SCHIP Coverage for Pregnant Women and Unborn Children
Released: 2008-01-08T00:00:00

Background

States that choose to cover pregnant women through the §1115 waiver authority must submit a proposal to the Centers for Medicare and Medicaid Services (CMS) for approval. States with approved §1115 demonstration programs define the available pregnancy-related services in their waiver terms and conditions agreements.

States that opt to extend SCHIP coverage to unborn children must submit an SPA to CMS for approval specifying the pregnancy-related services. Under the SCHIP SPA option, covered services must be related to the pregnancy or to conditions that could complicate the pregnancy, including those for diagnosis or treatment of illnesses or medical conditions that might threaten the health of the unborn child. Care after delivery for the mother, such as postpartum services, is generally not covered as part of the title XXI SPA option. Although CMS requires the care to be directed at the unborn child, the SCHIP unborn child SPA option effectively enables states to provide prenatal care to pregnant women including those with incomes at or above the Medicaid income eligibility thresholds and for individuals who do not qualify for Medicaid (or SCHIP) for other reasons, such as immigration status or incarceration. Finally, for the family coverage option, pregnancy-related benefits are those offered by participating private health plans.

Summary of State Variation in Pregnancy Coverage Under SCHIP

Table 1 summarizes the variation in pregnancy coverage among states with §1115 waivers and those using the SCHIP unborn child SPA option. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 12 states extended coverage through unborn child SCHIP SPAs and 6 states used the §1115 waiver authority (Rhode Island extends coverage to pregnant women through both authorities). The highest upper-income eligibility thresholds for pregnant women and/or unborn children under SCHIP was 300% FPL in California. Seven states established upper-income limits at 200% FPL. Four states exceeded 200% FPL, and six states set maximum income levels below 200% FPL.

Of the 12 states that offer pregnancy-related services to unborn children under the SCHIP SPAs, all but Tennessee extended coverage to the unborn children of undocumented aliens who otherwise would not have access to federally funded pregnancy-related services, except through emergency Medicaid. Two states used SCHIP SPAs to extend coverage to the unborn children of incarcerated women who are otherwise ineligible for SCHIP coverage.

Covered services under the §1115 waiver programs and the SCHIP SPAs generally consisted of comprehensive pregnancy-related services including prenatal care, labor and delivery services, and access to some form of coverage during the postpartum period. However, the length of coverage (e.g., prenatal period through labor and delivery, or prenatal period through 60 days postpartum period) and financing streams for the care associated with each of these pregnancy phases varied across states. For example, some states offered coverage from conception through 60 days postpartum care (financed with SCHIP funds), whereas others segmented the coverage to include prenatal care (financed with SCHIP funds), labor and delivery (financed with emergency Medicaid funds), and postpartum care (financed with state-only funds). In these states, program specialists pointed out that the pregnancy-related care is seamless to the mother despite the administrative complexities required of the state to submit claims under multiple funding streams. Three states indicated that the coverage offered to pregnant women and/or unborn children was comprehensive and not limited to pregnancy-related services. An additional four states specified that the available care included pregnancy-related care and associated health services including, for example, medically necessary dental or mental health benefits as long as the care was necessary to promote the health of the unborn child.

Postpartum care differs among states that chose to extend pregnancy coverage under the §1115 waiver authority as compared with those that offered coverage to unborn children under the SCHIP unborn child SPAs. There were 15 states that offered 60 days of postpartum care to at least some of their eligible populations, including each of the 6 states that offered pregnancy coverage under the §1115 waiver authority. Among the SCHIP SPA states, five states financed 60 days of postpartum care with state-only funds. Four SCHIP SPA states extended 60 days of postpartum care using SCHIP funds. CMS permitted this financing arrangement despite the fact that the unborn child regulation clearly states that federal SCHIP-financed care ends with the birth of the child. The reason CMS permits this is because the state has a global rate for their pregnancy services that includes the cost of prenatal care, labor and delivery, and 60 days of postpartum care. One SCHIP SPA state provided SCHIP-financed postpartum care through the end of the month that the child was delivered because those services have already been paid for under the monthly managed care capitation payment. Two SCHIP SPA states did not offer any form of care for the mother after the birth of the child except in the case of an emergency during which the mother would have access to emergency Medicaid services. Finally, two states (one §1115 waiver state and one SCHIP SPA state) provided access to extended family planning services and supplies as a part of their postnatal care benefit.