DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
SHO# 21-007 
RE: Improving Maternal Health 
and Extending Postpartum 
Coverage in Medicaid and the 
Childrens Health Insurance 
Program (CHIP) 
 
December 7, 2021 
 
Dear State Health Official:  
 
Medicaid is the largest single payer of pregnancy-related services and covers over 42 percent of 
births nationally.1 The Childrens Health Insurance Program (CHIP) also covers pregnant 
adolescents and, in some states, low-income pregnant individuals with income over the Medicaid 
income limit.  Together, Medicaid and CHIP play a critical role in ensuring access to care for 
pregnant and postpartum individuals, improving the quality of maternal health care, and 
addressing disparities in health outcomes and pregnant and postpartum care.  Sections 9812 and 
9822 of the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2) give states a new option 
to provide 12 months of extended postpartum coverage to pregnant individuals enrolled in 
Medicaid and CHIP beginning April 1, 2022.  The purpose of this State Health Official (SHO) 
letter is to provide guidance to states on implementation of this new state option. 
  
The newly extended postpartum coverage option offers states an opportunity to provide care that 
can reduce pregnancy-related deaths and severe maternal morbidity and improve continuity of 
care for chronic conditions such as diabetes, hypertension, cardiac conditions, substance use 
disorder, and depression.  More than half of pregnancy-related deaths occur in the 12-month 
postpartum period, and 12 percent occur after six weeks postpartum. Significant and persistent 
disparities exist in pregnancy-related morbidity and mortality.  Black and American 
Indian/Alaska Native individuals are up to five times more likely than White individuals to die 
from pregnancy-related complications and more likely to have a preventable death.2  There are 
also disparities in rates of postpartum follow-up care for conditions associated with morbidity 
and mortality.  Black individuals who had gestational diabetes were found to have among the 
lowest postpartum diabetes screening rates despite having the highest risk for progression to 
chronic diabetes.3   More generally, individuals who have a lower level of education, individuals 
who are Black or Hispanic, and individuals with co-existing morbidities, such as mental health 
                                                           
1 Medicaid covers 42.1 percent of births nationally; National Center for Health Statistics, Birth Data (updated June 14, 2021).  
Available at https://www.cdc.gov/nchs/nvss/birthshtm.  
2 Petersen, E. E., N.L. Davis, D. Goodman, et al. Vital Signs: Pregnancy-Related Deaths, United States, 20112015, and 
Strategies for Prevention, 13 States, 20132017. Morbidity and Mortality Weekly Report, vol. 68, no. 18, 2019, pp. 423429. 
Exact rates differ by demographic data. 
3 Herrick, C. J., Puri, R., Rahaman, R., Hardi, A., Stewart, K., & Colditz, G. A. (2020). Maternal Race/Ethnicity and Postpartum 
Diabetes Screening: A Systematic Review and Meta-Analysis. Journal of women's health (2002), 29(5), 609621. Available at 
https://doi.org/10.1089/jwh.2019.8081.  
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 2  State Health Official 
 
conditions, have lower rates of postpartum care.4  Extended postpartum coverage presents an 
opportunity for states to improve postpartum care and address these disparities.  States that have 
expanded Medicaid eligibility to provide coverage beyond 60 days postpartum report an increase 
in postpartum care visits, continuity in coverage, and enhanced engagement of individuals in 
health care.5  
Background  
 
Many pregnant individuals qualify for Medicaid on the basis of their pregnancy through the 
eligibility group for pregnant individuals described at 42 C.F.R.  435.116.  Pregnant individuals 
may also be eligible on another basis, for example, as a parent or caretaker relative or on the 
basis of disability status.  States also have the option to extend coverage to lawfully residing 
pregnant individuals and children, if they otherwise meet eligibility requirements under the 
states program (commonly referred to as the CHIPRA 214 option).  Under current law, 
pregnant Medicaid beneficiaries are eligible under the state plan for at least pregnancy-related 
services through the end of the month in which the 60-day period, beginning on the last day of 
pregnancy, ends (referred to as the 60-day postpartum period).6  This continuous eligibility 
applies through the end of the 60-day postpartum period regardless of the eligibility group in 
which the beneficiary is enrolled, and is not affected by changes in income that would otherwise 
result in a loss of eligibility.7  
 
Pregnant individuals also may be eligible for coverage in CHIP.  Pregnant adolescents eligible as 
a targeted low-income child in CHIP can receive prenatal and postpartum care along with 
other child health assistance.  States also have the option to extend CHIP eligibility to targeted 
low-income pregnant women through the end of the 60-day postpartum period, similar to 
Medicaid8, and to elect the CHIPRA 214 option for this population under section 2107(e)(1)(O) 
of the Act.  In addition, states have the option to extend child health assistance to unborn 
children who meet other applicable eligibility criteria for coverage under the CHIP state plan, 
thereby providing coverage to pregnant individuals who themselves are not eligible for Medicaid 
or CHIP.  Unlike postpartum coverage for targeted low-income pregnant individuals, postpartum 
coverage for pregnant individuals who received services during pregnancy on behalf of their 
unborn child is limited.   
State Plan Option to Provide 12 Months Postpartum Coverage  
 
The ARP provides Medicaid and CHIP agencies a new state plan option to provide 12 months of 
continuous postpartum coverage, regardless of any changes in circumstances, in Medicaid and 
CHIP (hereafter referred to as the extended postpartum coverage option or extended 
postpartum coverage).  Section 9812 of the ARP adds a new section 1902(e)(16) of the Social 
                                                           
4 Jones, E.J., T.L. Hernandez, J.K. Edmonds, and E.P. Ferranti. Continued Disparities in Postpartum Follow-Up and Screening 
Among Women with Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review. Journal of Perinatal 
Neonatal Nursing, vol. 33, no. 2, 2019, pp.136148. 
5 Gordon, S.H., B.D. Sommers, I. Wilson, O. Galarraga, and A.N. Trivedi. The Impact of Medicaid Expansion on Continuous 
Enrollment: A Two-State Analysis. Journal of General Internal Medicine, vol. 34, no. 9, 2019, pp. 19191924. 
6 Section 1902(e)(5) of the Social Security Act; 42 C.F.R.  435.170 
7 Section 1902(e)(6) of the Social Security Act; 42 C.F.R.  435.170; CMCS Informational Bulletin, Medicaid and Childrens 
Health Insurance Program (CHIP) Renewal Requirements, (December 2020). Available at https://wwwmedicaid.gov/federal-
policy-guidance/downloads/cib120420.pdf  
8 Section 2112(d)(2)(A) of the Social Security Act 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 3  State Health Official 
 
Security Act (the Act) to provide this authority in Medicaid, which is extended to CHIP through 
a new subparagraph (J) at section 2107(e)(1) of the Act, added by section 9822 of the ARP.  
When the state elects this option in Medicaid, it must also make the same election in a separate 
CHIP, as established under subparagraph (C) of section 1902(e)(16), as referenced in section 
2107(e)(1)(J) of the Act.  The option is currently limited to a 5-year period beginning on April 1, 
2022.  
 
The 12-month postpartum period begins on the last day of a beneficiarys pregnancy and extends 
through the end of the month in which the 12-month period ends.  Similar to the current 60-day 
postpartum period, under the extended postpartum coverage option, individuals are entitled to the 
extended postpartum coverage regardless of the reason the pregnancy ends.  States that do not 
elect the extended postpartum coverage option must continue to provide coverage for pregnant 
individuals in Medicaid through the 60-day postpartum period as currently required.  
 
States that elect to provide the extended postpartum coverage option are encouraged to educate 
beneficiaries about the availability of continuous extended postpartum coverage, including 
posting information on the state agency website and collaborating with providers and 
stakeholders in their state to provide outreach and education about the new option.  States may 
use Medicaid and CHIP administrative matching funds for beneficiary and provider education 
and outreach.  In addition, states are encouraged to update their notices to ensure pregnant 
individuals and beneficiaries are aware they are eligible for continuous extended postpartum 
coverage.  States are reminded that program information on Medicaid and CHIP must be 
provided in plain language and in a manner that is accessible to individuals who have limited 
English proficiency or are living with disabilities, as required at 42 C.F.R.  435.905(b) and 
457.110(a). 
 
Eligibility for Extended Postpartum Coverage  
 
In states that elect the 12-month extended postpartum coverage option, beneficiaries who are 
eligible for and enrolled in Medicaid or CHIP while pregnant, including lawfully residing 
children and pregnant individuals covered under the state option provided for at sections 
1903(v)(4)(A)(i) and 2107(e)(1)(O) of the Act (commonly known as the CHIPRA 214 option), 
are eligible for continuous coverage for the duration of the extended postpartum period.  Sections 
1902(e)(16) and 2107(e)(1)(J) of the Act authorize 12 months of continuous extended 
postpartum coverage to individuals who while pregnant are eligible for and have received 
coverage under the Medicaid or CHIP state plan or a demonstration project.  As a result, states 
cannot cover under the extended postpartum coverage option individuals who were not enrolled 
in Medicaid or CHIP in the state at some point during pregnancy.  Note that, for Medicaid, the 
12 months of extended postpartum coverage under this option applies to individuals who were 
pregnant and received Medicaid-covered services while pregnant during a period of retroactive 
eligibility granted under section 1902(a)(34) of the Act and 42 C.F.R.  435.915(a). 
  
The extended postpartum coverage option under the state plan is available to Medicaid 
beneficiaries enrolled in the group for pregnant individuals at 42 C.F.R.  435.116 as well as 
pregnant individuals enrolled in any other categorically or medically needy eligibility group.  
States must ensure they are able to provide continuous extended postpartum coverage for 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 4  State Health Official 
 
individuals enrolled in Medicaid on a basis that is not related to pregnancy status but who report 
a pregnancy or whom the state identifies as pregnant (e.g., based on claims data). 
 
In states that cover children and/or pregnant individuals in a separate CHIP, if the state elects the 
extended postpartum coverage option in Medicaid, pregnant adolescents eligible as targeted 
low-income children and individuals eligible as targeted low-income pregnant women who 
are enrolled in the separate CHIP must also receive the extended postpartum coverage. 
  
Section 9822 of the ARP did not change postpartum care for all pregnant individuals enrolled in 
CHIP, maintaining existing limitations.9  The 12-month extended postpartum coverage under 
section 2107(e)(1)(J) of the Act is only available to targeted low-income children who are 
pregnant or targeted low-income pregnant women.  Pregnant individuals receiving CHIP 
services who do not meet the definition of either targeted population may not receive extended 
postpartum coverage under the ARP option.  States should reach out to their CHIP Project 
Officer with any questions or technical assistance needs regarding coverage for such individuals. 
 
States must submit a Medicaid and CHIP state plan amendment (SPA) to adopt the extended 
postpartum coverage option.  In states that do so, the following populations must be provided 
continuous enrollment through the end of the 12-month postpartum period: 
 
  Current beneficiaries who are pregnant as of the effective date of the SPA or who enroll 
based on pregnancy or become pregnant after the SPA is effective;  
  Current beneficiaries who were enrolled in Medicaid or CHIP while pregnant and who 
are no longer pregnant when the SPA becomes effective, but who are still within a 12-
month postpartum period; and  
  Individuals who apply for Medicaid after their pregnancy ends, but who received 
Medicaid-covered services in the state while pregnant on or after the effective date of the 
SPA, if such services were received during a period of retroactive eligibility granted 
under section 1902(a)(34) of the Act and 42 C.F.R.  435.915(a), provided that they 
would have been eligible when they received such services if they had applied. 
 
When a state first implements the extended postpartum coverage option, there may be some 
individuals who were enrolled in Medicaid or CHIP while pregnant and are still less than 12 
months postpartum, but whose coverage was terminated prior to the effective date of the 
extended postpartum coverage option in the state.  While not required, states may choose to: 
 
1)  Identify these individuals and reinstate their coverage, provided they continue to be state 
residents.  These individuals would be eligible for coverage with continuous eligibility in 
the group from which they were disenrolled for the remainder of their 12-month 
postpartum period; or   
                                                           
9 For individuals receiving pregnancy-related care who may not otherwise be eligible for Medicaid or CHIP, states may only 
provide postpartum care if (1) the post-birthing individual would otherwise satisfy all eligibility requirements for CHIP except 
age, as described at section 2112(f)(2) of the Act; (2) the postpartum coverage is included as part of a bundled payment for 
prenatal care and labor and delivery benefits (CMS SHO #02-004; available at https://healthlaw.org/wp-
content/uploads/2018/09/cms release on prenatal care for fetuses.pdf); or (3) the state has implemented a health services 
initiative (HSI) to provide postpartum coverage. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 5  State Health Official 
 
2)  Approve coverage for any such individuals who submit a new application within their 12-
month postpartum period and provide them with continuous eligibility for the remainder 
of their 12-month postpartum period. 
 
In Medicaid, under both options, retroactive eligibility would be available, consistent with 42 
C.F.R.  435.915(a), to provide coverage for the three months prior to the date of reinstatement 
or reapplication if the beneficiary had received Medicaid services, at any time during that three-
month period, and would have been eligible for Medicaid at the time they received the services if 
they had applied.  In CHIP, states may develop a reasonable methodology in their state plan to 
determine the effective date of eligibility and avoid gaps in coverage for this population, 
consistent with 42 C.F.R.  457.340(g), including providing retroactive eligibility.  
 
Continuous Eligibility During Pregnancy and the Extended Postpartum Period 
 
Pregnant individuals who are eligible for extended postpartum coverage in Medicaid and CHIP 
are entitled to continuous eligibility through the last day of the month in which the 12-month 
postpartum period ends.10  Unlike the continuous eligibility provided under section 1902(e)(6) of 
the Act, which ensures pregnant Medicaid beneficiaries continue to be eligible through the end 
of the 60-day postpartum period despite changes in income, the continuous coverage afforded 
under section 1902(e)(16) of the Act ensures such coverage despite any changes in 
circumstances, similar to the continuous coverage provided to children, at state option, under 
section 1902(e)(12) of the Act.  Individuals receiving extended postpartum coverage remain 
eligible regardless of changes in circumstances that may affect eligibility such as a change in 
income, household composition, or categorical eligibility (e.g., reaching an age milestone or loss 
of Supplemental Security Income (SSI) for individuals eligible for Medicaid based on receipt of 
SSI).  For example, eligibility continues through the duration of the extended postpartum 
coverage period for pregnant adolescents in CHIP turning 19 and pregnant individuals enrolled 
in the Medicaid mandatory  group for children under age 19 described at 42 C.F.R.  435.118 at 
the time that they would ordinarily age out of eligibility under that group. 
  
We have determined that, despite the broad coverage protection afforded under the statutory 
language, states are expected to apply the same narrow exceptions applied to continuous 
eligibility for children under 42 C.F.R.  435.926(d)(2) through (d)(5) to the continuous 12-
month postpartum coverage provided under section 1902(e)(16) of the Act.  Thus, states 
providing extended postpartum coverage must ensure that pregnant and postpartum individuals 
eligible under the extended postpartum coverage option, who would otherwise lose eligibility 
due to a change in circumstances, remain enrolled in Medicaid or CHIP until the end of the 12-
month postpartum period, unless:  
 
  the individual requests voluntary termination; 
  the individual ceases to be a state resident; 
  the agency determines that eligibility was determined incorrectly at the most recent 
determination or redetermination of eligibility because of agency error or fraud, abuse, or 
perjury attributed to the individual; or 
  the individual dies.   
                                                           
10 American Rescue Plan Act of 2021, Pub. L. 117-2,  9812 and 9822 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 6  State Health Official 
 
CHIP regulations at 42 C.F.R  457.342 allow for two exceptions to continuous eligibility in 
addition to those in 42 C.F.R.  435.926(d): (1) non-payment of premiums, and (2) becoming 
eligible for Medicaid.  However, section 2107(e)(1)(J) of the Act, which applies 1902(e)(5) and 
(16) of the Act to CHIP, explicitly requires that individuals who were eligible while pregnant 
remain eligible under the state plan through the end of the 12th month after the end of the 
pregnancy regardless of any changes.  Therefore, the additional exceptions to continuous 
eligibility at 42 C.F.R  457.342 do not apply during the pregnancy and extended postpartum 
period under the option provided under section 2107(e)(1)(J) of the Act.11 
  
Renewals for Individuals Eligible for Extended Postpartum Coverage  
 
For individuals first enrolled at the end of their pregnancy, the regular renewal required under 42 
C.F.R.  435.916 may coincide with the end of the extended 12-month postpartum period. For 
most, however, the 12-month postpartum period will end after their regularly-scheduled renewal 
date.  The availability of continuous coverage for 12 months post-pregnancy under the extended 
postpartum coverage option renders any regular renewal scheduled before the end of the 12-
month postpartum period unnecessary. Rather, the Medicaid and CHIP agency must conduct the 
renewal at the end of the individuals extended 12-month postpartum period in accordance with 
renewal regulations at 42 C.F.R.  435.916 and 457.343.12  Because agencies do not need to 
complete renewals or redeterminations based on changes in circumstances until the end of the 
extended postpartum period, beneficiaries remain enrolled in the eligibility group in which the 
beneficiary was enrolled during pregnancy through the end of the 12-month postpartum period.  
 
We recognize that, absent a states election to provide 12 months of continuous postpartum 
coverage, some individuals enrolled in the group for pregnant individuals would be redetermined 
as eligible for the adult group at the end of the 60-day postpartum period and meet the definition 
of newly eligible in 42 C.F.R.  433.204(a)(1) for purposes of claiming the increased federal 
medical assistance percentage (FMAP) described in section 1905(y) of the Act.  The availability 
of increased FMAP for such individuals is discussed below.  
 
Benefits  
 
States electing the extended postpartum coverage option must provide full benefits to all 
pregnant and postpartum individuals, as described at sections 1902(e)(16)(B) and 2107(e)(1)(J) 
of the Act.  There may be some beneficiaries who become pregnant after enrolling in the adult 
group described in section 1902(a)(10)(A)(i)(VIII) of the Act and 42 C.F.R.  435.119.  
Coverage provided under an Alternative Benefit Plan (ABP) under section 1937 of the Act is 
considered full benefits for purposes of the extended postpartum option.  States must inform 
beneficiaries of any differences in coverage between the ABP and the benefits available to 
                                                           
11 While eligibility for Medicaid is not an exception to continuous eligibility during pregnancy and the extended postpartum 
period under ARP, it may be beneficial for a pregnant or postpartum individual to request voluntary termination of CHIP 
eligibility to enroll in Medicaid.  As such, beneficiaries who become Medicaid eligible need to be informed about the differences 
between the programs, including cost sharing, benefits, provider networks, and their eligibility for extended postpartum coverage, 
so they can make an informed decision. 
12 See CMCS Informational Bulletin Medicaid and Childrens Health Insurance Program (CHIP) Renewal Requirements, 
(December 2020) for more information on making accurate redeterminations of eligibility. Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf  
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 7  State Health Official 
 
individuals eligible as pregnant women (including any differences in benefits, premiums, and 
cost sharing). 
  
While most states provide full coverage to all pregnant Medicaid beneficiaries, some states limit 
the coverage available to beneficiaries who are enrolled in the group for pregnant individuals 
described at 42 C.F.R.  435.116 and have income above a threshold specified by the state.13  
States that have elected to provide only services related to pregnancy or a condition that may 
complicate pregnancy and to COVID-19 vaccines (and their administration) must submit a SPA 
to remove this coverage limitation while the extended postpartum coverage option is in effect. 
  
Under CHIP, the state must continue to provide the same scope of child health assistance as 
defined in section 2110(a) of the Act and pregnancy-related assistance as defined in section 
2112(d) of the Act during the extended postpartum period.  At a minimum, states must continue 
to provide comprehensive benefits consistent with the benefit coverage option elected in the 
CHIP state plan, as described in section 2103(a) of the Act, such as benchmark or Secretary-
approved coverage; however, states may elect to provide a more generous coverage option 
during the extended postpartum period. 
 
State Plan Amendment Submission 
 
States that elect the extended postpartum coverage option in Medicaid must also elect the option 
for a separate CHIP, unless the state only provides coverage to unborn children in its separate 
CHIP.  In order to elect the option, states must submit a Medicaid SPA through MACPro to 
extend postpartum coverage under Medicaid and, as appropriate, submit a CHIP SPA in the 
Medicaid Model Data Lab (MMDL) to extend postpartum coverage for pregnant individuals 
covered in a separate CHIP.  Subject to the requirements at 42 C.F.R.  430.12, et seq. and 42 
C.F.R.  457.60, states may submit SPAs with proposed effective dates no earlier than April 1, 
2022.  States are strongly encouraged, but not required, to maintain their SPA through March 31, 
2027, when the current statutory authority for the extended postpartum coverage option expires.  
CMS will work with states to identify other options to maintain extended postpartum coverage if 
the statutory authority to extend coverage is not reauthorized.  States may contact their Medicaid 
state lead for technical assistance to complete the Medicaid SPA and their CHIP project officer 
for technical assistance to complete the CHIP SPA. 
Federal Financial Participation for Newly Eligible Individuals Receiving Extended 
Postpartum Coverage  
 
Currently, many Medicaid beneficiaries (such as, but not limited to, those covered under the 
eligibility group for pregnant individuals described at 42 C.F.R.  435.116) become eligible for, 
and transition to, the adult group described at 42 C.F.R.  435.119, at the end of the 60-day 
postpartum period.  Some of the individuals who transition to the adult group after their 60-day 
postpartum period are newly eligible, as defined in 42 C.F.R.  433.204(a)(1), for purposes of 
the increased FMAP described in section 1905(y) of the Act (newly eligible FMAP).   
                                                           
13 Clause VII in the matter following section 1902(a)(10)(G) of the Act. Services related to pregnancy include prenatal, delivery, 
postpartum, and family planning services.  Because the health of a pregnant individual is so intertwined with the health of the 
expected child, most states consider all services required for categorically needy Medicaid beneficiaries to be pregnancy-related 
services.   
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 8  State Health Official 
 
States have shared concerns that electing the extended postpartum coverage option could result 
in the application of a lower FMAP than the state could claim for individuals who would 
otherwise be determined newly eligible in the adult group, if not for the states adoption of the 
extended postpartum coverage option.  States have expressed concern that, to make the extension 
of postpartum coverage financially possible for the state, the state would need to conduct a 
redetermination before the end of the 60-day postpartum period only to obtain information 
sufficient to determine whether the individual beneficiary qualifies as newly eligible so that the 
state may continue claiming the increased FMAP under section 1905(y) of the Act with respect 
to the individual.  However, this redetermination would be unnecessary for purposes of 
establishing the individuals eligibility for benefits and would be administratively burdensome 
for the individual and the state; its only purpose would be to support the states claiming of 
service expenditures at the applicable FMAP. 
 
To support states interested in adopting the extended postpartum coverage option under the ARP 
without requiring that they conduct a redetermination that would be unnecessarily burdensome 
for beneficiaries and the state, states may use a proxy methodology to account for the proportion 
of individuals covered under the extended postpartum coverage option who would otherwise be 
eligible for coverage in the adult group and for the newly eligible FMAP under section 1905(y) 
of the Act.  Under current law, states can claim the newly eligible FMAP for individuals if (1) 
the individual is eligible for the adult group under 42 C.F.R.  435.119; (2) the individual is 
newly eligible, as defined in 42 C.F.R.  433.204(a)(1); and (3) the individual is receiving 
benefits that meet the Alternative Benefit Plan requirements in section 1937 of the Act.  States 
may claim the newly eligible FMAP for individuals receiving extended postpartum coverage if 
the state implements a CMS-approved proxy methodology to ascertain the proportion of medical 
assistance expenditures for beneficiaries receiving extended postpartum coverage that are for 
individuals who would be eligible for the adult group and qualify as newly eligible, if the state 
completed a redetermination.  This option is available provided beneficiaries receiving extended 
postpartum coverage receive benefits satisfying the Alternative Benefit Plan requirements under 
section 1937 of the Act. 
 
Similar to the resource proxy methodology set forth in 42 C.F.R.  433.206(d), the extended 
postpartum coverage proxy methodology must identify the basis that would make an individual 
eligible for the adult group as newly eligible and must comprehensively describe the criteria used 
to determine the adjustment to the total medical assistance expenditures for individuals receiving 
extended postpartum coverage to identify the portion that may be claimed at the newly eligible 
FMAP under section 1905(y) of the Act.  For example, if parents between 100 percent of the 
federal poverty level (FPL) and 133 percent of the FPL are newly eligible in a state, the state 
would need a reasonable, statistically valid method to identify the percentage of individuals 
receiving 12-month postpartum coverage who are between 100 and 133 percent FPL whom the 
state would otherwise transition to the adult group and claim newly eligible FMAP; and then 
apply that percentage to the total expenditures for individuals receiving 12-month postpartum 
coverage to claim at the newly eligible FMAP.  The methodology must be auditable and based 
on statistically valid data.  The proxy methodology would not apply to individuals who are 
enrolled in the adult group when they become pregnant and remain in that group through 
pregnancy and the postpartum period. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 9  State Health Official 
 
States that adopt the extended postpartum coverage option and intend to claim the newly eligible 
FMAP using a proxy methodology must submit an FMAP SPA amendment that meets the 
requirements of 42 C.F.R.  433.206(h), as relevant to the proxy methodology.  CMS is available 
to provide technical assistance to states interested in developing a proxy methodology to claim 
the newly eligible FMAP for certain individuals during the extended postpartum coverage 
period.  
Opportunities to Improve Maternal Health  
 
In order to realize the potential of extended postpartum coverage to improve postpartum care and 
advance equity in health outcomes for beneficiaries, CMS encourages states to make a concerted 
effort to increase awareness of the extended postpartum coverage to both providers and 
beneficiaries.  To maximize the impact of adopting the extended postpartum coverage option, it 
also will be critical for states to measure and monitor utilization and quality of care in the 
postpartum period, and to work with health plans, providers and other stakeholders to improve 
maternal health care.  Drawing on the experiences of states in several learning collaboratives 
(discussed below), CMS has developed a number of tools and strategies that states can employ 
and can provide technical assistance to states to support these quality measurement and 
improvement activities. 
 
Care during the postpartum period involves not just a single visit but a series of encounters and a 
range of services tailored to the needs of the beneficiary.  The American College of Obstetricians 
and Gynecologists (ACOG) recommends that all postpartum individuals have contact with their 
health care providers within the first three weeks after delivery followed by individualized 
ongoing care as needed.14  Coverage during an extended postpartum period gives providers 
opportunities to assess beneficiaries physical recovery from pregnancy and childbirth, and, 
critically, to screen for and provide care to address conditions that can lead to morbidity and 
mortality in the later postpartum period.  High quality, comprehensive postpartum care should 
address chronic health conditions (e.g., diabetes or hypertension), mental health and 
psychological well-being (e.g., postpartum depression, interpersonal violence), and family 
planning (e.g., contraceptive counseling).  Postpartum visits are also a time for providers to 
counsel individuals on nutrition, breastfeeding, tobacco and other drug use, and other preventive 
health issues that affect both the postpartum individuals longer-term health and that of their 
infant, and to help individuals retain coverage under Medicaid or CHIP or successfully transition 
to other coverage at the end of the postpartum period, including enrollment in a qualified health 
plan available through the Health Insurance Marketplace.  
 
States may also consider building on person-centered models of perinatal care to support 
individuals in the prenatal, delivery, and postpartum periods, such as doula services and home 
visiting. Doula support, which can be delivered in a home setting, is associated with improved 
health outcomes including decreased likelihood of postpartum depression and near-universal 
breastfeeding among low-income individuals.15 Coverage of doula services may be effectuated 
                                                           
14 Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. 
Obset Gynecol 2018; 131:e 140-50. https://www.acog.org/clinical/clinical-guidance/committee-
opinion/articles/2018/05/optimizing-postpartum-care  
15 https://www.medicaid.gov/medicaid/quality-of-care/downloads/mih-expert-workgroup-recommendations.pdf  
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 10  State Health Official 
 
through multiple benefit categories, including, but not limited to, preventive services, services of 
licensed practitioners, clinic services, and freestanding birth center services. Similarly, while 
there is no distinct Medicaid state plan benefit called home visiting, states may cover many of 
the individual component services of home visiting programs through existing Medicaid 
coverage authorities.16 States can utilize value-based payment arrangements to incentivize the 
use of innovative maternal health care delivery models and improve health outcomes. CMS is 
available for technical assistance to states interested in adding these coverage options to their 
programs.  
 
Maternity Core Set 
 
To support states in their maternal, perinatal, and infant health-focused quality improvement 
efforts, CMS identified a core set of 11 measures for voluntary reporting17 by state Medicaid and 
CHIP agencies. This Maternity Core Set, which consists of seven measures from CMSs Child 
Core Set and four measures from the Adult Core Set, is used by CMS to measure and evaluate 
progress toward improvement of maternal and infant health in Medicaid and CHIP. The areas of 
maternal health addressed in this set include: timeliness of prenatal care, postpartum care visits, 
contraceptive care, elective delivery, and low-risk cesarean section births.  Two of these 
measures, Live Births Weighing Less than 2,500 Grams and Postpartum Care, are included in the 
State Health System Performance pillar of the Medicaid and CHIP Scorecard.18 Additionally, 
several measures on the Adult Core Set measure follow-up care for conditions that are associated 
with maternal morbidity and mortality (e.g., controlling high blood pressure and screening for 
depression and follow-up plan) and to assess ongoing well-woman care (e.g. cervical and breast 
cancer screening).19 
 
CMS strongly encourages states to stratify these quality measures and other metrics of interest to 
states by race, ethnicity, geography, language and other indicators in order to identify disparities 
in access to care and health outcomes and to develop targeted initiatives to improve maternal 
health equity. 
 
Maternal and Infant Health Initiative 
 
To improve access to and quality of care for pregnant and postpartum beneficiaries and their 
infants, CMS launched the Maternal and Infant Health Initiative (MIHI) in July 2014.20  Today, 
the MIHI is focused on driving improvement in three areas, each of which is associated with one 
or more Maternity Core Set measures: 
 
1)  Increase the use and quality of postpartum care visits; 
2)  Increase the use and quality of well-child visits; and 
                                                           
16 https://www.medicaid.gov/federal-policy-guidance/downloads/cib-03-02-16.pdf  
17 Pursuant to Section 50102(b) of the Bipartisan Budget Act, reporting on the seven measures that are part of the Child Core Set 
will become mandatory for states beginning in 2024. Additionally, the behavioral health measures on the Adult Core Set will also 
become mandatory in 2024, pursuant to Section 5001 of the SUPPORT Act. 
18 https://wwwmedicaid.gov/state-overviews/scorecard/state-health-system-performance/indexhtml  
19 https://wwwmedicaid.gov/medicaid/quality-of-care/downloads/2021-maternity-core-set.pdf  
20 https://wwwmedicaid.gov/medicaid/quality-of-care/improvement-initiatives/maternal-infant-health-care-quality/indexhtml  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 11  State Health Official 
 
3)  Decrease the rates of cesarean section births in low-risk pregnancies, defined as 
nulliparous (first-time pregnancies), term (37 or more weeks gestation), singleton (one 
fetus), vertex (head facing down in the birth canal) or NTSV births. 
 
These three areas of focus were selected based on input from a stakeholder workgroup, which 
was charged with identifying areas where Medicaid and CHIP programs had the greatest 
capacity to influence improvement and where CMS and states could, collectively, have the 
greatest impact on maternal and infant health care and outcomes. 
 
To support state Medicaid agencies and their partners in driving improvement in these areas, 
CMS designs and runs learning collaboratives, which combine webinars for all states featuring 
best practices and effective models of care with affinity groups that provide intensive quality 
improvement technical assistance to state teams committed to action in these areas.  Two 
learning collaboratives began in 2021: Postpartum Care and Infant Well-Child Visits.  The third 
learning collaborative, focused on low-risk cesarean section births, is scheduled to begin in 2022. 
CMS will continue to assess the quality measurement and improvement technical assistance 
needs of states and will develop future opportunities and resources to address the identified needs 
and to facilitate shared learning across states.  
 
CMS publishes quality measures and other data and resource materials on Medicaid.gov for 
states to use in their quality improvement efforts.  Currently available data and resources related 
to improving the quality of postpartum care are included in the Appendix of this letter. CMS 
anticipates adding additional resources as we learn more about states technical assistance needs 
and their successes and lessons learned from postpartum care quality improvement activities.  
Section 1115 Demonstrations  
 
CMS has approved several state section 1115(a) demonstrations to implement initiatives in 
Medicaid and CHIP aimed at immediate extension of postpartum coverage.  States that extended 
postpartum coverage through an approved section 1115 demonstration may choose to transition 
the authority for their extended postpartum coverage to the new SPA option.  These states, as 
well as states with a pending 1115 demonstration application to extend postpartum coverage, 
should contact their demonstration project officer to discuss their options.  
 
In addition, CMS has previously approved section 1115 demonstration projects providing 
coverage of family planning and related preventive health services, authorizing evidence-based 
home visiting services, and incentivizing providers to demonstrate specific quality improvements 
and beneficiary health outcomes for maternal health.  CMS supports states in submitting section 
1115 proposals to test approaches that address challenges associated with maternal mortality and 
morbidity and stands ready to work with states on such proposals. 
Closing 
 
CMS appreciates the partnership with states to ensure Medicaid and CHIP drive improvements 
in health outcomes and promote health equity, and CMS remains committed to collaborating 
with states to improve access to coverage and maternal health outcomes.  CMS is available to 
provide technical assistance to states as they extend postpartum coverage, implement innovative 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 12  State Health Official 
payment and delivery system efforts, and engage in initiatives to measure and improve quality 
aimed at addressing the needs of pregnant and postpartum beneficiaries.  Please submit requests 
for technical assistance to your CMS Medicaid state lead or CHIP Project Officer. 
Sincerely, 
Daniel Tsai 
Deputy Administrator and Director 
Cc: 
National Association of Medicaid Directors  
National Academy for State Health Policy  
National Governors Association  
American Public Human Services Association  
Association of State and Territorial Health Officials  
Council of State Governments  
National Conference of State Legislatures  
Academy Health  
National Association of State Alcohol and Drug Abuse Directors 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 13  State Health Official 
 
Appendix  
 
Resources for Improving the Quality of Postpartum Care  
 
The following resources to support states in improving the quality and effectiveness of 
postpartum coverage are available on Medicaid.gov. 
 
-  The Medicaid and CHIP Beneficiary Profile: Maternal and Infant Health provides an 
overview of the demographics, health status, health outcomes, risk factors, and health 
care utilization among reproductive age individuals, individuals with a recent live birth, 
and infants covered by Medicaid and CHIP. 
 
-  Quality of Maternal and Perinatal Health Care in Medicaid and CHIP: Findings from the 
2019 Maternity Core Set. CMS annually releases information on state progress in 
reporting the Maternity Core Set measures and assesses state-specific performance for 
measures that are reported by at least 25 states and that met CMS standards for data 
quality. This resource provides information about performance on frequently-reported 
health care quality measures in the Maternity Core Set. 
 
-  Postpartum Care Learning Collaborative webinar recordings and slides. CMS launched 
the Improving Postpartum Care Learning Collaborative in January 2021. The webinar 
series includes presentations from experts in the field and by state Medicaid and CHIP 
programs on strategies for states to improve the use of postpartum care for individuals at 
high risk of postpartum complications, improve the continuity of coverage for postpartum 
individuals, and implement payment reform to incentivize changes in maternal health 
care practice. 
 
-  Issue Brief: Lessons Learned About Payment Strategies to Improve Postpartum Care in 
Medicaid and CHIP. This issue brief summarizes some of the lessons learned by states 
that participated in CMS Postpartum Care Action Learning Series. The resource includes 
lessons for fee-for-service delivery systems as well as alternative payment models and 
population-based payment. 
 
-  Issue Brief: Improving Postpartum Care: State Projects Conducted through the 
Postpartum Care Action Learning Series and Adult Medicaid Quality Grant Program. 
This issue brief presents profiles of state quality improvement projects focused on 
improving postpartum care and includes driver diagrams summarizing system 
components and activities that are associated with increasing the rate and quality of 
postpartum care visits. 
 
-  Resources on Strategies to Improve Postpartum Care Among Medicaid and CHIP 
Populations. This document compiles strategies that have been shown to be effective to 
improve the postpartum care visit rate and the content of care. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 14  FAQs 
 
Frequently Asked Questions (FAQs) 
Sections 9812 and 9822 of the American Rescue Plan Act of 2021 (ARP): 12 Months Postpartum 
Coverage in Medicaid and the Childrens Health Insurance Program (CHIP) 
DECEMBER 14, 2021 
 
The following questions and answers apply to implementation of the 12-month extended 
postpartum coverage option under sections 1902(e)(16) and 2107(e)(1)(J) of the Act as outlined 
in State Health Official (SHO) letter #21-007, Improving Maternal Health and Extending 
Postpartum Coverage in Medicaid and the Childrens Health Insurance Program (CHIP). 
General Requirements 
 
Q1.  Are states required to provide 12 months postpartum coverage for Medicaid and 
CHIP beneficiaries?  
 
A1.  No.  States are not required to extend postpartum coverage in Medicaid and CHIP, but 
extending postpartum coverage offers opportunities to provide care that can reduce pregnancy-
related death and severe maternal morbidity and improve continuity of care for chronic 
conditions including behavioral health conditions.  States that have already expanded Medicaid 
eligibility to the adult group under 42 C.F.R.  435.119, which has allowed more individuals to 
remain enrolled beyond the end of the month in which their 60th day postpartum occurs, report an 
increase in postpartum care visits, continuity in coverage, and enhanced engagement of 
individuals in health care.1 
  
Q2.  Are states able to extend postpartum coverage only under Medicaid or a separate 
CHIP? 
 
A2.  No.  States that elect to extend postpartum coverage in Medicaid must also take up the 
option to extend postpartum coverage in their separate CHIP if they provide coverage to targeted 
low-income children (defined in section 2110(b) of the Act) who are pregnant and targeted low-
income pregnant individuals (defined in section 2112 of the Act) in a separate CHIP.  States may 
not adopt the option in a separate CHIP if the state does not elect to extend postpartum coverage 
in Medicaid. 
 
Q3.  Who is eligible for extended postpartum coverage on the effective date selected by the 
state? 
 
A3.  States that adopt the extended postpartum coverage option must provide 12 months of 
extended postpartum coverage to individuals who apply for coverage or become pregnant while 
enrolled in Medicaid or CHIP on or after the effective date of the state plan amendment (SPA).  
This includes individuals who apply for Medicaid after their pregnancy ends, but who were 
pregnant and received Medicaid-covered services in the state while pregnant on or after the 
effective date of the SPA if such services were received during a period of retroactive eligibility 
granted under section 1902(a)(34) of the Act and 42 C.F.R.  435.915(a).  In addition, states 
adopting this option must provide extended postpartum coverage to beneficiaries who are 
                                                            
1 Gordon, S.H., B.D. Sommers, I. Wilson, O. Galarraga, and A.N. Trivedi. The Impact of Medicaid Expansion on Continuous 
Enrollment: A Two-State Analysis. Journal of General Internal Medicine, vol. 34, no. 9, 2019, pp. 19191924. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 15  FAQs 
 
enrolled in Medicaid or CHIP on the effective date of the SPA and who are pregnant or who are 
within an extended 12-month postpartum period on such date. 
  
For example, a state elects to extend postpartum coverage beginning April 1, 2022.  Julie is 
enrolled in Medicaid on April 1, 2022, and had given birth while enrolled on November 15, 
2021.  The state must provide Julie with continuous extended postpartum coverage through the 
end of the month in which her 12-month postpartum period ends (November 30, 2022). 
 
Q4.  Do states have the option to provide extended postpartum coverage under the state 
plan for a period of less than 12 months? 
 
A4.  No.  The state plan option provides 12 months of postpartum coverage.  States extending 
postpartum coverage under the state plan option do not have the flexibility to establish a different 
postpartum period. 
 
Q5.  Can a state implement the 12-month extended postpartum coverage SPA option before 
April 1, 2022? 
 
A5. No. States may only elect the 12-month extended postpartum coverage SPA option with an 
effective date on or after April 1, 2022.  
 
However, states that wish to implement extended postpartum coverage before April 2022 may 
work with CMS to propose a section 1115 demonstration project for Medicaid and/or CHIP.  
Eligibility for Extended Postpartum Coverage 
 
Q6.  Does the American Rescue Plan (ARP) establish a new optional eligibility group in 
order for states to provide 12 months postpartum coverage in Medicaid? 
 
A6.  No, the ARP does not establish a new eligibility group.  Individuals who receive the 12-
month postpartum extension remain in the eligibility group in which they were enrolled when 
pregnant for the duration of the postpartum period.  For additional information on Federal 
Medical Assistance Percentage (FMAP) and coverage in the adult group, see questions Q21-22, 
below.  
 
Q7.  Is an individual entitled to extended postpartum coverage if they enroll in Medicaid or 
CHIP during the postpartum period? 
 
A7.  No.  To be eligible for extended postpartum coverage, the individual must have been 
eligible for and enrolled in Medicaid or CHIP while pregnant (including during a period of 
retroactive eligibility in Medicaid).  Individuals who apply for and are enrolled in Medicaid or 
CHIP after a pregnancy ends are not entitled to continuous eligibility for the remainder of their 
12-month postpartum period because they were not enrolled under the Medicaid or CHIP state 
plan while pregnant.  For additional information on eligibility for extended postpartum coverage 
granted during a period of retroactive eligibility, see question Q10, below. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 16  FAQs 
 
For example, an individual submits an application for Medicaid four months after giving birth.  
The agency determines the individual is eligible for Medicaid and enrolls the individual.  The 
individual is not entitled to extended and continuous postpartum coverage through the end of a 
12-month postpartum period, however, because the individual was not enrolled in Medicaid 
while pregnant.  
 
Q8.  Is an individual entitled to an additional 12-month postpartum period in Medicaid or 
CHIP if they become pregnant during the extended postpartum period?  
 
A8. Yes.  An individual who becomes pregnant during an initial extended postpartum period and 
therefore is enrolled in Medicaid or CHIP during such pregnancy would be entitled to an 
extended 12-month postpartum period following the end of the subsequent pregnancy.  The 
individual in this case would receive continuous coverage through the end of 12th month after the 
subsequent pregnancy ends consistent with section 1902(e)(16) or 2107(e)(1)(J) of the Act. 
 
For example, Emily is enrolled in Medicaid while pregnant. Her pregnancy ends in May 2022, 
and an extended 12-month postpartum coverage period begins.  Seven months later, Emily 
becomes pregnant again in December 2022, while she is still eligible for and enrolled in 
coverage.  Emilys subsequent pregnancy ends in September 2023.  At that point, a new 12-
month extended postpartum period will begin, and Emily will remain continuously eligible 
through the end of the subsequent extended postpartum period (through September 2024).  In 
September 2024, the state will need to conduct a redetermination of eligibility and determine 
whether Emily remains eligible for Medicaid under the same or another eligibility group. 
 
Q9: Do individuals who qualify as medically needy with a spenddown while pregnant have 
to continue to meet their spenddown each budget period to be eligible for the coverage 
available under the 12-month postpartum option? 
  
A9: No.  An individual who attained Medicaid eligibility through a spenddown while pregnant is 
eligible for the extended postpartum coverage even if the individual does not have sufficient 
incurred medical or remedial care expenses to meet their spenddown in any subsequent budget 
period during the pregnancy or extended postpartum period. For example, if a pregnant 
individual applies for Medicaid in January in a state that has adopted the 12-month postpartum 
option and covers medically needy individuals, and the individual establishes eligibility by 
meeting their spenddown in February, the state must maintain the individuals Medicaid 
coverage through the remainder of the individuals pregnancy and the end of the month in which 
the 12-month postpartum period ends. The individual will not have to meet a spenddown again 
until the end of continuous 12-month postpartum period.  
 
Q10.  Are individuals eligible for extended postpartum coverage if they enroll in Medicaid 
during their postpartum period but were pregnant during a period of retroactive 
eligibility? 
  
A10.  Yes, individuals who received Medicaid services and met Medicaid eligibility 
requirements while pregnant during a period of retroactive eligibility must be provided extended 
postpartum coverage. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 17  FAQs 
 
For example, Ava submits an application on June 15, 2022 and is determined eligible for 
Medicaid.  Ava was pregnant and gave birth on May 15, 2022, which is within the 3-month 
period prior to the month in which Ava applied for coverage.  The agency determines that Ava 
would have been eligible for Medicaid had she applied in May, and thus is covered retroactively 
to May, when she was pregnant.  Ava is entitled to extended postpartum coverage from the time 
of enrollment through the end of the month in which Avas 12-month postpartum period ends 
(May 31, 2023). 
 
Q11.  Do pregnant individuals who receive Medicaid or CHIP coverage under the 
CHIPRA 214 option qualify for extended postpartum coverage? 
 
A11.  Yes.  A state that has elected to cover lawfully residing pregnant individuals in Medicaid 
and CHIP under the option provided for at sections 1903(v)(4)(A)(i) and 2107(e)(1)(O), and has 
also elected the extended postpartum coverage option, must provide 12 months of extended 
postpartum coverage to such individuals under the option described at 1902(e)(16) and/or 
2107(e)(1)(J) of the Act.  Sections 1903(v)(4)(A) and 2107(e)(1)(O) of the Social Security Act 
provide states the option to provide full Medicaid and/or CHIP coverage to lawfully residing 
children and pregnant individuals, if they otherwise meet eligibility requirements under the 
states program (e.g., income and state residency requirements). This option is commonly 
referred to as the CHIPRA 214 option. 
 
Section 1902(e)(16) of the Act, added by section 9812 of the ARP, and section 2107(e)(1)(J) of 
the Act, added by section 9822 of the ARP, provide states with an option to provide coverage 
during an extended 12-month postpartum period for individuals who, while pregnant, were 
eligible for and received Medicaid or CHIP under the state plan, or a waiver of such plan.  If this 
option is elected, states cannot offer extended postpartum coverage to only some individuals 
enrolled in Medicaid or CHIP while pregnant, but must provide extended postpartum coverage to 
all such individuals. Thus, in a state which has elected both the CHIPRA 214 option for pregnant 
individuals in Medicaid and CHIP and also elects the option to provide 12 months of extended 
postpartum coverage under sections 1902(e)(16) and 2107(e)(1)(J) of the Act, lawfully residing 
adolescents who become pregnant while enrolled in Medicaid or CHIP and pregnant individuals 
covered under the Medicaid or CHIP state plan (or waiver of the state plan) during pregnancy 
would be eligible for the extended 12-month postpartum coverage.2   
Continuous Eligibility for Individuals During Pregnancy and the Postpartum Period 
 
Q12.  Does the ARP require states that elect the option to provide 12 months postpartum 
coverage to provide continuous eligibility to individuals in Medicaid and CHIP during the 
pregnancy and extended postpartum period? 
 
A12.  Yes.  Individuals who are eligible for extended postpartum coverage in Medicaid and 
CHIP are entitled to continuous eligibility throughout the pregnancy and postpartum period until 
the last day of the month in which the 12-month postpartum period ends.  Pregnant and 
postpartum individuals in states that elect the ARP option remain eligible regardless of changes 
                                                            
2 A list of which states have elected to cover lawfully residing children and pregnant women in Medicaid and CHIP, is available 
at https://www.medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip-coverage-lawfully-residing-children-pregnant-
women 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 18  FAQs 
 
in circumstances that may affect eligibility such as a change in household composition, a change 
in categorical eligibility (e.g., reaching an age milestone, eligibility conferred through receipt of 
other program benefits).  States must ensure that individuals eligible for extended postpartum 
coverage, who would otherwise lose eligibility due to a change in circumstances, remain enrolled 
in Medicaid or CHIP until the end of the 12-month postpartum period, unless: (1) the individual 
requests voluntary termination, (2) the individual ceases to be a state resident, (3) the agency 
determines that eligibility was determined incorrectly at the most recent determination or 
redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the 
individual, or (4) the individual dies. 
  
Q13.  Does the ARP require states to provide continuous eligibility to pregnant individuals 
in Medicaid regardless of changes in circumstances, even if the state does not extend 
postpartum coverage? 
 
A13.  In states that do not extend postpartum coverage, pregnant individuals enrolled in 
Medicaid are entitled to continuous eligibility through the last day of the month in which a 60-
day period, beginning on the last day of pregnancy, ends, regardless of changes in income that 
would otherwise result in a loss of eligibility, as required at 42 C.F.R.  435.170.  States that 
provide postpartum coverage consistent with 42 C.F.R.  435.170 must act on changes in 
circumstances that may affect eligibility, other than changes in income, while the individual is 
pregnant or in their 60-day postpartum period.  In states that do not provide extended postpartum 
coverage, we believe changes in circumstances that may affect eligibility for pregnant and 
postpartum individuals are rare, and may include, for example, a change affecting categorical 
eligibility or a change in immigration status.  
 
Q14.  Does the ARP require states to provide continuous eligibility to pregnant individuals 
enrolled in a separate CHIP if the state does not adopt the option to provide 12 months of 
extended postpartum coverage? 
 
A14.  No.  Section 2107(e)(1)(J) of the Act provides that section 1902(e)(5), which requires 
continuous eligibility for pregnant individuals in Medicaid, applies to separate CHIPs only if the 
state has adopted the extended postpartum option in section 1902(e)(16).  There is not a 
continuous eligibility requirement for pregnant individuals enrolled in CHIP unless the state 
adopts the option in sections 1902(e)(16) and 2107(e)(1)(J) of the Act.  
 
Q15.  Are states required to transition individuals enrolled in CHIP who become eligible 
for Medicaid during the continuous extended postpartum period? 
 
A15.  No.  Section 2107(e)(1)(J) applies paragraphs 5 and 16 of section 1902(e) of the Act 
equally to CHIP, which requires that if an individual was eligible for CHIP and receiving 
services while pregnant, they are entitled to continuous eligibility throughout their pregnancy 
and postpartum period.  Therefore, states must keep individuals enrolled in CHIP for the duration 
of their pregnancy and extended postpartum period, even if they become eligible for Medicaid, 
unless one of the allowable exceptions to the continuous eligibility period (as discussed in Q12) 
is applicable.  However, we note that if an individual voluntarily elects to end their CHIP 
enrollment during their extended postpartum period, the individual would not be entitled to 
continuous eligibility for the remainder of their 12-month postpartum period in Medicaid.  In 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 19  FAQs 
 
order to enroll in Medicaid, the individual would need to establish eligibility on a basis other 
than their postpartum status.  
 
Q16.  In a separate CHIP, may states disenroll individuals for non-payment of premiums 
during their pregnancy or extended postpartum period? 
 
A16.  No.  Section 2107(e)(1)(J) of the Act applies the requirements of section 1902(e)(16) of 
the Act to CHIP, which requires that an individual who was eligible under the state plan while 
pregnant remain eligible until the last day of the 12th month after the pregnancy ends, regardless 
of changes that may affect eligibility.  Because the individual met all CHIP requirements during 
the pregnancy, they are entitled to continuous eligibility in CHIP for the entire duration of their 
pregnancy and extended postpartum period even if they do not pay premiums. 
Renewals for Individuals Receiving Extended Postpartum Coverage 
 
Q17.  When should states conduct renewals for pregnant and postpartum individuals? 
 
A17.  Pregnant individuals enrolled in Medicaid and CHIP in a state that elects to provide 12-
months postpartum coverage are entitled to continued coverage through the end of the 12-month 
extended postpartum period regardless of changes in circumstances, except in the case of a 
change in state residency, voluntary termination, an erroneous determination of eligibility, or 
death.  For almost all pregnant individuals, the end of the postpartum period will occur after the 
individuals regular renewal date.  States that adopt the 12-month extended postpartum option 
will not need to conduct a redetermination or renewal prior to the end of the extended postpartum 
period.  The state will need to complete a full renewal, consistent with 42 C.F.R.  435.916 and  
 457.343, at the end of the extended postpartum period.  
 
For example, Sydney applies for Medicaid in June 2022 and is enrolled in the eligibility group 
for pregnant individuals under 42 C.F.R.  435.116 in a state that elects to provide 12-months 
postpartum coverage under section 1902(e)(16) of the Social Security Act.  Sydneys 12-month 
eligibility period for purposes of regular renewals, described at 42 C.F.R.  435.916(a)(1), 
extends from June 1, 2022, to May 31, 2023.  But because Sydney is eligible and enrolled in 
Medicaid while pregnant, she is entitled to continuous eligibility through the end of the month in 
which her 12-month postpartum period ends.  Sydneys pregnancy ends December 15, 2022.  
Her 12-month postpartum period ends December 31, 2023, which is after the end of her regular 
12-month eligibility period (May 31, 2023).  Because Sydney is eligible for continuous 
eligibility through the end of the extended 12-month postpartum period, the agency does not 
need to complete a renewal by May 31, 2023, and may not act on changes in circumstances until 
she reaches the end of her postpartum period (December 31, 2023). 
 
Q18.  Are states required to move pregnant and postpartum individuals between Medicaid 
eligibility groups during a period of continuous eligibility? What if the individual is 
enrolled in the adult group under 42 C.F.R.  435.119 and becomes pregnant?  
 
A18.  No.  A redetermination of eligibility is required to move individuals between eligibility 
groups, but because pregnant individuals are entitled to continuous eligibility, states electing to 
provide 12 months of extended postpartum coverage do not need to complete a renewal or act on 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 20  FAQs 
 
changes in circumstances, with limited exceptions (see Q17), until the end of the individuals 12-
month postpartum period.  Therefore, Medicaid beneficiaries may remain in the eligibility group 
in which they are enrolled during pregnancy through the 12-month postpartum period, including 
individuals enrolled in the adult group under 42 C.F.R.  435.119 who become pregnant after 
enrollment in the adult group and were not transitioned to another group during the course of 
their pregnancy. 
  
Q19.  May states complete periodic renewals of eligibility based on available information 
during a period of continuous eligibility? 
 
A19.  Yes.  A state may, but is not required to, conduct redeterminations and periodic renewals 
of eligibility based on available information without requesting information from the individual 
during a period of continuous eligibility, and if appropriate, move the individual to a new 
eligibility group as long as the transition to the new group would not result in a loss of or 
reduction in coverage (e.g., reduction in benefits, increase in premiums or cost 
sharing).  However, states may not send a renewal form or request additional information from 
the individual in order to complete a renewal or redetermination based on a change in 
circumstances, unless the state has information indicating the individual is no longer a state 
resident or is deceased.  A state may also not request additional information or terminate 
coverage for an individual whose eligibility is renewed based on available information during a 
period of continuous eligibility if the individual responds to the renewal notice to inform the 
state that the information used to determine eligibility is not correct. 
  
Q20.  May a state redetermine eligibility at the end of the 60-day postpartum period 
described at 1902(e)(5) of the Social Security Act for individuals eligible for extended 
postpartum coverage who are enrolled in a group for which pregnancy status is a factor of 
eligibility? 
 
A20.  A state may, but is not required to, redetermine eligibility based on available information 
for individuals enrolled in an eligibility group where pregnancy status is a factor of eligibility 
who are eligible for extended postpartum coverage at the end of the month in which the 60th 
postpartum day occurs.  Individuals determined eligible at application for the group for pregnant 
individuals described at 42 C.F.R.  435.116 must be provided a 12-month eligibility period in 
accordance with requirements for renewals for MAGI-based individuals at 42 C.F.R. 
 435.916(a)(1).  For individuals enrolled in the group for pregnant individuals or a group where 
pregnancy status is a factor of eligibility, the end of the 60-day postpartum period represents a 
change in circumstances that impacts their eligibility for the group.  At the end of the 60-day 
postpartum period, states typically must act on the end of the 60-day postpartum period as a 
change in circumstances, consistent with 42 C.F.R.  435.916(d)(1), and transition the individual 
to another group for which the state is able to determine the individual is eligible.  In states that 
have adopted the extended postpartum coverage under section 1902(e)(16) of the Act, the state 
must provide continuous coverage for 12 months postpartum under the group for pregnant 
individuals if the state is unable, at the end of the 60-day postpartum period, to determine that the 
beneficiary is eligible for another group conferring full Medicaid benefits without requesting any 
information from the beneficiary. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 21  FAQs 
 
For example, Jane submitted an application on January 10, 2022, and was determined eligible for 
and enrolled in the group for pregnant individuals with verified income equal to 50 percent of the 
federal poverty level (FPL) in a state that has adopted the extended postpartum coverage option.  
Her effective date of coverage is January 1, 2022, and her 12-month eligibility period extends 
through December 31, 2020.  Janes pregnancy ends on August 16, 2022, her 60-day postpartum 
period ends October 31, 2022, and her 12-month postpartum period ends August 31, 2023.  The 
states income standard for parents and caretaker relatives is 65 percent FPL. 
 
Because Jane is eligible for extended postpartum coverage, the state does not need to 
redetermine eligibility at the end of Janes 60-day postpartum period or complete a renewal of 
eligibility until the end of her 12-month postpartum period (August 31, 2023), and she may 
remain enrolled in the group for pregnant individuals through the remainder of her extended 
postpartum period.  However, if the state does not have any information indicating Janes income 
has changed since application when she reaches the end of the 60-day postpartum period 
(October 31, 2022), it is permissible for the state to shift Janes coverage to the eligibility group 
for parents and caretaker relatives effective November 1, 2022.  The state will need to complete 
Janes next regular renewal at the end of her extended postpartum period.  
Federal Financial Participation 
 
Q21.  What FMAP applies to individuals enrolled in the adult group who become 
pregnant? 
 
A21.  States are not required to track the pregnancy status of beneficiaries enrolled in the adult 
group and are not required to move them to the eligibility group for pregnant individuals if the 
state becomes aware of their pregnancy.  Beneficiaries who become pregnant must be given the 
option of moving to the pregnancy-related coverage category.  States must inform beneficiaries 
of the differences in coverage between the adult group and pregnancy-related coverage 
(including any differences in benefits, premiums, and cost sharing), and if the state covers any 
additional benefits for pregnant individuals under 42 C.F.R.  440.250(p) not provided to other 
individuals eligible under the state plan, such benefits also must be provided to pregnant 
individuals enrolled in the adult group in an alternative benefit package.  If an individual enrolled 
in the adult group who becomes pregnant does not elect to switch groups and remains enrolled in 
the adult group, the individuals status for FMAP purposes (as newly eligible or not) is 
unchanged until such time the individual is determined eligible for another group, which would 
in no case be sooner than the end of the 12-month postpartum period. 
 
Q22.  Is increased FMAP related to the adult group available to states for individuals 
covered in the extended postpartum coverage option who might otherwise qualify for the 
adult group? 
 
A22.  Yes.  Increased FMAP is available for beneficiaries receiving coverage during an extended 
12-month postpartum period who would meet the requirements for coverage in the adult group 
described in 42 C.F.R.  435.119 and the definition of newly eligible in 42 C.F.R. 
 433.204(a)(1). 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.    Page 22  FAQs 
 
For individuals who would otherwise transition to the adult group after the 60-day postpartum 
period, the state would typically determine whether they meet the requirements for coverage 
under the adult group and the newly eligible criteria under 42 C.F.R.  433.204(a)(1) for the 
purpose of the increased FMAP.  However, because a state adopting the option to provide 12 
months of postpartum coverage does not need to conduct a redetermination of eligibility until the 
end of the extended postpartum period, the state might not conduct the determination under 
Subpart E of Part 433 for adult group FMAP.  Instead, states seeking to claim the increased 
FMAP for newly eligible individuals enrolled in the adult group may adopt a proxy methodology 
to determine the percentage of beneficiaries who would have transitioned to alternative benefit 
package coverage as newly eligible beneficiaries in the adult group for whom newly eligible 
FMAP is available.  Once the methodology is approved by CMS, the state would apply the 
relevant percentage to medical assistance expenditures for the entire extended postpartum 
population to claim the increased FMAP for the proportion of newly eligible individuals 
determined under the proxy methodology. 
 
If a state chooses to conduct renewals based on available information as discussed in Q19 and 
Q20, this will have implications on whether and how a state develops a proxy methodology to 
claim newly eligible FMAP.  CMS will provide additional technical assistance on the possibility 
of using a proxy methodology to states in this circumstance.  
SPAs and Capitation Rate Amendments 
 
Q23.  Are states required to submit separate state plan amendments (SPA) to provide 
extended postpartum coverage in Medicaid and its separate CHIP? 
 
A23.  Yes.  States must submit a Medicaid SPA as well as a CHIP SPA in order to make the 
election in both programs.  CMS will make a Medicaid SPA template available in MACPro and 
a CHIP SPA template available in MMDL. 
 
Q24.  Are states required to create new managed care capitation rates for a 12-month 
postpartum period? 
 
A24.  Capitation rates paid by states to Medicaid managed care plans must be actuarially sound 
in accordance with 42 C.F.R.  438.4, including that the capitation rates are appropriate for the 
populations to be covered and the services to be furnished under the contract between the state 
and plan.  Therefore, the states actuary must evaluate if programmatic changes to the managed 
care program, such as a change in eligibility and coverage, impact the development of actuarially 
sound capitation rates or require a rate amendment if the programmatic change occurs after the 
development of the capitation rates for the applicable rating period.  The state and its actuary 
should ensure that the rate development standards and documentation expectations outlined in 
the Medicaid Managed Care Rate Development Guide are met within the rate certification. 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract.  This document is intended only to provide clarity to the public regarding existing 
requirements under the law.