and availabilty of prenatal care
. In a 
Massachusetts' "Healthy Start" brochure, Medicaid-covered prenatal care servce 
is not referred to as a welfare program but rather as a way to receive health 
insurance for pregnancy-related care. It also lists a toll-free telephone number
so pregnant women can locate a doctor or 
nurse-midwife and provides 
information about food assistance programs and other community resources. 
Current income eligibilty levels are clearly stated in brochures developed by 
Michigan. From ths inormation, a woman can quickly see if she meets the 
income and family-size qualifications used to determne eligibilty for Medicaid-
covered prenatal care. Documentation required at the time 
of application and
available enhanced servces (transportation to provider sites and 
educational 
classes) are also listed. A separate two-sided leaflet describes Michigan s 24-hour 
prenatal care telephone 
lie which provides information about servce benefits 
and availabilty, as well as information on WIC.  Arkansas and Louisiana to simpli the 
application process; however, the women
are stil requied to change application sites. 
Some States are e'iediting formal eligtoilty determinations once 
alLhe reQu
documentation is received. Over one-third of the States report expedited formal
determations, with Alaska and Oregon reporting five day 
processing times.
Other States claiming to expedite formal determinations are Virginia (10 
days),
Vermont (10 days), West Virginia (13 days), Arona (14 days), Minnesota 
(15 days), and Washigton (15 days). 
Eligtoilty workers are being outstationed by some States. 
Some of the 
alternative sites that States are using to outstation eligibilty 
workers include: 
high-volume hospitals (Florida, Louisiana, Mississippi, Missouri, North Carolina
Texas, and the District of Columbia); perinatal clinics (California); and WIC sites
and health offces (Vermont). Ths 
approach puts eligibilty workers in locations
where pregnant women are most likely to seek prenatal care and
, also, separates
the application site from the welfare offce
, thus helping diffse the ''welfare 
stigma. 
Prvi  Parttin. 
Some States Ofer  Incenes to Inceae 
Special efforts are being made to recruit providers
. Currently, 75 percent of the 
States report effort to encourage new providers to accept women eligible for 
Medicaid-covered prenatal care. Many States are conducting educational training
to dispel negative provider attitudes toward '
'welfare '' women. States are meeting
with medical societies and 
physician groups, forming task groups and conducting

provider surveys to identify barrers to provider participation.

Connecticut has provider-relation representatives to assist with problems 
encountered with Medicaid patients; Minnesota has hired a staff person 
designated to handle provider problems. 
Maryland and Texas use nurses to
recruit providers. Michigan has billng representatives who help doctors file 
Medicaid claims. 
Some States have increased reimbursement rates and provide 
assistance with
liabilty protection
. The state of Washington allows higher reimbursement rates 
for primary care clinics located in distressed areas. Louisiana 
reimburses at
90 percent of private insurance rates. Maine offers 
$5000 - $10,000 supplements
toward medical insurance if obstetricians and gyecologists agree to practice in 
areas where there are provider shortages. A state legal defense fund to help
with malpractice litigation has been established in 
Missouri. Florida extends 
sovereign immunity (legal protection) to providers 
of Medicaid servces.  POT 
COST REUCTONS Wl EXCE $97 MION 
INSIV CA 
NENATAL  IS REUCE BY JUST 1 PERCE. 
li 
The  between inant mortlity, low birweight, and lack of adequate prenatal 
care has been well-documented (Chdren s Defense Fund 1989; Committee on 
Governent Operations 1988; GAO 1987). A woman who does not receive 
early and continuous prenatal cae triples her risk of deliverig a low birhweight 
baby (GAO 1987). Among low birhweight babies, about half require expensive 
neonatal intensive care, costing from $12,000 to $150 000 per child (Offce of 
Technology Assessment 1987). Unfortunately, low birweight babies are 
40 times more likely to die durig their fist week of lie (GAO 1987). Even if 
low birhweight babies survve, they are at signficantly increased risk of suffering 
lielong physical or mental disabilties. 
Low Birhweight Babie Are Ver Costly. 
Low birthweight babies account for a very disproportionate 
share of the costs of 
maternity care paid for by Medicaid. As 
shown in Figue 1, the Alan 
Guttmacher Institute (Torres and Kenney 1989; Kenney, Torres, Dittes, and 
Macias 1986) has estimated that six percent of all 
Medicaid-subsidized deliveries 
require expensive neonatal intensive care which comprise fully 30 percent of 
Medicaid maternity care costs. The average cost of neonatal intensive care is 
$15 814, as contrasted with a normal birweight delivery which costs $2 948. 
Figue 2

LBW DELIVERIES 
CAUSE DISPROPORTIONATE COSTS 
Percent

100  94%

Percent of Cost 
2f/o	 Percent of 
Deliveries 
Normal	 LBW 
Delivery  Delivery 
Source: Alan Guttmacher Institute figure based on the estimated

cost for delivery and care for a baby (Kenney et ai, 1986).
 FJI 2

RE 
MEAD  8IRTHGHT

LOW 
BABIES SAVES LIVES AND MONEY

Low Biweig,t Baby
 Normal Size Baby 
verage Medicaid
 Average Medicaid 
delivery cost  delivery cost 
$1,950  $3,533 
According to an Alan Guttmacher 
Institute study (Torres et al. 1989; 
Kenney et al. 1986), Medicaid subsidizes
deliveries for about 630,
000 low income 
women each year. Six percent of all 
$97.1 million  Medicaid deliveries require neonatal 
intensive care and cost an average of 
$18,950 amounting to a total cost of 
Amount saved if number of low  $716 milion. If the number of low 
birthweight babies requiring neonatal
birthweight babies requiring 
intensive care is reduced by just 
neonatal intensive care is 
reduced just  $97.1 milion wil be saved.  testing, and even grocery stores, laundromats, and shopping centers to 
locate new eligibles. 
- Use communty residents, women who have received Medicaid-covered 
prenatal care and AFC recipients in the Federal Jobs Opportunty 
and Basic Skils (JOBS) program as outreach workers. 
could 
~ HCFA 

. Collaborate with the National Center for Education in Maternal and 
Child Health, supported by PHS, to serves as a repository and distnoution 
center for State and nationally-developed Medicaid-covered prenatal care 
outreach materials. The HCF A central offce, coordinating with regional 
HCF A and PHS staff, would need to periodically identify, collect, and 
issue a compendium of inormation to the National Center. State 
Medicaid and Maternal and Child Health directors would need to be 
notified of available materials and subsequent updates. 
matching Federal funds are available to assist with State 
. Clarify that 
effort to conduct client outreach. 
Healthy Start National Public 
. Coordinate outreach effort with the 
Information Campaign. Such effort should stress the benefits of 
Medicaid-covered prenatal care as preventive health care rather than 
welfare-related assistance. 
could 
~ States 

. Create a unique and readily identifiable theme and "logo" for the prenatal
care campaign. 
. Establish a statewide toll-free hotline, coordinated with existing MCH
hotlines, to provide information about access and availabilty of Medicaid-
covered prenatal care. 
Streame  Proc. 
Simpli and  the Application 
~ HCFA should: 
. Ensure, in reviewing and approving State Plans, that States comply with
the requirements to: 
- Use outreach locations other than welfare offces to accept and begi
processing applications for Medicaid-covered prenatal care.  - Provide sufcient reimbursement to ensure adequate numbers of 
providers are available to deliver Medicaid-covered prenatal care. 
- Specify the noninstitutional obstetrical payment rates in Medicaid State 
Plan amendments. 
- Provide payment for servces rendered by certified nurse practitioners 
or certifed family nurse practitioners if they are authoried under State 
law to perform those servces. 
~ PHS should: 
. Use loan repayment and the National Health Servce Corp recruitment 
programs to increase the number of doctors, nurses, and other health 
professionals servng pregnant women. 
~ States sbould: 
. Survey providers to assess bow many are both available and willng to
deliver Medicaid-covered prenatal care. 
. Set reimbursement rates for Medicaid-covered prenatal care at a level 
suffcient to ensure that an adequate number of 
providers are available to
deliver this care. 
. Promote expanded use of alternative health care providers to deliver 
routine Medicaid-covered prenatal care. 
. Assess the feasibilty of assisting providers with liabilty insurance 
increase their partcipation in delivering Medicaid-covered prenatal care. 
. Alow provider access to state eligtoilty 
verication systems. 
could 
~ HCFA 

. Develop a legislative proposal to guarantee temporary Medicaid 
coverage
until the end of the presumptive eligibilty period. 
This coverage would
allay provider apprehensions of havig to continue care for women later 
found ineligible for full Medicaid benefits. 
. Develop a legislative proposal authoriing full Medicaid benefits for 
pregnancies deemed at high-risk during the presumptive eligibilty period.  . Pending the development of such a system to track participation rates 
consider using probabilty samples to estimate the number of newly
eligible women enrolled in Medicaid-covered prenatal care. 
. Work with MCH, ACF, State Medicaid directors and State public health 
offcials to develop 
measure the 
minimum reportng requirements to 
effects of the eligibilty expansions on improved 
birh outcomes. Minimal 
data elements should include: the health status of all partcipants 
(substance abuser or medically high-risk pregnancy); demographic 
inormation (age, race, marital status, income, family size, educational 
level, and employment status); trimester enrolled for prenatal care; the 
bir 
number of prenatal care visits completed;  outcomes (live or dead); 
and the baby s birhweight. Also, to avoid duplication of effort, HCF A
should coordinate with the PHS Interagency Committee on Infant 
Mortality (ICIM), Data and Surveilance subgroup in its development 
of a 
Federal maternal and infant health data 
strategy. 
~ States should: 
. Develop either a centralized data collection 
system or enter into formal
agreements with other agencies to assure access to information needed 
for evaluating outcomes. 
could 
~ HCFA 

. Work with MCH, ACF, State Medicaid directors, State public health
offcials, and the State Bureaus of Vital Statistics to assess the potential
of linking existing databases, e.g., eligtoilty, medical payments, vital
statistics, to measure both participation rates and outcome 
measures. 
. Plan and seek funding for a multi-
year evaluation of the effectiveness of 
the eligibilty expansions on improved birth outcomes. 
The evaluations 
should be structured to permit separate 
analysis of women considered at
high risk (substance abusers
, medically high-risk
, etc. 
could 
~ States 

. Conduct an evaluation of implementation effort and their subsequent
impact on lowering infant mortality rates and the 
incidence of low 
birthweight babies. This could be 
done in conjunction with HCF A and 
other appropriate agencies.
 ENDNOTES

In 1986, the United States place eighteenth worldwide for overall infant monality, behind such 
nations as Spain, Singapore, and Hong Kong. When considered alone, the black infant monality
rate place the U.S. twenty-eighth, behind Cuba, Bulgaria, and Czehoslovakia, and tied with
Poland, Hungary, Portugal, and Costa Rica (Children s Defense Fund 1989). 
Children s Defense Fund (1989) projec that between 1989 and the year 
200, approximately $6
bilion will be spent in first-
year costs alone to care for low birthweight infants whose mothers 
recive inadequate care during pregnancy. 
In 1985, one out of four women of childbearing age had either no insurance or, if insured, were
not covered for maternty care. The uninsured women were almost three times more likely to 
get delayed prenatal care than women with private health 
inurance (Children s Defense Fund
1989). 
Goals directly related to prenatal care, low birthweight, and infant monality are: 1) reducing the
national infant monality rate to no more than nine deaths per 1 00 
live births; 2) reducing
infant monality rates for specfic subgroups and regions to no more than 12 deaths per 1,
live birhs; 3) reducing the national incidence of low birthweight to no more 
than five percent of
all births; 4) reducing the incidence of low birthweight for specfic subgroups and regions to no 
more than nine percent;  5)  enrollng 90 percent of all pregnant women in prenatal care in their
first trimester; 6) enrolling viually all women in a regionali system of primary, secndary,
and tertiary care for prenatal, maternal
, and perinatal health servce; and 7) ensuring all women
have appropriately attended deliveries (Children 
s Defense Fund 1989). 
The Minority Health Initiative 
categori Blacks, Hipanics, Asian and Pacific Islanders, and

American Indians/Alaskan Natives as the predominate U.
S. minority populations.

To develop the Minority Health Initiative, an interdepartmental workshop wa held 
to identify
and recmmend how to improve exiting HHS 
servce and how to reach increaed numbers of 
minorities. Representatives from each Operating Diviion (OPDIV and Staff Diviion
(STAFIV 
were members. In addition, key informants from 
each predominate minority group
met for an informal discuion to exchange idea on how servce delivery of HHS programs to
minority populations can be improved. A report wa submitted to the Secetary on the Minority
Health Initiative as an internal HHS docment on 
November 13, 199. 
Subsequent to our field work, OBRA-90 mandated use of specal application form 
for
Medicaid-covered prenatal care. Appendix F ilustrates some of the problems this new
legislation wa designed to resolve. 
Transponation servce are available by invoking Section 1902(a)(8) of the Socal Security Ac
which guarantee an individual the opportunity to apply for 
medical asistance and be helped
with reaonable promptnes; Section 1902(a)(19) requires that this 
gurantee be safegurded and
that eligibilty for care and servce will be provided in a way that is consistent with simplicity of
administration and in the best interest of the recpient; and 
Section 1903(a)(17) provides that
Federal matching funds are available for activities deemed 
necsary for the proper and effcient
administration of the State Plan. However, the State must 1) use the leat costly 
mode of 
transportation and 2) use any other available funding source(s) which provide transponation 
without charge g., church groups or charitable organizations. 
, e. APPENDICES

Glossary of Terms 
Appendi 
Appendi B:  Signcant Legislative Changes 
Appendi C:
 1991 Federal Povert Guidelines for Pregnant Women 
Appendi D:
 Methodology of Local Site Selection 
Appendi E:  Coverage Options for Pregnant Women, as of January 
1991 
Appendi F:  Comparison of Select Information on Formal Eligibilty Forms 
as of January 1991 
Appendi G:  State Reported Statistics--Estimations for 1990, 1991 
Appendi H:  References 
Appendi I:  Sumary of HCF A' s Comments to Specific Recommendations 
and OIG's Response 
Appendix J:  Departmental Comments: Health Care Financing 
Administration, Public Health Servce, Administration for 
Children and Families, and the Assistant Secretary for Planning 
and Evaluation  APPENDIX A

GLOY 
OF 
CI 
Fam 
Ai to  (AF: Cah payments to eligible neey famies with
with 
dependent chdren to cover 00ts for foo, shelter, clothig, and other items of daily livig deemed 
necry 
by each State. 
Cu 
Ambulto 
Refers to outpatient servce. 
Asun 
Wai 
Test  Asts and resource , a car, home, capital gain, gif, or loan 
, e.g.
(Federal Regiter, Februry 20, 1991), are not counted when calculating a woman s income to 
determe eligibilty for Medcaid-cvered prenatal care. 
Contiuo1l EI"bDity Guarantee coverage for Medcaid serVce from the time a pregnnt women 
is formally accpted until the end of the month in which her 60 days  ocrs. 
post panum 
Fe Pov Le A simplied version of the Federal Goernment' 
s statistical povert theshold
used by the Bureau of Census in accrdnce with Secon 673(2) of OBRA-81. The port income 
guidelies are used by the HHS for  administrative purpes.  e., persons are clasifed as being either 
above or below a set standard to determe eligibilty for public asistance. Effecive Februry IS, 
1991, the 
 base-line povert threshold for a family of one is S6,620; a family of two, S8 88; a family of
three, Sl1 14O a family of four, S13,40; a family of five, $15,66 a family of six $17 
920; a family of 
seven, S20,18O a family of eight, $2244 and for each additional member above eight, S2,60 per
person. Financial eligibilty for Medicaid-cvered prenatal cae is based on percentage multiples
, e. 
130 percent or 185 percent of the guidelines (Federal Regiter, Februry 20, 1991). 
Prt 
Ha-tRe 
High-Rik or  Women For th study, women who are substance abusers
medcall high-rik, teenagers, and women in their mid-thes or above are include in th category. 
Int Monaty Rate A ratio used to repon the number of deaths among innts under one year of
00 lie binh. 
age per 1,
Prta Ca 
th  As defied by the Alan Guttmacher Intitute (1987:14), it is .poor or no
care and les- adequate care. Care is considered por if staned in the third trester, or if there
had ben onl one prenatal viit and gestation wa 22-29 weeks, two viits and gestation wa 3031 
weeks, thee viits and gestation wa 32-33 weks, or four viits and gestation wa 
oc 
34 weeks or longer. Care is considered les than adequate if the 
fit viit did not  before the
secnd trester, or if there were only three prenatal viits and gestation wa 22-25 weeks, or four
viits and gestation wa 2629 weeks, or five viits and gestation wa 3031 weeks, or six viits and
gestation wa 32-33 weeks, or seen viits and gestation wa 34-35 weeks, or eight viits and gestation
wa 36 weeks or longer. 
Lo Birght: Weight at bin that is les than five and one-half pounds. 
Medcad-C Prta Ca A 
fied period of time in which a pregnant woman can recive 
Medicaid servce. She is eligible for these servce: 1) by viue of 
her income and family siz (see
Appendix C) or 2) by already being an AFC 
recpient. Benefits begin from the time a woman is 
determined formally eligible unti the end of the month in which 60 days postpanum occrs. At the
nee 
end of this time period, if she  continued Medicaid assistance, she must reapply and meet
AFC 
eligibilty requirements.  APPENDIX B

SlGNCA IBJSTI QlGES  EXAN EUGmIL
TO 
FO  CA 
PREATAL  SEVICE 
MBICAVB 
XI  Sol Sety 
oTniltyle t h efo cf tt hofe  apions on JnAncot h/ acsa bre an ra medndiecd wthrsoeugdh  tahe:l ugh ch(aGgievse na ftfh  cst ccophe ionf  tahs  ws tluL),  
Tax Equity and Fiscal Responsibilty Ac (rFR P.
I- 97-248) of 1982 
Deficit Reduction Ac (DEFR P.I- 98-369) of 198 
Conslidated Omnibus Recncition Ac (COBRA P.I- 99-272) of 1985 
Omnibus Budget Recnciiation Ac (OBRA P .L99-509) of 1986 
. Omnbus Budget Recnciation Ac (OBRA P.I-l00203) of 1987 
Medcare CaWtrphic Coverage Ac (MCCA P.I-l0036) of 1988. 
Omnibus Budget Recnciation Ac (OBRA P.I-I01-
239) of 1989. 
Omnbus Budget Recnciation Ac (OBRA P.I-I01-SOS) of 199. 
TEFR-8 
allowed States to consider pregnant women as an optional eligibilty group 
under their 
DEF-8 
Medcaid progrms. Both  and COBRA-85 mandated or permitted eligibilty 
exansions
for new groups of pregnt women. Madated eligibilty included 1) pregnnt women who met Aid 
to Families with Dependent Children (AFC) eligibilty standards for income and resource
requiements; 2) a new defition for a two-member family, i.e., the woman s unborn chid could now 
be considered a member of the household; and 3) an exension 
of 60 days post panum eligibilty to
all pregnant women enrolled in an approved Medcaid plan, regardles of eligibilty group. Optional
eligibilty exended flexbilty to target 
pregnant women. 
COBRA-8 als 
allowed State flexbilty to modif exting Medicaid servce delivery sytems

(National Governors' Asocation 1989).  As  an option, States can use targeted ca management

without fit obtaing a Federa waiver, thus permttig servce to pregnant women as a target

grup. Th change lets Sta es offer enhance prenatal care benefit packages to pregnant women

without havig to offer the same servce to other 
groups of Medicaid recpients. 
Though OBRA-8, States were given the option to 
rais the Medicaid income standard to 
100 percnt of the Federal poert level and to waive an aset test when calculating a woman 
income to determe her eligibilty. For States not waivig the 
sae  th  aset test, the test used could be the
as or more liberal  the one under the cah asistance progrms. 
Additionally, States were
gien the option to guntee contiuous eligibilty throughout pregnancy until 60 days post panum,
regares of income chages. It al authori a period of presumptie eligibilty in which a
pregnt woman ca recive ambulatory care before being formally accpted for Medcaid.
Determtion is bas solely on income and pregnancy verification. 
fuer 
OBRA-8 gave States  options to cover all pregnt women with family incomes under
185 percnt of the Fedefraa po ert level, as well as to impoe premiums on the eligibilty of a 
pregnt women whos  and 185 percent of the Federal 
income fell between  ISO  povert level.
MCCA-8 mandated the income standard be set at 100 
percnt of the Federal povert level. It also 
exended contiuous eligibilty to all eligible pregnant women who would lose eligibilty beuse of
income changes. 
OBRA-89 mandated the income standard to be set at 
133 percent of the Federal povert level, with
the option to increae it up to. 185 percent of the Federal povert level.  APPENDIX C

FEER  GUIEL  PRAN 
1"1  POVETY INCOME  FOR  WOME 
AL STATF CECEP ALASKA AN HAWAl, PLUS D. 
Mandate
: 133 Percent of 1991 Federa Povert Income Guidelies 
Famy Siz  Anua Income  Monthy 
$ 8,804.  $ 733. 
810.40  984. 
816.  234. 
17, 822.  485. 
20, 827.  735. 
23, 833.  986. 
839.40  236. 
29, 845.  487. 
For family units with more than 8 members, add $3 005.80 to annual income for 
each additional member. 
Qptional: 150 and 185 Percent of 1991 Federa Povert Income Guidelies 
Famy Siz  150% Annua  185% Anua 
Income  Income 
$ 9,930  $12 247 
13,320  16,428 
710 
20, 100  790 
490  28,971 
880  152 
270  333 
660  514 
th 
For famy unts with more  8 members, add $3390 for 150% and $4181 
anua 
for 185 % to  income for each additional member. 
guidline publishe in 
"Based on income  the  Federal Re2ister on 2/20/91. 
C - 1
 APPENDIX D

LO 
P.c0 
MEDOLOY 
OF 
SIT 
A pursive sample was drawn of eight States representig dierent combinations 
the four Federal options to expand eligtoilty for Medicad-covered prenatal cae 
(using 100185 percent of the Federal povert level, using presumptive eligtoilty, 
guaranteemg contiuous eligibilty, and dropping the aset test). Selected were 
Alabama, Arkansas, Florida, Maryland, Pennsylvania, Colorado, New Jersey, and 
New Hampshie. The fit five States have had all four options in place for the 
longest tie; Colorado had recently implemented al these expansions; New Jersey 
had adopted all options but also had permssion from the Health Care Financing 
Admstration to remai at  povert 
100 percent of the Federal  level unti their 
legilatue met in early 1991; and New Hampshie had not yet adopted any optional 
expansions. 
With  mium 
each State, we selected a  of two counties with the highest volume 
of Medicad  State as havig diculties 
birts and/or the counties identied by the 
deliverig prenatal care. The  Alabama: Autauga, Jefferson, 
19 counties were 
Montgomery, and  Arkansas: Chicot, Desha Colorado: Denver 
Shelby;  , and Philips; 
Florida Maryland: Alleghany and Baltiore 
and EI Paso;  : Alachua and Hisborough; 
New Jersey New Hampshire: Hillsboro and Sulvan; and 
City;  : Ocean and Union; 
Pennsylvania: Delaware and Phiadelphia. 
Next we asked the State agency responsible for implementig eligtoilty expansions 
for Medicad-covered prenatal care to identi their counterpart with each county.
In tur, these local contact were asked to identi supervsors and intake workers for 
both presumptive eligIoilty and formal 
intae/determation. The State agency also 
assisted in identig one to thee health care providers in each county who had 
seen the most Medicaid-eligIole pregnant women in the prior year. Once the 
providers were selected, we origially asked them to identify and arrange intervews 
with women who were curently receiving, or had received, Medicaid-covered 
prenata cae and who fit the description of a new eligible. (See Appendix A) 
However, due to provider diculty in distingushig new eligtoles from AFC-
eligibles, we subsquentl asked to contact only women who had accessed Medicaid-
covered prenata cae though presumptive eligtoilty rather than though AFC 
(excludig New Hampshie). 
As shown in Table 1, we intervewed a total of 233 persons. In addition, we 
analyzed State and loca policies and procedures and examined available outreach 
materials and application forms. 
D - 1  APPENDIX E

COVEGE OPTONS FOR PREGNANT WOMEN. AS OF JANUARY 1991

Presumptive  Dropped  Continuous  Eligibilit as a % of 
Eligibilty  Asset  Eligibilty  Povert & Date 
Test  Implemented 
Alabama  7/88  7/88  7/88  133%  4/90 
Alaska  1/89  1/89  133%  4/90 
Arizona  1/88  1/88  140%  0/90 
Arkansas  4/87  1 0/88  4/87  133%  4/90 
California  185%  7/89 
Colorado  1/90  6/90  6/90  133%  4/90 
Connecticut  1/89  1/89  185%  1/89 
Delaware  1/88  1/88  133%  4/90 
4/87  4/87  185%  6/90 
Florida  10/87  10/87  10/87  150%  7/90 
Georgia  1/89  1/89  133%  4/90 
Hawaii  1/89  1/89  1/89  185%  1/90 
Idaho  1/89  1/89  1/89  133%  4/90 
Ilinois  5/90  4/87  133%  4/90 
Indiana  0/88  7/88  7/88  133%  4/90 
Iowa  1/90  7/89  185%  7/89 
Kansas  7/88  150%  7/89 
Kentucky.  6/89  8/88  185%  7/90 
Louisiana  1/89  1/89  1/89  133%  4/90 
Maine  0/88  0/88  0/88  185%  0/88 
Maryland  7/87  7/87  7/87  185%  7/89 
Massachusetts  4/88  7/88  7/88  185%  7/88 
Michigan  1/88  1/88  185%  0/88 
Minnesota  7/88  7/88  185%  7/88 
Mississippi  10/87  1 0/87  185%  1988 
Missouri  7/90  7/90  7/90  133%  7/90 
Montana  1/91  7/90  1/91  133%  4/90 
(continued on next page)

E  APPENDIX F

1N11N 
COPAIN 
OF SELCT  fOUN ON

AS OF JAUAY'''' (POR TO OBR-IO)*** 
FORM  EUGI FO. 
UNIQUE  JOINT  NOTICE  LENGTH  RACE! 
APPLICATION  PE & FORMAL  ETHNIC 
FOR  APPLICATION  REFERRAL  FORM  GROUP 
PREGNANT  FORM  FOR OTHER 
WOMEN  GOVT. 
PROGRAMS 
5 PG 
NO PE  16 PG  OPT. 
NO PE  8 PG  OPT. 
4 PG 
NO PE 
1 PG 
NO PE  18 PG  OPT 
NO PE  5 PG 
NO PE  6 PG 
1 PG 
NO PE  3 PG 
34 PG  OPT. 
OPT. 
2 PG 
10 PG 
NO PE  29 PG  OPT. 
NO PE  4 PG 
3 PG 
8 PG 
5 PG 
3 PG  OPT. 
NO PE  3 PG  OPT. 
NO PE  2 PG 
NO PE  11 PG 
15 PG 
14 PG  OPT.  APPENDIX G

Stte Reported Estimated Numbers and Cost to

Serve Non-AFC Medlcald-Covered Women In 1990, 1991

Estimated Cost to Enroll 
Estimated  1# 
Non-AFDC
 Change  and Deliver PNC to  Change 
Medicad-Covered
 Non-AFDC 
Women
 Medicaid-Covered 
Women (Milions) 
1990  1991  1990  1991 
Alaba. 
$3. 
20,  20,  $35. 
Alaska.  181  390  $13.  $17.  32. 
Arzona.  784  $17. 
Arkansa +  000  300  $10.  $11. 
California +

Colorado  (1)  225  $5. 
Conneccut +

Delaware  824  449  34.  $3.  $7.  119. 
DC +  350  71.  $1.  $2.  86. 
Florida +  20,  29,395  43.  $9.  $147.  56. 
Gergia +  18,738  28,542  52.  $56.  $95.  67. 
Hawaii +  258  $18. 
Idaho  361  415  * $14.  * $16.  19. 
** $3.  ** $4. 
Ilinois +  745  734  53.  $12.  $18.  41. 
Indiana.  12,061  $18. 
Iowa +  000  500  50.  * $12.  * $18.  50. 
Kaas 
(1)  000  000  $10.  $10. 
Kentuck +  972  10.  15.  $3.  $4.  15. 
Louisiana +

Maine +  472  800  22.  60. 
Maryland +  (1)  (2)  13,  19.  (3) $25.  (3) $31.  23. 
11,398 
Mahusett 
Michigan +  500 
Minneota +  11,  $2. 
tJlt.illip 
19,471 
G - 1
 (1) The State report they do not collect data on the number of non-AFDC women served, 
nevertless, might have submitted estimates. 
(2) Cannot distinguish between women certed presumptively eligible and those women who applied 
direc to the loc welfare offce and were certed eligible without being first found presumptively 
eligible. 
Cots 
(3) Without Administrative 
of Women 
(4) Average Monthly  II 
(5) Estimates as of 7/9 
(6) Estimates August-May 1990 
Includes Federal and State matching funds

Only Includes State Porton

CN Only

Both CN & MN

CN = Catergorically Needy Individuals receiving Federally-supported financial assistace. 
MN = Medically Neey Individuals who are eligible for medical but not financial assistace. 
NR = States Not Reportng Information 
Note:	 Estimates of parcipation may include AFDCeligible women. 
Estimates of cost in some States might have included Federal and State matching funds in 
their estimates. This table gives baseline estimates. 
G - 3
 APPENDIX H

RECE

Brow 
Sarah.  Prenatal Care: Reachinl! Mothers. Reachinl! Infants.  Washigton, D.C.: Intitute of 
Medcie, 1988 
Dis 
Centers for  ControL  The National Innt Monalitv Surveilance Proiec  Public Heath

Report (Vol. 102 No.2:126-22).

Chdren s Defense Fund.  The Health of America s Children: Maternal and Child Health Data 
k. Washigton, D.  , 1989.

Commttee on Government Operations.  Barrers to Prenatal Care: Can the United States Do More 
with Le?  Hous Report 100574, Union Calendar No. 34 (April 19,1988). 100th Congres, 2nd 
Sesion. Washigton, D.C.: U.S. Governent Priting 
Offce, 1988. 
Federal Regiter. Washigton, D.C.: U.S. Governent Printing Offce (Vol. 56, No. 34:669-61). 
Ir 
Ginburg, Susnn, Deborah Le-Idema, and  Desiminl! Evaluations of the 
Pettigrew. 
ansions of Medicaid Coveral!e for Premant Women and Children: Final ReDon.  Rockve
Maryland: Profesional Management Asociates, Inc., 1989. (prepared for HHS/Asistant Secetary
for Planng and Evaluation. 
Health Care Financig Admitration.  Medicaid Statistical Abstract: Results of the State Medicaid 
Al!encv Infant Monalitv Data Survev 1989.  Baltimore, Maryland: Bureau of Data Management and
Strategy Offce of Statistics and Data Management, June 5, 199. 
Jane 
Hi, Ian T. and  BreyeL  Cordinatinl! Prenatal Care. National Governors Asociation,
Washigton D.C., 198. 
Intitute of Medicie.  Prevntinl! Low Birthweil!ht.  Washington, D.C.: National Acdemy Pres
198:2627. 
Kenney, Asta Aida Torres, Nancy Dittes, and Jennifer Macias. .Medicaid Exnditures for Maternty
and Newrn Care in America.  Familv Planninl! PersocCtives 18 (No. 3, May/June): 103-
110, 1986. 
Offce of Evaluation and Inpections (OEI). U.S. Department of Health and Human Servce/Offce 
Acc 
of Inspecor General.  to Medicaid-Covered Prenatal Care: A Manal!ement Advisorv Report. 
OCtober 199. 
Offce of Evaluation and Inpeions (OEI). U.S. Department of Health and Human Servce/Offce
of Inpeor 
GeneraL  ComDrehensive Perinatal Care Pr02lm. May 199. 
Offce of Evaluation and Inpeions (OEI). U.S. Department of Health and Human Servce/Offce
of Inpeor  Lol 
Manal!ement and ImDlementation Stratel!es to Reduce Infant 
General.  Monalitv:
A Manal!ement Advirv Report. 
July 1989. 
Ca 
Offce of Technology  Health Technolol! 
Asment.  Study 38: Neonatal Intensive Care for
Low Birthweil!ht Infants: Cots and Effecivenes
. Washington, D.C.: Government Printing Offce,
198. 
H -
 APPENDIX I

SUMMAY OF HCFA' S COMMENTS TO SPECIFIC RECOMMENDATIONS

AND OIG'S RESPONSE

SUY: 
REOMMATION la 
Develop a comprehenive outreach strateg. 
should 
HCF A 

. Work  Children and Familes (ACF), State Medicad 
with PHS, Administration  Cor 
Direcors, and State MCH offcials to  standards to enure 
develop a minimum set  oC 
effecive client outreach to heighten awarenes  oC  Medicaid-cvered prenatal cae and to 
taget new eligibles. Such  Cor: 
guidelines should provide 
Coordinating Medicaid outreach activities with 
Materal and Child Health clinics, 
WIC ceter, and community and migrant health center. 
Conducting ongoing, cordinated State and locl ad capaign. 
Displaying Medicad benefits and income eligibilty requirements 
 Medicaid-cvered 
Cor 
prenatal cae on media materials. 
Using such loctions as churches, housing projec, neighborhood health and
receation ceter, 
groc  provider sites where women go  Cor  pregancy testing, and even
stores, laundromats, and shopping center to locte new eligibles. 
Using community residents, women who have recved 
Medicaid-cvered prenatal cae
and AIC recpients in the Federl Jobs 
Opportunity and Basic Skills 
(JOBS)
program as outreach worker. 
HCFA Comments 
The HCF A  doe not concur with the par of the recommendation to develop a minimum
set of stadards. Beuse of the considerable differences among States, and their 
Medicad and Maternal and Child Heath progras, we believe it is not appropriate to
pursue the development of sets of stadads for outreach activities. However
, we could
collaborate with the Public Heath Service (PHS), Administrtion for Children and
Fames 
(ACF), State Medicad Directors, and State Matern and Child Heath (MCR) 
officials to identify common  elements of effective tagete and community-wide outrch 
effort, and develop guides for State agencies which 
ilustrte those elements in pratice.  The reprt  tnougn a national advertsing capaign
also suggests that HCF A  , stress 
the benefits of prenata ca. HCF  doe not concur 
with ths par of the
recmmendation. Whe we endorse such a capaign, we believe that it should be 
develope and implemente as par of the national public information and education effort 
Heathy Sta" intiative. 
for the "
DIG RemoRse

Collaboration is an excellent way to achieve common goals. If an agreement ca be 
reached with the National Center for Education in Matern and Chid Heath to 
kee an
updte fie of Medicad-cvered prenata cae materials and distrbute them upon request, 
ths approch would encourage State sharng and avoid duplication of effort. The HCF A 
centr offce, cordinatig with regional HCF A and PHS sta, would nee to 
periodcay identify, collect, and issue a compendium of information to the National 
Center. State Medicad and Maternal and Child Heath officials would nee to be kept
appri 
of avaiable materials and subseuent updates. 
Heathy Sta initiative Heathy Sta 
As a par of the 
 , a national  National Public 
Information Campaign is being develope in conjunction with the National Ad Council.
During a five-yea effort, national attention wil be given to the benefits of prenata cae. 
The DIG encourages HCF  Heathy Sta 
A to collaborate in the development of the 
materials. 
We revise par of our recmmendation to reflect these 
changes: (See page 21 for

complete text.)

Collorae 
with the Natinal Center Jor EduCDn in Matern and Chil 
PHS, to serve as a reposiory and diriutn  Health, supported by
center Jor Stae and nanay-dveloped Medica-
covered prenata care outreach materils. The HCFA centra oJfice, cordnang with regina
HitCoFnA nannd  PtoH tShe s Ntafa, twnoau lC neneteedr .to  Spteare iMcaeyd ciad anntd,  McollUeercnt,  aanndd  iCsuhei la H ceoamhpe ondffuimc ioj
woul need to be kept apprid oj availk maeri  updes. 
and subsequent 
Coordnae outach  Health, Start Natinal Pulic Informtin 
efforts with the  CamDaim. Such
efforts shoul stss the benejis oj Medica-cvered prena care as preventve healh care 
raher than welfare-related assistance. 
REOMMATION 
2a I 
I SUMY: 
Simplify and streamline the application procs. 
should 
HCFA 
Ensure, in reviewng and approving State plans, that States 
comply with the requirements 
to:  Along with trsprttion and less strngent eligibilty requirements, the tagete 
populations nee assistace with chid cae  before they ca 
even  consider applying. 
Without chid cae, many of the women wil not be able to accss these 
services. Since 
HCF A is responsible for Medicad eligibilty and does not presently have a way to handle
ths sitution, the OIG recmmends HCFA tae the lead and collaborate with PHS and/or
ACF to assure chid cae availabilty durig the application procss. 
We revise par of our recommendation to reflect these changes: (See page 22 for
complete text.) 
Prmote Stle efforts to  1)  ensure the newly-d)1eloped appliCDn fonn are not lengthy and 2)
expedie processing ti for forml Medicaid eligiil detennnans andor implement 
presumptive eligiUit.

Collorae 
with PHS and ACF to promote  provi for 
slte efforts to  chUd care durig the
appliCDn process. 
Y: REO 
ATION 38 I 
I S 
Develop incentives to increae provider participation. 
should 
HCF A 

Ensure, in reviewing and approving State plans, that States are 
complying with the
requirements to: 
Provide suffcient reimbursement to enure adequate 
numbers of provider are
available to deliver Medicaid-cvered prenatal care. 
Spefy the noninstitutional obstetrical payment rates in Medicad 
plan amendments. 
Provide payment for services rendered by 
ceified nurse practitioner or cetified
family nurse practitioners if they are 
authorize under State law to perform those
service. 
HCFA Comments an  01G Response 
HCF A 
 concurs with this par of the recommendation, subject to a revision of the opening
statement: (See page 23 for complete text.) 
Contnue to ensure, in re)1iewing and approving Stle plans, that Stles are 
complying with the
requirements to: 
1- S
 REOMMATION 
I SUMY: 
Clafy poDey and monitor implementation of Medicaid expanions for prenatal care. 
should 
HCF A 

nee 
. Work closely with State Medicaid directors to identify 
for guidance, tecnical

asistace and training and develop action plans to provide them.

Inform States of new legislative options and mandates in a timely manner to allow for 
prompt implementation. 
Conduct locl site visits to monitor the implementation of the Medicaid eligibilty 
expansions. For example, have each regional offce annually visit a sample of locl 
presumptive eligibilty and formal application sites, as well as service delivery sites. 
HCFA Comments 
concurs with ths recommendation. HCF A addresses these topics on an ongoing 
HCF A 
basis. These topics are regular agenda items for the Medicad MCH- Technica Advisory
Group. On a quarly basis, HCFA' s regional offices reprt to centr office, the
progress of individua States in implementing prenata cae intiatives, and any problems
encountered by States in their regions. Also, regarding the loc site visits to monitor the 
implementation of Medicad eligibilty expansions, site visits are a par 
of the current 
formal progra management review protocls. 
SUY: 
REOMMATION 
Develop data collection systems and evaluation procses to meaure progres of the eligibilty
expansions and future program effects. 
should 
HCF A 

. Work with State Medicaid and MCH directors to develop minimum reporting 
requirements to track  participation rates. Minimal data elements should include: the 
number of women who could be eligible to 
recve Medicaid-cvered prenatal care; the
number who have been enrolled by various categories, such as AIC, 
medically neey,
and prenatal care only; the number presumptively eligible; and the attrition rate of 
women not completing the application procs. 
Pending the development of such a system to track participation 
rates, consider using
probabilty samples to estimate the number of newly eligible women enrolled in Medicaid-
covered prenatal care.  points in ti. Ths maes it diffcult to sepate claims for mothers frm those for infants, which, in 
tu, maes it diffcult for HCFA to determe what selVice us and expeditu were for newborn. 
phr "
In the send pagraph under ths heaing, the  diffcualtyc in  acing" doe not provide a clea
pictu of the problem involved. State Medicadn ageenccie s have  to their own Medicad claims data. 
clai 
The "critica evaluative elements" liste are not  to pay  and, therefore, ar not included 
rine thueis  rerd. Ths inormtion would be usfu, but Medicad Sta agencies ar not currtly
to collect it. 
Relyig on the linkage of infant birt, death, and Medicad clams recrds to produce

evaluative results wil be frustrtig, if not inconclusive. Also, as pointe out by the

HCF A comments, the State Medicad agencies are not currently required to collect the

tys of information neeed to meaure outcomes. For thes very reans, DIG urged

that steps be taen to ensure the neeed data is captured. Also, HCFA' s own study,

Medicad Statistica Abstrcts: Results of the State Medicad Agency Infant Mortty

Data Survey: 1989" reports that Medicad agencies have difficulty accessing critica

evaluative elements. This survey was designed to "determne the availabilty of 
information relate to the heath of pregnant women and infants" (Heath Care Financing
Admistrtion 
1990: 1). 
Therefore, DIG continues to recmmend that HCF A assure that critica evaluative 
elements are collecte by the States, either though the Medicad agency, PHS or Vita

Statistics. HCF A should cordinate its 
effort with the PHS Interagency Committee on

Infant Mortity (ICIM, Data and Surveilance subgroup. Ths subgroup, under the

direction of the Centers for Disee Control, is developing a Federa maternal and infant

heath data strtegy, resulting in a Federa Data and Use Bok.

Ba 
on HCFA comments, DIG revise its recmmendation. (See page 25 for full text.) 
Work with MCH, ACF, State Medica directors and Stae public healh offici to de,elop
minium reportng requirements to  measure the effects of the eligisilt e xpansins on impro,ed 
Minin da 
bith outcomes.  elements shoul includ: the healh  of aU partciants
(substnce abusers or medically high-ri pregnncy); demogrphic infonnn 
mDri  (age, race,
status, income, family si, educa1Ule,reils,  and employment stus); trester enrolld 
for pre1U care; the number of prenata care  completed; birth outcomes (l,e or dead; and
bay s birth weight. Also, to a,oUlM duoplircta tin of effort, HCFA shoul coordlUe with the PHS 
Interagency Committee on Infant  (ICIM), Data and Su",eilnce subgrup in its
de,elopment of a Federal matemal and infant heallh dlta straegy. 
COMMS 
I TEHNCAL 
In addition to the comments above, HCFA provided severa 
tehnica comments which we 
used to make revisions as appropriate. (Te full text of these comments is included in 
Appendix J.  APPENDIX 
DEPARTMENAL COMMEN: 
HEAm CA FINANCING ADMINISTRTION, PUBUC REAm SERVICE, 
ADMINISTRTION FOR CHILREN AND FAMIUES, AND

THE ASSISTANT SECRETARY FOR PLANING AND EVALUATION

J - 1
 " : ,--" ., " -=-:  .." -:==- : -
TJealth Care 
DEPARTMENT OF HEALTH &. HUMAN  VICES  Financing Administration
PDDIG I.
,A 
Memorandum
DIG-EI 
SEP 
1 3 1991 
DIG-OI 
Date
 AIG-MP 
AGaid Rm. Wisletnsrkay, tPoh.rD . "" "\ OGC/IG 
From
 "V  EXSEC
DAm-s 
OIG Draf Inpection: "Medicad Exanions for Prenata Cae:  State and Local 
Subject 
Implementation," OEI-06-90-00160 
Inpector General

Offce of the Secreta 
We have reviewed the subject draf inpecton which descnoes State and loca

effort to implement eligIoilty expanions for Medicad-cered prenatal cae and to

overcome barers to accssibilty of prenata cae. Mandatory changes in eligibilty

for pregnant women were addressed in the report However, the mai focus of the

report was on the options avaiable to States to increase the accssibilty of prenata

cae.

The report found that al States have set their income stadad for povert

level pregnant women at 133 percent of the Federal Povert Level 
(FL), as

required by law. Many States have alo adopted some of the optional eligibilty

expansions, includig waier of the asset/resource test, contiuous eligIoilty,

extension of the FPL, and presumptie eligibilty. However, a number of factors

inbit accss to prenata cae for Medicad-eligible women.

OIG recommends that HCF A develop a comprehensive outreach strategy, 
streame 
the application process, develop incenti 
to increase provider 
clar 
parcipation,  policy and monitor implementation of Medicad expanions for 
prenatal cae, and develop data collecton sytems and evuation processes to 
measure the progress of the eligibilty expanions and futue program effects. 
caot 
Although HCFA support the general intent of the report we 
concur with 
the detaed recommendations presented by OIG. Our comments on the 
recommendations are attched for your consideration.

Than you for the opportunty to review and comment on th report.
believe that the report is a usefu crtique that we wi use as we contiue to 
implement Medicad' s Maternal and Inant Health Intiatie. Pleae advie us if you 
agree' with our position on the report s recommendations at your earliest 
convenience. 
Attachments 
v.1 '7-1I  ". :J 
. r
C. .:_  .. J 
J 2:i.:.:' 
:- . 1 

\ I
 Page 2

Though a national ad campaign stress the benefits of Medicad-covered 
prenatal cae as preventive health cae intead of welfare-related 
Healthy Start 
assistace. Coordinate outreach effort 
with the 
capaign. 
HCFA Response 
HCF A does not concur with the par of the recommendation to develop a  minim 
set of standards. Because of the considerable dierences among States, and their 
Medicad and Maternal and Chd Health program, we believe it is not appropriate 
to purue the development of sets of stadards for outreach actities. However, we 
could collaborate with the Public Health Servce (PHS), Admtration for Chdren 
and Fames (ACF), State Medicad Directors, and State Maternal and Chd 
Health (MCH) offcials to identi  elements of effective tageted and 
common 
community-wide outreach effort, and develop gudes for State agencies which 
ilustrate those elements in practce. 
HCF A alo does not concur with the par of the recommendation to establish a 
lited stag 
centralied resource center. Given  and fiancial resources, we do 
not believe creatig another resource center would be cost-effectie. The National 
Center for Education in Maternal and Chd Health supported by PHS, serves that 
sta 
fuction. Regional HCF A and PHS  could identi inovatie outreach 
s centr 
material and practce, and then HCF A' offce could issue a compendium 
of inormation though the exiting centrald resource center. 
OIG' s recommendation alo  could clar that matchig Federal 
includes that HCF A 
fuds are avaiable to assist with State effort to conduct client outreach. We 
concur with th par of the recommendation. HCF A has frequently clared the 
avaiabilty of matchig fuds for outreach though memoradum, policy 
interpretations, and technca assistace diected to both Medicad and Maternal and 
Chd Health agencies, and we wi contiue to do so. 
The report alo  could though a national adverting capaign, 
suggests that HCFA 
stress the benefits of prenata cae. HCF A does not concur with th par of the 
recommendation. Whe we endorse such a capaign we believe that it should be 
developed and implemented as par of the national public inormation and 
education effort for the ''Heathy Sta" intiatie. 
Recommendation 2

streame 
Simpli and  the application process.  Page 4

Recommendation 3

Develop incentives to increase provider parcipation. 
HCFA should: 
Ensure, in revjewig and approvig State plan, that States are complyig 
with the requiements to: 
reimburement to ensure adequate numbers of 
Provide sufcient 
providers are avaable to delier Medicad-covered prenata cae. 
payment rates in Medicad 
Specif the nonititutional obstetrca 
State plan amendments. 
Provide payment for servces rendered by certed nure 
certed fam nure practtioners if they are 
practtioners or 
authoried under State law to perform those servces. 
could 
HCFA 
gutee 
Develop a legilatie proposal to  temporar Medicad coverage 
Th 
unti the end of the presumptie eligIoilty period.  coverage would 
alay provder apprehensions of havig to contiue cae for women later 
found ineligIole for fu Medicad benefits. 
Develop a legislatie proposal authorig fu Medicad benefits for 
rik durg 
pregnancies deemed at high- the presumptie eligIoilty period. 
Develop a stadad defition of "quaed" provder, designatig the
mium 
number of Medicad recipients who must be anualy served. 
HCF A Response

HCFA agrees that provder recrtment and retention should be a priority of the 
Medi  d intiatie. We are cuently formulatig reguations which implement 
obstetrca and pediatric payment rate requiements. 
HCF A defers comment on the two legilatie propos. Al legilatie proposal 
will be considered with the A-19 process with HCF  Page 6

HCF A should: 
mium 
Work with State Medicad and MCH diectors to develop 
. Mial 
reportg  data 
participation rates
requirements to track 
elements should include: the number of women who could be eligible to 
receive Medicad-covered prenata cae; the number who have been 
enrolled by vaous categories, such as AFC, medicay needy, and 
prenata cae only; the number presumptiely eligible; and the attrtion 
rate of women not completig the 
application process. 
Pending the development of such a 
system to track paricipation rates 
consider using probabilty samples to estiate the number of newly 
eligtole women enrolled in Medicad-covered prenata cae. 
Work with MCH ACF, State Medicad diectors and State public health 
mium 
offcial to develop  reportg requiements  measure the 
bir to  Mial 
effect of the eligtoilty expanions on improved  outcomes. 
data elements should include: the health status of 
al parcipants 
(substace abuser or medicay high-risk pregnancy); demographic 
inormation (age, race, maPta status, income, famy size, educational 
trester 
level, and employment statu);  enrolled for prenata cae; the 
bir 
number of prenata cae 
viits completed;  outcomes (lie or dead); 
bir 
and the baby'  weight. 
could 
HCFA 
Work with MCH ACF, State Medliicagd  diectors and State public health 
exitig 
offcial to assess the potential of  databases, e.g., eligibilty, 
medica payments, vita statitics, to measure both parcipation rates and 
outcome measures. 
fudig 
Plan and seek  year evuation of the 
for a multi- effectieness of 
bir 
the eligibilty expanions on improved  outcomes. The evaluations 
strcted 
should be  to permt separte analysis of women considered at 
high rik (substace abusers, medicay high-risk, etc.  Page 8

Providig a technca assistance document on using the two model 
simplied application form. The fist form is under Title V, for use in 
Sta 
applyig simultaeously under Head  Medicad WIC, MCR, 
communty/migrant/ or homeless health center program. And, the 
second form is for use in applyig for Medicad onl. 
Techncal. Comments 
th 
Page 2	 The report's char on  page is confing. A complete briefig on how 
th 
eligibilty groups work is not appropriate in  response to your report; 
however, we wi provde thi inormation to your sta upon request. 
The fist sentence of the last pargraph should be altered to read, 
HCFA is contiuig to implement a Medicad Maternal and Inant 
Health Intiatie..." The sentence, as it curently appear, iners that 
th 
is a new intiatie. Alo, with  sentence, the Technca Advisory 
Group (TAG) is caed the Medicad/CH TAG. It includes 
representaties of both Medicad and Title V agencies. 
Page 12	 Under the headig, ''Furer, HCFA and Most States Lack Centraled 
Data.. " one problem that is not addressed is how Medicad identicatioli 
(ID) numbers are assigned to newborn. In some States, Medicad 
numbers are automaticay .gien to newborn; in other States, only inants 
remaig 
with high expenses are gien numbers; and, in the  States, the 
vag  tie. Th 
ID numbers are  points in 
assigned to chidren at 
dicut  clai 
makes it  to separate  for mothers from those for inants, 
which in turn makes it dicut for HCF A to determe what servce use 
and exenditues were for newborn. 
th 
In the second paragrph under  dicuty
headig, the phrase "
accssing" does not provde a clear picte of the problems involved. 
clai 
State Medicad agencies have accss to their own Medicad  data 
The "crticay evuatie 
elements" lited are not necessar to pay clais 
Th 
and, therefore, are not included in these records.  inormation would 
be usefu but Medicad State agencies are not curently requied to 
collect it. 
Page	 Under the incenties 
offered by diferent States to encourage prenata 
cae, we suggest that the coupon books issued by Alabama be included. 
Page 18	 Based on the figues  OIG in the char number 5 should be 
gien by 
$99 628 200 not $96 642,000. Alo, number 6 should be $81,055 800 not 
$78 069 600.  ( ? 
/ / 
&.  . .,.  '"., -. " . . " \:;. -,..  ,-  \,- ,  . \ :;, 
" ....w  j(t"JJ  IfF 
REm 
DEPARME OF  HUMA SERVICES  CL;Lf:- Public Helt 
. ;yJL  C/I/ 
Memorandum 
199 
NOV 2 I 
Assistant Secretary for Health 
From 
(OIG) Draft Report " Medicaid 
Subjec  Office of Inspector General 
Care: 
Expansions for Prenatal  State and Local Implementation 
To - Inspector General, OS 
At t a c h e d are the PHS co mm e n t s on the sub j e c t 0 I G r e po r t . The 
report provides useful information on State and local efforts 
covered prenatal 
implement eligibility expansions for Medicaid-
care and to overcome barriers to accessibility and availability 
of prenatal care.

We concur with the report  s recommendation directed to PHS.

our comments, we identify the actions taken or planned 

implement this recommendation. In addition , we provide general

comments concerning the on-going activities of the PHS

Interagency Committee on Infant Mortality that relate directly to

the issues addressed in this report.

()'h1
Mason, M.  , Dr.

Attachment 
PDIG 
cO: 
AIG-II  '7 ;"1' 
oc/IG
EXSI
DASB  :J -..

- -: fT
:: 2 
.1.  Departent of 
A model application developed by DHHS and the 
Agricul ture for streamlining applications for child assistance

programs has been approved by both Departents and sent to OMS

Federal Reaister

prior to publication in the 
PHS also recommends that the OIG report point out the recent

work of the National Governors' Association (NGA), in

conjunction with HRSA, in the area of Medicaid reforms.

Specifically, approximtely 2 years 
ago, under a cooperative 
agreement with HRSA, NGA prepared reports which indicated that

financing reforms alone were not sufficient to solve problems

of access to the underserved. 
HRSA currently has a second 
examne more recent Medicaid 
cooperative agreement with NGA to 
expansions and reforms. Finally, the report might also note

that SHCDA provides substantial technical assistance to health

reforms. 
centers to help them implement Medicaid 
OIG Recommendation 
PHS should use loan repayment and the National Health Service

Corps  numer of 
(NHSC ) recruitment programs to increase the 
doctors, nurses, and other health professionals serving

pregnant women.

PHS Comments

We concur. The NHSC program currently meets the intent of this
recommendation. The  based 
NHSC specifically targets community-
systems of care in medically undeserved areas for the placement 
of health professionals who become available through its 
scholarship program, loan repayment program, and the 
recrui tment of volunteers. A high percentage of the patients
seen in these primry 
health care programs are pregnant women
and children. 
The mission of the NHSC is to provide health personnel to urban 
and rural communi ties and underserved or unserved populations 
with the greatest need. NHSC' s goal is the improvement of
access to primry 
care services in these communities and 
populations. 
elimnating federally 
Essentially, the NHSC has the mission of 
designated health professional shortage areas (HPSA) throughout 
the United States. To this end, the NHSC seeks to provide an 
primry 
adequate supply of  care and mid-level health 
professionals to communities, special population groups and 
public or private non-profit health facilities in HPSAs.  dwifery Program awarded
The Nurse Practitioner and Nurse 

$6, 059, 033 in FY 1990 for 36 projects that support preparation 
of nurses who are able to serve as nurse midwives, obstetrical
and gyecological practitioners, 
and pediatric practitioners. 
In all cases, these nurses focus on patient teaching, guidance, 
ties. 
counseling and health screening acti vi 
prove
PHS funds have been used to support traineeships to 

admnistration and competency of personnel in maternal and
child health programs. In 
FY 1990, $187,241 was awarded for 
traineeship support in maternal and child health. 
OTHER COMMENTS

Regarding the recommendation directed to HCFA and the States

that they develop a comprehensive outreach strategy, caution

vi ties. 
must be exercised in emphasizing outreach acti  Outreach 
efforts have to be backed up by adequate system capacity.
 g- .. , 
. ; 
. .... /;:)' : \ :-~: ~;:~- , !-:' .-....  .:..  . .. ..-,\.  :.::-:- .'"  .:.- -.. -. --' "'." . ... 
ERVICES / 
091&JJti\IS  Instor Genal 
office of 
( J" v DIG-Pm 
moran 
I 0  DIG-AS 
DIG-EI  It/ /
. Kuserow 
Date  O! 
From Inpector Genera AIG-MP 
Richar 
EOGC/IGX   SEC
DAT 
Subiect OIG Dra Report "Medicad Exanions for Prenata Cae  f.i 
Implementation," OEI-090-0160  State and Loca 
To Mar 

11 
taGter r - -
 is:! l 
I"  PSllSangS eacnred   TVE  vauatiJeto  n"YtA  iQ;LA Lo/ J)  -,t  t:  OST - f?(  ;' ..C I dJ
SEP 2 5 
/991 
2 . 
; i"1 I 
Attached for your reew and comment is a copy of our draft)nspecti 
l!:report :;3;  . 
Medicad Exanions for Prenata Cae: 
State and Loca Implemenultion. 
Our inpecton descn"bes State and loca effort to implement eligI"bilty exanions
for Medicad-cered prenata cae 
and to overcome barers to accibilty and

avaabilty of prenata cae. We found  Janua  ma 
tht, as of  1991,  States have

endorsed the optiona eligI"biIty exanions. Howev, signcat prblems prevent

newly eligIcle women from 
receivg Medicad-cered prenata cae: 
inadequate

client outreach, a cubersome application proce dicuty recrtig 
prenata cae

providers, problems implementig presptie  stag 
trg eligIciIty, 
shortges and the

need for more tiely inormtion and  frm the Heath Cae Fmacig

Admitrtion (HCF A). Alo, data collecton is incient to meae 
progress

and outcomes some States ar inovtiely implementig the exanions and a

1 percent decreae in neonata intensive ca ca potenti reduce Medicad 
costs 
mion. 
by over $78 
We recommend actons by HCFA, the Public Heath Servce and 
the States to 

develop a comprehensive outreach strtegy, sipli and stre=mclinle  the application

process, develop incenties to increase provder parcipation, 
policy and

monitor implementation, develop data collecton sytems and 
evuation 
measure progres and outcomes and establih a State centrd  processes to

authority to fully

implement the 
exanions.

dr 
We would apprecite 
receivg your comments on the  report withi 30 days of

the date of thi mf:::oradum

If you have any questions or comments about th  e ca 
sta  report plea  me or have

your  contact Mata Zita 
at FT 269-2678.

Attachment