Pregnant women

Eligibility

Medicaid and CHIP are important sources of coverage for pregnant women, paying in 2010 for nearly half of the nearly 4 million births in the United States. Maternity-related services covered by the programs include prenatal care, labor and delivery, and 60 days of postpartum care.

Between 1984 and 1990, Congress repeatedly expanded Medicaid eligibility for low-income pregnant women, creating new mandatory and optional eligibility groups. Since 1989, pregnant women with incomes at or below 133 percent of the federal poverty level (FPL) have been a mandatory Medicaid eligibility group and all but four states have extended Medicaid coverage to pregnant women above the currently required level of 138 percent FPL.Click here for income eligibility thresholds for pregnant women.

The Omnibus Budget Reconciliation Act of 1986 (P.L. 99-509) allowed states to permit certain qualified providers to provide ambulatory prenatal care to pregnant women on the basis of preliminary eligibility information, even if they have not formally been determined eligible.  Presumptive eligibility allows women to obtain Medicaid-covered prenatal care immediately. This mechanism ensures that providers are paid for any services they deliver during the presumptive eligibility period, even if the pregnant woman is not subsequently determined eligible. Under current law, a presumptive eligibility period lasts for up to 60 days, when the full eligibility determination must be completed for coverage to continue.

States can also provide CHIP-financed services to pregnant women, although the program covers far fewer pregnant women than Medicaid. Specifically, states may cover pregnant women, regardless of immigration status, through the unborn child option by revising the definition of the term child in federal regulations to include the period from conception to birth (CMS 2009CMS 2002). Additionally, the Children’s Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3) created additional CHIP eligibility pathways by allowing states to provide comprehensive health care coverage for uninsured, targeted low-income pregnant women under the CHIP state plan. Finally, states can use Section 1115 demonstration waivers to provide CHIP-funded coverage to pregnant women.

Click here for legislative milestones in Medicaid coverage of pregnant women.

For more on Medicaid eligibility, see Federal Requirements and State Options: Eligibility.

TABLE 1. Eligibility Pathways for Pregnant Women

Eligibility group Federal statutory and regulatory requirements State plan options
Pregnant women Poverty-related pregnant women

  • Pregnant women must be covered at least up to 133 percent FPL.1
  • States must extend coverage to these women for 60 days postpartum.
Poverty-related pregnant women

  • States have the option to cover pregnant women with incomes up to 185 percent FPL.

CHIP options

  • States have the option to cover pregnant women through the unborn child option.
  • States have the option of covering uninsured pregnant women in CHIP.
Notes: FPL is federal poverty level. Aid to Families with Dependent Children (AFDC) is the cash assistance program that was replaced by Temporary Assistance to Needy Families (TANF) in 1996. CHIP is State Children’s Health Insurance Program.
1 In some states, pregnant women must be covered up to 185 percent FPL because they had already expanded to these levels when legislation was enacted in 1989 to mandate coverage up to at least 133 percent FPL. States are required to maintain these higher preexisting thresholds.
Source: MACPAC, 2017, Federal Requirements and State Options: Eligibility .

 

Learn more about Medicaid and CHIP policies affecting pregnant women:

Maternity Services: Examining Eligibility and Coverage in Medicaid and CHIP (from MACPAC’s June 2013 report)

Issues in Pregnancy Coverage under Medicaid and Exchange Plans (from MACPAC’s March 2014 report).

Update on Pregnancy-Related Medicaid and Minimum Essential Coverage

 

1The ACA set a single income eligibility disregard equal to 5 percentage points of the FPL. For this reason, eligibility is often referred to at its effective level of 138 percent FPL ($33,534 in the lower 48 states and the District of Columbia), even though the federal statute specifies 133 percent FPL.