Coverage for Pregnant Women Under the ACA
By Jennifer Dolatshahi
This blog post was originally published on State Refor(u)m’s State of Implementation Blog
The Affordable Care Act (ACA) creates new coverage options for pregnant women through Medicaid expansion and subsidized marketplace coverage. It also creates some new challenges in coverage of pregnant women because of overlapping eligibility levels and the potential for concurrent enrollment in subsidized marketplace coverage and pregnancy-related Medicaid coverage. In this blog, we share some newly released data on state eligibility levels for Medicaid and for the Children’s Health Insurance Program (CHIP) coverage of pregnant women and highlight some important issues related to their coverage in the context of the ACA.
Overlapping eligibility levels
With the addition of new coverage options through the ACA, there is considerable overlap in insurance affordability program (IAP) eligibility levels for pregnant women. (Illustrated in Figure 1.) For example, a pregnant woman with income at 140 percent of the federal poverty level (FPL) could be eligible for federal marketplace subsidies as well as coverage in pregnancy-related Medicaid or CHIP, depending on Medicaid and CHIP policies in her state. NASHP analysis finds that in 2014, all states expanding Medicaid (26, including DC) will have overlapping eligibility levels with traditional pregnancy-related Medicaid. At income levels above 200 percent FPL, nearly 40 percent of all states (20, including DC) will have overlapping eligibility levels between pregnancy-related Medicaid or CHIP and subsidized marketplace coverage.
Some women may transition between types of Medicaid coverage because of their pregnancy status. Under federal rules, women who are pregnant at application for Medicaid are not eligible for the Medicaid expansion but are eligible for pregnancy-related Medicaid. Women who become pregnant while already enrolled in the Medicaid expansion, however, can choose to remain in this coverage until their next renewal or request to move into pregnancy-related Medicaid.
Concurrent enrollment in Medicaid and marketplace coverage for pregnant women
Pregnant women are permitted to concurrently enroll in subsidized marketplace coverage and pregnancy-related Medicaid. Two factors make this possible—the overlapping eligibility described above, and the Internal Revenue Service’s (IRS) final rule that indicates pregnancy-related Medicaid is not minimum essential coverage (MEC) and therefore does not disqualify women from also enrolling in subsidized marketplace coverage. The IRS rule recognizes that states provide different levels of Medicaid benefits to pregnant women in the pregnancy-related eligibility category, and so the rule permits these women to also enroll in subsidized marketplace coverage and potentially receive coverage for additional services. Women who become pregnant while enrolled in subsidized marketplace coverage may also enroll in pregnancy-related Medicaid, if they are otherwise eligible.
While pregnant women may be concurrently eligible for Medicaid and subsidized marketplace coverage, this federal policy did not become evident until the latter half of 2013, and state eligibility systems may not have been programmed to handle the option of concurrent enrollment. In the federal and some state marketplaces, pregnant women eligible for both programs may be directed into pregnancy-related Medicaid without the option of also enrolling in a subsidized marketplace plan.
Adding to the coverage complexities for pregnant women, it is possible that women enrolled only in pregnancy-related Medicaid could face the ACA’s tax penalty for not maintaining MEC because this coverage is not considered MEC. While the IRS is waiving the tax penalty for pregnant women in 2014, the agency has not yet indicated what it will do in the future. In the preamble to the final MEC rule, the IRS indicated that that the U.S. Department of Health and Human Services (HHS) could provide a hardship exemption from the tax penalty for pregnant women. It is unknown whether HHS will grant such an exemption.
Implications for CHIP coverage of pregnant women
According to NASHP research funded by the March of Dimes, 18 states, including DC, are providing CHIP coverage for services provided to pregnant women in 2014. This includes 15 states providing coverage under the CHIP unborn child coverage option and four providing coverage for the pregnant woman. (States can have more than one pregnancy-related CHIP program.) The IRS’ MEC rule deemed CHIP coverage generally to be MEC. However, some pregnancy-related CHIP programs cover a limited set of pregnancy-related services only. As with Medicaid coverage of pregnant women, understanding the interactions and intersections of the coverage options under CHIP and the marketplace will be important for states and the pregnant women seeking such coverage. States will benefit from further clarification on the implications of the MEC rule for women receiving pregnancy-related services under CHIP.
The myriad implications of the ACA for coverage of services for pregnant women may cause confusion for women as well as states, and how policies unfold will be important for states to watch in 2014. There has been some early guidance and the Centers for Medicare and Medicaid Services has indicated that additional guidance is forthcoming. Establishing clear policies and concerted efforts to educate state staff, consumer assisters, and women about coverage options will be important to ensure adequate and seamless coverage for pregnant women.
Is your state considering any options to address the complexities of coverage for pregnant women in 2014 and beyond? Let us know in a comment below, or in our pregnant women discussion.