Medicaid Coverage for Pregnant and Postpartum Persons.
The Health Care Authority administers the Medicaid program, which is a state-federal program that pays for health care for low-income state residents who meet certain eligibility criteria. Washington's Medicaid program, known as Apple Health, offers a complete medical benefits package to eligible families, children under age 19, low-income adults, certain disabled individuals, and pregnant women.
Apple Health provides coverage to pregnant individuals with countable income at or below 193 percent of the federal poverty level, regardless of citizenship or immigration status. Once an individual is enrolled, they are covered regardless of any change in income through the end of the calendar month that includes the sixtieth day after the end of the pregnancy.
Federal Activity Related to the COVID-19 Pandemic.
On January 31, 2020, the Secretary of Health and Human Services declared a federal public health emergency exists due to COVID-19. The declaration has been renewed several times and the most recent declaration expires on April 21, 2021.
On March 18, 2020, Congress passed the Families First Coronavirus Response Act which includes a provision to increase each state's federal matching rate by 6.2 percent during the federal public health emergency. To receive the increased matching rate under its medical assistance program, a state may not: (1) adopt more restrictive eligibility standards; (2) increase premiums under the state's program; (3) discontinue coverage for an enrolled individual prior to the end of the public health emergency period, unless the individual requests a voluntary termination or is no longer a resident of the state; or (4) fail to provide coverage for testing services and treatments for COVID-19.
On March 11, 2021, the American Rescue Plan Act of 2021 (Act) was signed into federal law. Among other provisions, the Act provides states the option to amend their state Medicaid plans to allow an individual who, while pregnant, is eligible for medical assistance coverage to remain eligible for that coverage for 12 months following the end of the pregnancy, rather than the current 60-day period. The expansion of the medical assistance coverage takes effect April 1, 2022.
Eligibility for Apple Health coverage for pregnant and postpartum persons is expanded from 60 days from the end of the pregnancy to one year from the end of the pregnancy. The expanded coverage is implemented in two phases:
The Health Care Authority (Authority) may not enroll persons in the expanded pregnancy and postpartum program if they are eligible for other medical assistance programs that include a federal match component. The Authority must expedite eligibility determinations for those who are presumptively eligible for medical assistance programs with a federal match component. The Authority must submit quarterly reports to the Caseload Forecast Work Group on the number of people who are presumptively eligible and waiting for the completion of their determinations, the number of people who were presumptively eligible and now receiving health coverage, and the outreach activities that were undertaken.
The Authority must seek federal financial participation that may be available through current health care coverage programs and other current and future funding sources and may be used to fund the expanded pregnancy and postpartum coverage program. If federal matching funds are not available for the expanded pregnancy and postpartum coverage program by the effective date of the act, the Authority must submit a waiver to the federal Centers for Medicare and Medicaid Services to request federal matching funds. The Authority must provide the expanded pregnancy and postpartum coverage to all eligible persons regardless of whether or not the waiver request is approved. By December 1, 2021, the Authority must report to the Legislature on the status of the waiver request and any necessary statutory changes.
The Authority must work with stakeholders, community organizations, and the Washington Health Benefit Exchange to establish a community education and outreach campaign to facilitate applications for and enrollment in the expanded pregnancy and postpartum coverage program or other more appropriate coverage.
Medicaid managed care organizations must report annually to the Legislature on their work to improve maternal health for their enrollees. The information must include postpartum services offered to enrollees, the percentage of enrollees using each service, outreach activities to engage enrollees in available services, and efforts to collect eligibility information to ensure the enrollees are placed in programs to receive the maximum federal match.
(In support) Women need access to health care for a full year after a baby is born to promote their own health and the health of their babies. When people lose coverage for Medicaid after just 60 days, they lose access to their health care providers at a vulnerable time when continuity of care is crucial and about 45 percent of them become uninsured. Ending postpartum coverage before new mothers are able to address issues leads to those issues becoming more stressful, more costly, and more difficult to address later. Approximately 30 percent of pregnancy-related deaths occur 43 to 365 days postpartum. Women often enter the health system for the first time during pregnancy and this gives them an opportunity to address underlying medical issues. Adequate Medicaid postpartum coverage increases access, decreases preventable deaths, and avoids more expensive emergency room care.
The COVID-19 pandemic has increased the likelihood of maternal depression and anxiety. Perinatal mood and anxiety disorders can occur any time up to one year postpartum and can inhibit strong parent-baby attachment. Behavioral health conditions are the leading cause of pregnancy-related deaths in Washington. A study showed that untreated mood and anxiety disorders in pregnant women and new mothers cost $14.2 billion per year in the United States.
Maternal mortality rates have a disproportionate impact on communities of color. In Washington, American Indian and Alaska Native mothers are six to seven times as likely to die from a pregnancy-related cause as white women. Multi-racial, Hispanic and Asian mothers are nearly twice as likely to die from a pregnancy-related cause as white women. Low-income women, immigrant women, women living in rural areas, and women of color disproportionately experience pregnancy-related complications and receive insurance through Medicaid. Extending postpartum coverage for Medicaid patients will help mitigate some of the racial and ethnic disparities in the health care system.
During the federal public health emergency there has been continuing Medicaid coverage and without this bill there could be a cliff where people lose coverage. The federal government will be offering a match for this coverage in an upcoming bill and by acting now, Washington can take advantage of these federal matching funds.
(Opposed) None.
(In support) About half of Washington's pregnancies are covered by Medicaid. In Washington, about one third of all pregnancy-related deaths occur between 43 to 365 days postpartum. Pregnancy-related complications do not suddenly appear. Assuring continuous coverage would give new moms access to care for ongoing chronic health conditions such as heart disease, diabetes, and high blood pressure. Comprehensive care before, during, and after pregnancy is crucial to improve health outcomes for both moms and babies. This bill fixes an unsafe gap in health coverage to ensure moms have continuous uninterrupted care.
This policy provides many statewide fiscal benefits. Preventative care is less costly than caring for acute complications of poorly controlled chronic conditions. For example, Pap smears screen for cervical cancer, but many women get their first Pap smear, or the first in many years, when they receive Medicaid pregnancy coverage. In most cases, abnormalities are not addressed until at least six weeks postpartum after the mother has recovered from pregnancy. Definitive treatment and diagnosis usually take more than one visit, but during this time Medicaid coverage expires. Often, women do not follow-up with care, which can result in the development of cervical cancer, which costs the state much more to treat than to prevent. Another example are patients who delay tuberculosis treatment until after delivery. If Medicaid expires and patients do not return for treatment, there are increased risks of communal tuberculosis spread. The costs of managing such an outbreak is much higher than providing prophylactics for nine months. There are also many societal benefits of treating maternal behavioral health conditions and postpartum depression for the health of the mother and the benefit of their children. Children of birthing parents with mood and anxiety disorders have a higher risk of behavioral and developmental disorders, which costs the state millions in early childhood and school-based intervention. Especially during the pandemic, there are skyrocketing rates of mental health disorders in connection with higher rates of financial and food insecurities and less access to social supports. Pediatricians often have more contact with the family during the first year of a child's life than the parent does with their own health care provider, and they see the devastatingly common symptoms. A recent study found that untreated mood and anxiety disorders among pregnant women and new moms costs the United States $14.2 billion a year. These disorders inhibit strong parent-baby attachment and eventually result in significant societal cost. This upfront investment will have long-lasting savings. The American Rescue Plan Act of 2021 also provides states with a five-year option for 12 months of postpartum Medicaid coverage. Starting in April 2022, states can receive a federal match rate for this extension of postpartum coverage.
Women of color have a disproportionately high mortality due to pregnancy-related causes. Maternal mortality rates for American Indian and Alaska Native women in our state are 4.7 times higher than non-Hispanic black women and 9.1 times higher than non-Hispanic white women. People who have experienced trauma and racism need support. Adequate Medicaid coverage is a tool to help combat racial and ethnic disparities.
(Opposed) None.