Ensuring Continuous Coverage for Pregnant and Postpartum Medicaid Enrollees under OBBBA

• In Event: Medicaid Policy Levers in Maternal and Child Health: Enrollment, Services, and Access

Abstract

Introduction/Background:While many pregnant and postpartum Medicaid enrollees are in pregnancy-related eligibility pathways, some are in the Affordable Care Act expansion category. Starting January 2027, the One Big Beautiful Bill Act (OBBBA) requires that expansion enrollees satisfy new work requirements and undergo more frequent eligibility redeterminations. Although pregnant and postpartum women are exempt from work requirements and not subject to semiannual eligibility checks due to pregnancy- and postpartum-related continuous coverage requirements, they could face disenrollment if state Medicaid agencies cannot successfully identify them.  

Purpose/Research Question:We assess the number and characteristics of pregnant and postpartum women who may be at risk of coverage losses under OBBBA; explore challenges states may face in ensuring coverage continuity; and identify actions states, the Centers for Medicare & Medicaid Services (CMS), and other stakeholders can take to protect coverage. 

Data:We analyzed data on Medicaid enrollees with live-birth deliveries in 2022 from the 2021–2023 T-MSIS Analytic Files in 36 expansion states; interviewed 11 key informants representing Medicaid policy experts, maternal health advocates, and state Medicaid eligibility officials; and reviewed CMS guidance and policy materials related to pregnancy/postpartum coverage. 

Research Design and Methods:We calculated the number and share of birthing enrollees with expansion coverage six months prior to delivery, the month of delivery, and six months following delivery, nationally and by state, and tabulated enrollees’ age, rurality, and health conditions/complications. We also conducted a thematic analysis of interview notes to identify common themes and key insights. 

Results/Findings:Among Medicaid enrollees who gave birth in expansion states in 2022, 15.6 percent, or over 137,000 individuals, were in the expansion category during the month they delivered, 23.8 percent were in the expansion category six months before delivery, and 15.9 percent were in the expansion category six months following delivery. These shares varied considerably across expansion states, ranging from below 3 percent in Rhode Island and Utah to nearly 40 percent or higher in Louisiana and Montana during the month of delivery. Enrollees in California, Kentucky, Louisiana, New York, and Pennsylvania represented nearly half of all enrollees in the expansion category during the month of delivery. Over half of pregnant expansion enrollees (52.1 percent) had a chronic physical and/or behavioral health condition. Historically, states have not needed to proactively track pregnancy among expansion enrollees, which could hinder their ability to automatically exempt them from OBBBA’s work requirements and eligibility checks.  To ensure states do not inadvertently subject pregnant and postpartum women to work requirements and semiannual eligibility checks, states will need to make timely use of claims/encounter data, increase ex parte renewals, and educate enrollees and stakeholders about pregnant and postpartum women’s entitlement to continuous coverage, and CMS will need to provide timely guidance and oversight. 

Conclusion/Implications:With well over 100,000 pregnant and postpartum women likely to be in the expansion category in 2027 and at risk of disenrollment under OBBBA, it will be important to implement approaches that ensure timely identification of pregnancy to provide needed exemptions while managing privacy and legal concerns.

Author

• Jennifer Haley, Urban Institute
  Presenting Author