. . .

MEDICAID-COVERED 

PRENATAL CARE 

MAGEMEN ADVIRY RERT 

ACCESS TO 

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 

Secretary and the Congress fully and currently informed about programs or management 

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. 

OFFCE OF EVALUATION AN 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 

the Office of Investigations. Inspections are conducted in accordance with professional 

standards developed by DEI. These inspections are tyically short-term studies designed 

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 

PRENA TAL CARE 

ACCESS TO 

MAGEMENT ADVIRY REPORT 

RICH P. KUSSEROW 

INSPECTOR GENERAL 

OEI-090162 OCOBER 199

.. . 

ACCE TO MEDICAI-CVERED PRENATAL CAR 

OAI 90162 

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 

In the early 1980s, the Congress provided a way for more women to receive 

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). 

Catastrophic Costs Related to Inadequate Prenatal Care 

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 

prenatal carel is also a contributing factor to infant mortality. Of women receiving 

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 threefourths of associated health risks may be detected during the first prenatal care visit 

(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, e. , a car, home, and 

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 

infant mortality are available to comrimnity and migrant health centers through the 

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 Medicaidcovered 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 

already in place are cited as reasons for not using presumptive 
eligibilty. . For example, Vermont reports a 10-day expedited formal 

determination process; Minnesota, a 15-day turnaround. 

Signcat Baers Sti Ext to Accing and Delierig Medcad-Cered 

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 

cases or, already eligible Medicaid recipients. 

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. Ninetyfour 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 eligibles (SO BRA) nor high-risk women. 

(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 

prenatal care servces within 14 days of being presumed eligible and 2) 

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 

needed to get Medicaid-covered prenatal care. In addition, women are 

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 followthrough 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 

Eighty-eight percent of the States say they have problems with 

health care providers not accepting Medicaid. More than half of 

the Medicaid eligibilty supervsors think women don t even apply 

for Medicaid-covered prenatal care servces because women feel 

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 

Eighty-six percent of the States say low reimbursement rates 

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. 

In 12 South Carolina counties, networks of nonprofessionals (lay 

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. 

PRELIMARY RECOMMATIONS - ESENT 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.


Increasing awareness of the need for prenatal care, as well as the 

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 nonprofit 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 
;... .;

Drop the Ast 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 

processing at the local welfare office, eliminating the need for a woman 

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. 

Simpli the Eligibilty Verication Proc. 

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 

formal acceptance status. By doing so, biling wil be less problematic 

. 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 

servces. The system needs to be accessible to both health care 

providers and eligibilty workers. Ninety-seven percent of the State 

respondents agree this servce is needed. 

Asure Adequate Provder Paricipation to Delier Medicad-Cvered Prenata 

Cae Servce. 

Seventy-six percent of the States have already raised reimbursement 

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


1. The Alan Guttmacher Institute (Gold, Kenney, and Singh, 1987:14) defined 

insufficient prenatal care as "poor or no care and less-than adequate care. Care is 

considered poor if started in the third trimester, or if there had been only one 

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 

before the second trimester, or if there were only three prenatal visits and gestation 

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. 

3. Presumptive eligibilty allows pregnant women to receive ambulatory prenatal care 

before being formally accepted into the Medicaid program. Determination is based 

on income and determined by a Medicaid-qualified provider or intake worker. 

determined presumptively eligible, the woman remains in this status for 14 calendar 

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 

the presumptive determination is made: If the woman fails to make formal 

application within the 14-day.period, presumptive eligibilty ends on the 14th day 

after the presumptive determination. 
. .