. .
. .
MEDICAID-COVERED 
ACCESS  TO 
PRENATAL CARE 
MAGEMEN ADVIRY RERT 
l"VICES' 
V.r 
'0 
lt""la 
. OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND INSPECTIONS 
OCOBER 199
 . ,

. "
OFFCE OF INSPECTOR GENERA

The mission of the Office of Inspector General (DIG) is to promote the efficiency, 
effectiveness, and integrity of programs in the United States Department of Health and 
Human Services (HHS). It does this by developing methods to detect and prevent fraud 
waste, and abuse. Created by statute in 1976, the Inspector General keeps both the 
Congress fully and currently informed about programs or management 
Secretary and the 
problems and recommends corrective action. The OIG performs its mission by 
conducting. audits, investigations, and inspections with approximately 1 400 staff 
strategically located around the country. 
AN 
OFFCE OF EVALUATION  INSPECTONS 
This report is produced by the Office of Evaluation and Inspections (OEI), one of the 
three major offices within the DIG. The other two are the Office of Audit Servces and 
Investigations. Inspections are conducted in accordance with professional 
the Office of 
standards developed by DEI. These inspections are  term studies designed 
tyically short-
to determine program effectiveness, efficiency, and vulnerabilty to fraud or abuse. 
This management advisory report (MA), Access To Medicaid-Covered Prenatal Care 
presents preliminary findings regarding: 1) barrers to State and local implementation of 
optional eligibility expansions for Medicaid-covered prenatal care servces and 2) effective 
techniques to implement these expansions. Two companion reports will be issued 
addressing more detailed findings from a two-phase study conducted at both State and 
local levels.

The MAR was prepared under the direction of Ralph Tunnell, the Regional Inspector 
General of Region VI, Office of Evaluation and Inspections. Participating in this project 
were the following people: 
Carolyn Neuwirth, Project Leader, Region VI, OEI 
Michelle Adams, Program Analyst, Region VI, OEI 
Elsie Chaisson, Program Analyst, Region VI, DEI 
Carol Cockrell, Program Analyst, Region VI, DEI 
Christine Owens, Program Analyst, Region I, OEI 
Maruta Zitans, Program Specialist, Washington, D.  , OEI  , ,

MEDICAID-COVERED 
ACCESS  TO 
PRENA TAL CARE 
MAGEMENT ADVIRY REPORT 
RICH 
P. KUSSEROW 
INSPECTOR GENERAL 
OEI-090162  OCOBER 199
 ..  . -
ACCE TO MEDICAI-CVERED PRENATAL CAR 
90162 
OAI 
PUROSE 
This management advisory report (MAR) presents preliminary findings regarding 
1) barriers to State and local implementation of optional eligibilty expansions for 
Medicaid-covered prenatal care services and 2) effective techniques to implement 
these expansions.

BACKGROUN 
, the Congress provided a way for more women to receive 
In the early 1980s
temporary assistance with pregnancy-related health care through Medicaid (title XIX 
of the Social Security Act). This preventative prenatal care was aimed at reducing 
the incidence of infant mortality and low birthweight babies (LBW). 
Care 
Catastrophic Costs Related to Inadequate Prenatal 
LBW babies are three times more likely to be born of women who receive no 
prenatal care (U.S. General Accounting Office, 1987). Costs to maintain these 
babies in neonatal intensive care units can range from $12,000 to $150 000 per child 
(Office of Technology Assessment
, 1987). 
Closely linked to LBW is infant mortality. In 1985, two-thirds of infant deaths 
occurring during the first month of life were LBW babies (U.S. GAO, 1987). Those 
survving risk long-term physical and mental disabilities. Receipt of insufficient 
l is also a 
Of women receiving 
prenatal care contributing factor to infant mortality. 
insufficient care, infant mortality rates are highest among unmarred women, 
teenagers, the least educated, blacks, Hispanics, and poor marred women (Gold 
Kenney, and Singh, 1987).

Of all groups, teens are the least likely to get early prenatal care, thus placing 
themselves, as well as their babies, at the highest risk of health complications 
(Children s Defense Fund, 1989). Data from the National Infant Mortality 
Surveilance project (Centers for Disease Control, 1987) confirms that infants born of 
teen mothers are more likely to be LBW and more likely to die in the first year of 
life. 
The U. S. Department of Health and Human Servces has long contended that three-
risks may be detected during the first prenatal care visit 
fourths of associated health 
(Committee on Government Operations, 1988). Cost savings from subsequent 
interventions could greatly reduce expenditures for direct medical care of LBW 
babies. The Institute of Medicine (1988) calculated that in 1985 for every $1 spent  on insuring adequate prenatal care for low-income, poorly educated women, total 
expenditures could be reduced by $3.38 from costs accrued during a LBW baby s first 
year. 
federal  ative Cpanges Exand Eligibilty 
Some of the most sweeping legislative changes in eligibilty for Medicaid-covered 
prenatal care were authorized by the Sixh Omnibus Budget Reconciliation Act 
(SOBRA-86).  It decoupled Medicaid eligibilty from Aid to Familes with 
Dependent Children (AFC), which could promote a new mindset of non-welfare 
related Medicaid-covered prenatal care. Through this enabling legislation, States 
were given the option to set eligibilty limits up to 185 percent of the Federal 
poverty level (FPL). 
Other State options authorized by SOB  are: 
Continuous Eligibilty--Mter a pregnant woman s initial eligibilty is 
determined, she is guaranteed Medicaid coverage throughout her 
pregnancy and 60 days postpartum, regardless of income changes. 
Presumptive Eligibilty--Based on a cursory review of income, a 
pregnant woman may be immediately presumed eligible at time of 
application and may be temporarily covered for ambulatory prenatal 
care until formally accepted into the program. 
Resources (Asset) Test--Resources and assets , a car, home, and 
, e. 
savings, could be disregarded in processing a pregnant woman 
application. 
As of April 1, 1990, States were mandated to provide Medicaid-covered prenatal 
care servces to women with family incomes up to 133 percent FPL ($13,380 for a 
family of three). 
Other OIG Reports Address Issue of Infant Mortality 
In recent OIG reports, two programs aimed at reducing infant mortality were 
reviewed. One study reported that supplemental funding to areas with high rates of 
comrimnity and migrant health centers through the 
infant mortality are available to 
Comprehensive Perinatal Care Program (OEI, May 1990) but that these grants need 
to be more widely distributed. In another study, a local program to reduce infant 
mortality was analyzed. 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).
 METHODOLOY 
A descriptive analysis of Federal and State eligibility expansions for Medicaid-covered 
prenatal care servces was undertaken in a two-phase study at the State and local 
level. Phase 1 involved onsite visits in one to two counties per State in eight States. 
Sample selection depended on whether the county had the highest volume of 
Medicaid births and/or it was identified by the State as having diffculties with 
access/delivery of Medicaid-covered prenatal care. 
Data collection for Phase 1 was completed in June 1990. Visits were made to 
Alabama, Arkansas, Florida, Maryland, Pennsylvania, Colorado, New Jersey, and 
New Hampshire. The first five States represent a sample of those most eagerly 
endorsing all federally mandated and optional eligibilty expansions for Medicaid-
covered prenatal care since SOBRA-86. Colorado represents a State most recently 
implementing all the expansions; New Jersey, a State with all the options but with 
permission from HCFA to remain at 100% FPL until their legislature meets in 1991; 
and New Hampshire, a State not yet adopting any optional expansion categories. 
A total of 233 persons were surveyed: 15 Medicaid-eligibilty supervsors, 44 eligibilty 
intake/determination workers, 36 providers, and 137 women who are either currently 
receiving or have received Medicaid-covered prenatal care. 
Phase 2 involves telephone and mail surveys with key informants in all 50 States plus 
the District of Columbia. As of this writing, 43 States have been contacted. 
PRELIMARY FIINGS 
The following preliminary findings are based on selected Phase 1 and Phase 2 data. 
State Implementation of Optional Authorities for Medcad-Cered Prenata 
Cae Servces Is Mied. 
Of the 43 States surveyed so far, 40 have waived the asset/resource 
test; 41 have opted for continuous eligibilty. 
Far fewer States (19) have elected to voluntarily raise the level of 
poverty above 133 percent FPL. 
Fifteen States are at 185 percent 
FPL, with 6 at this level since 1988 and 5 since 1989. 
Only 21 States have adopted presumptive eligibilty. Either 
administrative complexity or having a streamlined eligibilty process 
presumptive 
already in place are cited as reasons for not using  eligibilty. . For example, Vermont reports a 10-day expedited formal 
determination process; Minnesota day turnaround. 
, a 15-
Signcat Baers Sti Ext to Accing  Medcad-Cered 
and Delierig 
Prenata Cae Servce. 
Even though potentially one of the least complicated and easiest Medicaid 
programs to administer, barriers stil hinder access to, and delivery of, prenatal 
care servIces. 
Insufficient Client Outreach Often Keeps Medicaid-Covered Prenatal 
Care a Well-Hidden Secret 
When asked to identify SOBRA women to be intervewed, most States 
and providers had difficulty with this request. Most women receiving 
Medicaid-covered prenatal care servces were either borderline welfare 
, already eligible Medicaid recipients. 
cases or
Knowledge of Medicaid-covered prenatal care servces is stil being 
spread primarily through the ''welfare grapevine. " Eighty-nine percent 
of the States rely on this informal means of communication. Ninety-
four percent of Medicai  eligibilty supervsors intervewed during Phase 
1 say their agency relies on clients tellng clients. 
Even among the States reporting some form of active outreach, over 
half neither target new  BRA) nor high-risk women. 
eligibles (SO 
(SOBRA eligibles include women who are above the poverty level used 
for other government-sponsored programs and who are usually marred 
better educated, regularly employed in low paying jobs, as well as those 
who are underinsured. Women who are substance abusers, medically 
high-risk, teenagers, welfare recipients, and women in their mid-thirties 
or above are considered high-risk. 
Conflcting Timeframes to Process Presumptive Eligibles Leave Some 
Women Without Medicaid-Covered Prenatal Care Servces 
SOBRA-86 allows a maxmum presumptive eligibilty period of 45 days. 
This timeframe includes 1) application for continued Medicaid-covered 
presumed eligible and 2) 
prenatal care servces within 14 days of being 
the determination of formal eligibilty. If a woman waits until the 14th 
day to make a formal application, eligibilty workers would then have 
up to 31 days to make a fQrmal eligibilty determination (initial 14 days 
of presumptive eligibility + 31 days to process case = 45 days to 
inform a woman of her formal eligibilty status).  A few States are not adhering to this timeframe but are allowing an 
additional 2 weeks to process a formal eligibilty application 
(initial 14 
days of presumptive eligibility + 45 days to process case = 59 days to 
inform a woman of her formal eligibility status). In such cases a 
woman could potentially be without Medicaid coverage for prenatal 
care servces for up to 14 days. Clearly, such States are not following 
the legislative timeframe established by SOBRA-86. 
The Application Process is Cumbersome 
Complexity of the application form, use of multiple application sites 
and uncertain eligibilty status are hindering access to Medicaid-covered 
prenatal care servces.

Six-eight percent of the States say they have a problem with women 
not completing the application process. Few States use a simplified 
application form tailored to collect only the few eligibilty requirements 
, women are 
needed to get Medicaid-covered prenatal care. In addition
having to make a formal application at a site other than where their 
pregnancy is verified or where they were determined presumptively 
eligible. Over three-fourths of the women report having to go to 
another location. Other listed factors contributing to lack of follow-
through are requiring face-to-face intervews with the formal eligibilty 
worker to get an application form, the stigma attached to going to the 
welfare office, lack of transportation to application sites, and formal 
eligibilty intake workers asking for too much informatiqn in an attempt 
to see if a woman qualifies for other programs. 
Reimbursement and Liabilty Issues Are Disincentives for Providers to 
Accept Medicaid Eligibles 
Providers Not Accepting Medicaid Is a Major Problem 
have problems with 
Eighty-eight percent of the States say they 
Medicaid. More than half of 
health care providers not accepting 
the Medicaid eligibilty supervsors think women don t even apply 
because women feel 
for Medicaid-covered prenatal care servces 
providers don t accept Medicaid; nearly a third of the women in 
Phase 1 report the same.  Low and Slow Reimbursement Are Major Obstacles to Provider 
Part cipation 
low reimbursement rates 
Eighty-six percent of the States say 
contribute to provider dissatisfaction; 60 percent of the States 
say slow turnaround for reimbursement discourages provider 
participation. 
Cost of Liabilty Insurance and Belief that Medicaid Clients are 
More Likely to Sue Keep Some Providers from Accepting 
Medicaid 
Seventy-one percent of the States think providers don 
participate in Medicaid-covered prenatal care servces because of 
the high cost of liabilty insurance. Also, 62 percent of the 
States say providers' perception that Medicaid clients are more 
likely to sue is a problem in getting providers to participate. 
Only ambulatory care can be paid for by Medicaid while a 
woman is presumptively eligible. Hospital inpatient care for 
such pregnancy-related complications as miscarrage, early 
delivery, or need for sophisticated procedures such as an 
ultrasound are not covered during this period. Therefore, some 
women may not be receiving medically necessary servces. 
Additionally, some doctors are reluctant, or flatly refuse, to 
accept presumptively eligible women, judging the financial or 
liabilty risks of servng them too great. 
Thew 
Opstetrician/Gynec010gists (O  emains a System 
Capacity Issue 
Over half of the States report a shortage of OB/GYNs in both urban 
and rural areas, with "a quarter of States experiencing a shortage in 
rural areas only.

Inovatie Practces to Enhance Acc to, and Deliery of, Medcad-Cered 
Prenata cae Servce Do Ext. 
Client Outreach 
Examples of well-developed print materials are found in New 
York' s brochures, handouts that hang on doorknobs, and posters. 
Printed in both English and Spanish, they include listings of 
servces available, income requirements to qualify for Medicaid ..  .. - . , " , "
covered prenatal care, and a toll-free number for more 
information. 
Designating a special name to Medicaid-covered prenatal care 
servces also heightens women s awareness. Ohio calls its 
program "Healthy Start"; Utah  Baby Your Baby ; and 
Colorado  Baby Care . Since June of this year, Ohio s "Healthy 
Start" campaign has done intensive television advertising, run 
over 100 newspaper ads, used a marketing firm to do speeches 
and participate in talk shows, as well as running "Baby Fairs" to 
let women know about. Medicaid-covered prenatal care servces. 
Several States have solicited non-profit and private 
organizational support for client outreach. The March of Dimes 
assists Arkansas, Blue Cross-Blue Shield aids New Hampshire 
and Maryland, and private organizations are used by Sou 
Carolina. 
, networks of nonprofessionals (lay 
In 12 South Carolina counties
women) are used to contact the hard-to-reach population. In 
Virginia, lay women act as "mother" role models for pregnant 
teens. 
Florida and Alabama have outstationed eligibilty workers 
lessening the welfare stigma and making the application process 
more accessible. 
. South Carolina and Colorado give coupon books to women 
receiving prenatal care. 
Application Form 
Several States have developed shortened application forms to. 
collect only the information required for Medicaid-covered 
prenatal care eligibilty. Colorado, Ohio, and Vermont report 
usirig a shortened application form designed 
especially for 
Medicaid-covered prenatal care servces. 
Provider Incentives to Accept Medicaid 
Maine offers OB/GYNs between $5000 and $10 000 supplements 
toward medical insurance in exchange for practicing in shortage 
areas.  ,,;.
Washington State uses a Physician Marketing Plan to contact 
new providers. Also, primary care clinics in. distressed areas are 
given higher reimbursement rates. 
Missouri is establishing a State legal defense fund, as well as a 
provider education program. 
Maryland has hired seven nurses to do provider outreach. 
- ESENT 
PRELIMARY RECOMMATIONS  ELEMENf OF 
MODEL SYSTEM

Certain essential elements for more effective access/delivery of Medicaid-covered 
prenatal care servces emerged from both in-depth State and local inter;ews with 
key informants and recipients, as well as onsite observations. 
Gettg 
the Word Out is Critica. 
Eight-five percent of the State respondents agree that active outreach 
needs to be conducted.

, as well as the 
Increasing awareness of the need for prenatal care
availabilty of Medicaid funds to pay for these servces, should be done 
at Federal, State, and local levels. 
Conduct a national ad campaign similar to "Just Say No 
supported through private sponsorship and grants from non
profit organizations.

Establish a statewide hot line to provide information about 
access/delivery of Medicaid-covered prenatal care servces. 
Existing State maternal and child care hotlines could be shared 
for this purpose. Ninety-eight percent of the surveyed States 
agree on the need for a hot line. 
Do statewide targeted marketing to SOBRA eligibles, high-risk, and 
hard-to-reach women. Such outlets as churches, housing projects 
neighborhood recreation centers, and shopping centers would be helpful 
in identifyng w.omen early in their pregnancies (OEI, 1989r  ;... .;
Ast 
Drop the  Test. 
NinetY-ejght' -peTceritOfthi Sfate.:respondents agree that the asset test 
should be dropped as an eligibilty condition for Medicaid-covered 
prenatal care servces.

Guarantee Contiuous Eligibilty Unti 60 Days Postparm. 
All State respondents believe continuous eligibilty should be 
guaranteed until 60 days postpartum. 
States with Presumptie Eligibilty Should Adhere to the 45-Day 
Determation Period 
Assure States are abiding by the 45-day presumptive eligibilty time 
frame as prescribed in SOBRA-86. 
Combine Both the Presumptie Eligibilty and Formal Application Procss into 
. One Function, Whether Contrcted Out or Kept With the Medicad 
Agency. 
Non-Medicaid intake workers can gather the needed information for 
application: income verification, family size determination, residency 
establishment (Federal and State), and identification of any children 
under 6 years old residing with the applicant. The application, plus 
the documentation needed to verify this information, can be sent for 
, eliminating the need for a woman 
processing at the local welfare office
to go to another site to formally apply. 
Six-two percent of the State respondents agree that this function 
could be combined. This process would eliminate the need for 
transportation to a second application site, as well as avoid the stigma 
associated with applying at a welfare offce. 
Develop a shortened application form to collect only the few eligibilty 
items needed to get Medicaid-covered prenatal care servces. 
Proc. 
Simpli the Eligibilty Verication 
To clarify eligibility status, issue two separate cards or letters: one to be 
used during the ptesumptive eligibilty period and another for use after 
formal acceptance which is valid until 60 days postpartum. Fifty-seven 
percent of the States agree this would lessen confusion for both servce 
recipients and providers.  Use only one contro  number to track both presumptive eligibilty and 
, biling wil be less problematic 
formal acceptance status. By doing so
. for health care providers. Eighty-six percent of the State respondents 
concur. 
Have an on-line or telephone eligibilty verification system to track the 
current status of women receiving Medicaid-covered prenatal care 
to be accessible to both health care 
servces. The system needs 
providers and eligibilty workers. Ninety-seven percent of the State 
respondents agree this servce is needed. 
Paricipation to Delier Medicad-Cvered Prenata 
Asure Adequate Provder 
Cae Servce. 
have already raised reimbursement 
Seventy-six percent of the States 
rates; 17 percent offer some tye of assistance with liabilty insurance. 
Encourage use of such alternative health care providers as certified 
nurse midwives, family nurse practitioners, and physician assistants.  ENDNOTE

Institute (Gold, Kenney, and Singh, 1987:14) defined 
1. The Alan Guttmacher 
poor or no care and less-than adequate care. Care is 
insufficient prenatal care as "
, or if there had been only one 
considered poor if started in the third trimester
prenatal visit and gestation was 22-29 weeks, two visits and gestation was 30
weeks, three visits and gestation was 32-33 weeks, or four visits and gestation was 34 
weeks or longer. Care is considered less than adequate if the first visit did not occur 
visits and gestation 
before the second trimester, or if there were only three prenatal 
was 22-25 weeks, or four visits and gestation was 26-29 weeks, or five visits and 
gestation was 30-31 weeks, or six visits and gestation was 32-33 weeks, or seven visits 
and gestation was 34-35 weeks, or eight visits and gestation was 36 weeks or longer. 
2. Title XIX of the Social Security Act has been amended through the: 
Tax Equity and Fiscal Responsibilty Act (TEFRA P.L.97-248) of 1982. 
Deficit Reduction Act (DEFRA P.L.98-369) of 1985. 
Consolidated Omnibus Reconcilation Act (COBRA P.L.9.9-272) of 
1985. 
Omnibus Budget Reconcilation Act (OBRA P.L.99-509) of 1986. 
Omnibus Budget Reconcilation Act (OBRA P.  I00-203) of 1987. 
Medicare Catastrophic Coverage Act (MCCA, P.L.I00-3601P.  I01-234) 
of 1988.

Omnibus Budget Reconcilation Act (OBRA P.L.I01-239) of 1989. 
eligibilty allows pregnant women to receive ambulatory prenatal care 
3. Presumptive 
before being formally accepted into the Medicaid program. Determination is based 
qualified provider or intake worker. 
on income and determined by a Medicaid-
, the woman remains in this status for 14 calendar 
determined presumptively eligible
days from the date of presumptive determination. If the woman makes a formal 
application for Medicaid within these 14 days, her temporary eligibilty will continue 
until the earlier of the date the State makes a formal determination or 45 days after 
If the woman fails to make formal 
the presumptive determination is made: 
day.period, presumptive eligibilty ends on the 14th day 
application within the 14-
presumptive determination. 
after the  . .