DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop C2-21-15 
Baltimore, Maryland 21244-1850 
Center for Medicaid and State Operations 
 
                   SHO # 09-006 
                    CHIPRA #2 
 
May 11, 2009 
 
 
Dear State Health Official: 
 
The Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 
111-3, ensures that States are able to provide necessary health coverage for low-income 
uninsured children eligible under the Childrens Health Insurance Program (CHIP).  Section 111 
of CHIPRA adds a new section 2112 to the Social Security Act (the Act) which gives States the 
option to provide necessary prenatal, delivery, and postpartum care to low-income uninsured 
pregnant women through an amendment to its State child health plan (CHIP plan) (as described 
in section 2112).  This letter provides general information concerning the new option and 
guidance on amending your CHIP plan to reflect the coverage of pregnant women, should your 
State wish to take advantage of this option.  
 
Background 
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Prior to CHIPRA, States could provide services to pregnant women either through a Section 
1115 demonstration program or under the CHIP State plan by covering unborn children.  
CHIPRA allows States to continue providing coverage through these two options or through a 
new option of covering pregnant women under the CHIP plan.  This letter outlines the 
differences between options to assist States in adopting coverage for pregnant women. 
 
Continuation of Existing Section 1115 Pregnant Women Demonstrations 
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The CHIPRA allows States to continue existing section 1115 demonstrations that provide 
coverage for pregnant women with title XXI funds.  These States may continue demonstrations 
or modify their CHIP plans to include pregnant women as described below. 
 
Continuation of Coverage for Unborn Children Under the CHIP Plan 
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States will continue to have the option of considering an unborn child to be a targeted low-
income child and therefore eligible for coverage under CHIP, if other applicable eligibility 
criteria are met.  This permits States to provide health care services to promote healthy 
pregnancies, regardless of the mothers eligibility status.  States may continue to pay for 
pregnancy and delivery services through a bundled payment or global fee method, under which a 
single payment is made for prenatal care, labor, delivery, and postpartum care.     Page 2  State Health Official   
 
 
New Option to Cover Targeted Low-Income Pregnant Women Under the CHIP Plan 
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The CHIPRA also allows States the option of providing health care coverage for uninsured, low-
income pregnant women under the CHIP plan.  Under this option, the pregnant woman is eligible 
for coverage, rather than the unborn child.   
 
States that choose to cover pregnant women under the CHIP plan are eligible to receive 
enhanced Federal Medical Assistance Payments (FMAP) for such expenditures and have the 
option of providing presumptive eligibility to pregnant women.   
 
As established in CHIPRA (Section 111), in order to cover pregnant women through the State 
plan option under CHIP, States must meet the following criteria: 
  States may only provide coverage under the CHIP plan for pregnant women who were not 
eligible under the Medicaid State plan as of July 1, 2008; 
  States must cover pregnant women under Medicaid up to the minimum income level of 185 
percent of the Federal poverty level (FPL).  Any State that currently does not provide 
Medicaid coverage for pregnant women up to this income level, can only claim regular 
FMAP for pregnant women covered under a Medicaid expansion whose family income is 
at or below 185 percent of the FPL; 
  States may not establish a higher income eligibility level for pregnant women than the 
States eligibility level for targeted low-income children; 
  States must cover children under 19 years of age under Medicaid or CHIP, up to a 
minimum income level of 200 percent of the FPL; 
  States must not apply an effective income level for pregnant women under CHIP that is 
lower than the Medicaid effective income level and cannot cover higher income pregnant 
women without covering lower income pregnant women; 
  States must not apply any preexisting condition exclusion or waiting period for CHIP 
coverage of pregnant women;  
  States must not impose any cap or limitation on the enrollment of targeted low-income 
children, and must not have any waiting list or any procedures designed to delay 
applications for enrollment; and 
  States may not require enrollee cost sharing for preventive or pregnancy-related services. 
 
Benefits 
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States have the flexibility to offer coverage that meets the requirements of section 2103 of the 
CHIP statute under the new CHIP option for pregnant women, including in most cases, benefits 
during a 60-day postpartum period. 
 
Coverage of Both the Unborn Child and Pregnant Women  
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States may opt to cover both the unborn child and pregnant women under the CHIP plan.  If 
States elect both options, we want to emphasize that States will need to uniquely identify   Page 3  State Health Official   
 
enrollees so that there is no duplication of payment for services.  Eligibility under either category 
is subject to screening for Medicaid eligibility, and payment is not available under CHIP for 
services that would be covered under Medicaid.   
 
Submitting a CHIP Plan Amendment 
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States wishing to adopt any of the options described above and be eligible for funds under title 
XXI, must submit a CHIP plan amendment, which must be approved by the Secretary.   
States adopting such an expansion will be able to amend their CHIP plan by submitting the 
enclosed addendum to the CHIP plan and budget form.  The addendum sections correspond to 
the relevant sections in your current State Child Health Plan Template. 
 
States that have implemented CHIP through a Medicaid expansion program, but wish to extend 
coverage to unborn children and/or pregnant women under a separate child health program, may 
do so by submitting the same CHIP plan amendment above.  Such States would then continue to 
cover children from birth through age 18 under Medicaid expansion programs, and would 
operate separate CHIP programs only for pregnant women and/or unborn children. 
 
To incorporate either of these provisions into the CHIP plan, the State, through the appropriate 
State official, should submit these pages electronically to both the Centers for Medicare & 
Medicaid Services (CMS) Central and Regional Offices.  Once approved, these pages will be 
added to the current State Child Health Plan as an addendum describing coverage for pregnant 
women.  Before submitting such an amendment, please review the current approved CHIP plan 
to determine if it is necessary to amend additional sections simultaneously (e.g., if a new benefit 
package is being adopted, if cost sharing is being modified just for this eligibility group, if 
different service delivery type is being used, if different enrollee protections apply, or if the State 
has not previously implemented a separate child health program).  Note that if a State does not 
choose to use the same benefit type and package of services for pregnant women or unborn 
children, the State needs to submit a revised section 6 of the State plan with its amendment.  
Questions or assistance may be provided by your Central Office or Regional Office project 
officer. 
 
In addition to offering the option of covering targeted low-income pregnant women under the 
CHIP plan, CHIPRA requires that children born to a woman receiving pregnancy-related 
assistance shall be deemed on the date of the childs birth to have applied for coverage under 
CHIP or Medicaid, and shall be found eligible for the appropriate program, and until the child 
reaches age one (as described in section 2112(e) of the Act).  During this deemed eligibility 
period, the new law stipulates that the child health or medical assistance eligibility identification 
number of the mother shall also serve as the identification of the child.  Additionally, during this 
period, all claims shall be submitted and paid for the child under the mothers identification 
number (unless the State issues a separate identification number for the child before the child 
reaches age one).  
 
Draft State plan template pages to implement these options are enclosed.  CMS is in the process 
of obtaining the required Office of Management and Budget (OMB) clearance under the 
Paperwork Reduction Act for the State plan amendment (SPA) templates.  Given that States may 
need considerable time to complete these templates, CMS is sharing in draft the SPA template at   Page 4  State Health Official   
 
this time.  Until such time when this SPA template is assigned an OMB clearance number, States 
are not obligated to respond. 
 
It is well established that access to prenatal services and care throughout a mothers pregnancy 
improves health outcomes for both the mother and child.  Therefore, we encourage States to 
consider these options to establish eligibility for this vulnerable population. 
           
            Sincerely, 
 
                 /s/ 
 
            Jackie Garner 
            Acting Director 
            Center for Medicaid and State Operations 
 
Enclosure 
 
cc: 
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health 
 
Ann C. Kohler          
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Barbara Levine 
Director of Policy and Programs 
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy