SENATE BILL REPORT

SB 6128

As Reported by Senate Committee On:

Health & Long Term Care, January 27, 2020

Ways & Means, February 11, 2020

Title: An act relating to improving maternal health outcomes by extending coverage during the postpartum period.

Brief Description: Extending coverage during the postpartum period.

Sponsors: Senators Randall, Darneille, Dhingra, Frockt, Hasegawa, Hunt, Kuderer, Lovelett, Salomon, Stanford, Van De Wege, Nguyen and Wilson, C.

Brief History:

Committee Activity: Health & Long Term Care: 1/20/20, 1/27/20 [DPS-WM].

Ways & Means: 2/04/20, 2/11/20 [DP2S, w/oRec].

Majority Report: That Substitute Senate Bill No. 6128 be substituted therefor, and the substitute bill do pass and be referred to Committee on Ways & Means.

Signed by Senators Cleveland, Chair; Randall, Vice Chair; O'Ban, Ranking Member; Conway, Dhingra, Frockt, Keiser, Muzzall, Rivers and Van De Wege.

Staff: LeighBeth Merrick (786-7445)

Majority Report: That Second Substitute Senate Bill No. 6128 be substituted therefor, and the second substitute bill do pass.

Signed by Senators Rolfes, Chair; Frockt, Vice Chair, Operating, Capital Lead; Mullet, Capital Budget Cabinet; Brown, Assistant Ranking Member, Operating; Honeyford, Assistant Ranking Member, Capital; Billig, Carlyle, Conway, Darneille, Dhingra, Hasegawa, Hunt, Keiser, Liias, Muzzall, Pedersen, Schoesler, Van De Wege, Wagoner, Warnick and Wilson, L..

Minority Report: That it be referred without recommendation.

Signed by Senator Becker.

Staff: Sandy Stith (786-7710)

Background: The Health Care Authority (HCA) administers Washington's Apple Health program providing medical assistance primarily through Medicaid. Apple Health offers eligible families, children under age 19, low-income adults, certain disabled individuals, and pregnant women a complete medical benefits package.

Currently, Apple Health provides coverage to pregnant individuals with countable income at or below 193 percent of the federal poverty level (FPL), 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 month, following the 60th day after the pregnancy end date. For example, if a pregnancy ends June 10, health care coverage continues through August 31st.

Individuals receive this post-partum coverage regardless of how the pregnancy ends. Individuals who apply for coverage after the baby’s birth may not receive postpartum coverage, but they may qualify for help paying costs related to the baby’s birth if they submit the application within three months after the month in which the child was born.

In 2016, the Legislature established The Maternal Mortality Review Panel (Panel) to review and identify factors associated with maternal deaths occurring in the state, and to make recommendations to improve healthcare for women. The Panel's 2019 report to the Legislature included a recommendation to ensure funding and access to postpartum care and support through the first year after the end of pregnancy.

Summary of Bill (Second Substitute): Beginning, January 1, 2021, HCA must provide health care coverage to pregnant and postpartum persons with a countable income at or below 193 percent of the FPL, subject to available funds. The coverage must be provided up to 12 months post pregnancy on a fee-for-service basis. HCA must seek any available federal financial participation or funding sources. Once eligible for federal financial participation, the program that is subject to available funds expires and HCA must provide health care coverage up to 12 months post pregnancy to to pregnant and postpartum persons with a countable income at or below 193 percent of the FPL.

HCA is directed to submit a waiver request to the Centers for Medicare and Medicaid Services (CMS) to allow for the state to receive federal match for the coverage period past 60 days to one year post-pregnancy. HCA is required to provide coverage regardless of CMS' approval of the waiver, and report to the Legislature on the status of the waiver request by January 1, 2021.

EFFECT OF CHANGES MADE BY WAYS & MEANS COMMITTEE (Second Substitute):

• Establishes a program that is subject to available funds that extends postpartum coverage on a fee-for-service basis up to 12 months beginning January 1, 2021.

• Terminates the state only program when federal financial participation becomes available.

• Extends postpartum coverage up to 12 months once federal financial participation becomes available.

EFFECT OF CHANGES MADE BY HEALTH & LONG TERM CARE COMMITTEE (First Substitute):

• Replaces references to "medicaid" and "medical assistance" with "health care coverage" so the extension to 12-months post pregnancy applies to both federal and state-only coverage.

Appropriation: The bill contains a section or sections to limit implementation to the availability of amounts appropriated for that specific purpose.

Fiscal Note: Available.

Creates Committee/Commission/Task Force that includes Legislative members: No.

Effective Date: Ninety days after adjournment of session in which bill is passed.

Staff Summary of Public Testimony on Original Bill (Health & Long Term Care): The committee recommended a different version of the bill than what was heard. PRO: Expanding coverage to support birthing parents has bi-partisan support and is extremely important to decreasing maternal mortality rates that largely impact communities of color and rural areas. The current coverage gap is unsafe and it is critical we provide birthing parents with a continuity of care. Implementing the program will take time which is why we chose the January 1, 2021 date. One third of the maternal deaths the Panel reviewed occurred between 43 to 365 days postpartum. Extending the coverage will not only decrease maternal mortality rates, it will also help the thousands of women who experience pregnancy related morbidity. This bill will help address the postpartum mental health and substance use issues the Tribes face. Adverse childhood experiences often result from a child not bonding with their parent in their early stages of life. Postpartum depression can prevent parents from bonding with their child and may not onset until after two months postpartum. Treatment and medication for postpartum anxiety and depression is costly and parents without health coverage many choose not to access it because they can not afford it. The expansion should be included in the managed care rate development process.

Persons Testifying (Health & Long Term Care): PRO: Senator Emily Randall, Prime Sponsor; Dr. Laura Sienas, American College of Obstetricians and Gynecologists; Cori Domschot, MomsRising; Molly Firth, Perigee Fund; Patty Hayes, Public Health-Seattle & King County; Dr. Anisha Srinivasan, Washington Chapter of the American Academy of Pediatrics; Jan Olmstead, American Indian Health Commission; Chris Bandoli, Association of Washington Healthcare Plans.

Persons Signed In To Testify But Not Testifying (Health & Long Term Care): No one.

Staff Summary of Public Testimony on First Substitute (Ways & Means): The committee recommended a different version of the bill than what was heard. PRO: We want to make sure we take advantage of all federal funding available. We continue to have conversations about ways we can implement the program, including through a capped program, so we can get services to our most vulnerable populations, while we seek federal match. There is currently legislation at the federal level that may allow states to get an even greater federal match for implementing this policy. As we make changes to this bill, we are working on ways to make sure we can implement the full program. This bill is important for fiscal reasons that are not included in the fiscal note. Our maternal mortality rates are extremely high. New mothers often put their own self care on hold which means their children may not get their best parenting ability. The fiscal note does not capture the impacts of unaddressed adverse childhood experiences and post-partum depression. These can have impacts in the TANF caseloads and housing and essential needs grants. The importance of 12-month coverage instead of 60 days is because suicides frequently occur after 8 months. We are missing a segment of our population that is at the greatest risk. The transition time from pregnancy to recovery is when we see unmet health needs. This extension would give new moms access to care for chronic health conditions. Many patients enter care for the first time during pregnancy and receive diagnoses of chronic conditions. Women are highly motivated when pregnant to address behaviors and make positive change. Adequate Medicaid coverage helps to increase access to care, avoid more preventable deaths, and avoid more emergency care for chronic conditions that could have been controlled with ongoing care. We often identify mental health issues with new mothers at a child's well child visit at four, six, and nine months. Parents need health care coverage beyond 60 days in order to get well. Post-partum mood disorders do not always start immediately after delivery. These mood disorders inhibit strong parental-child attachments and eventually lead to large societal costs. After Medicaid coverage expired, the options for care are costly. Some options include high out of pocket costs. The requirement to meet high deductibles can lead to limiting care because of inability to meet those out of pocket costs. Conditions that develop between 60 days and 12 months can be extremely costly making this extended coverage highly meaningful to families. The recent maternal mortality review found significant racial disparities. In Washington, American Indian and Alaska Natives are six to seven times more likely to die from pregnancy-related complications than white women. Multi-racial and Hispanic women are twice as likely. The health access review for this bill showed that increasing coverage up to one year would increase access and that increased access would reduce health disparities. States across the country are pursuing this policy as is the federal government. The federal legislation incentivizes states to take advantage of this opportunity by providing states that implement the policy with an increased federal match for one quarter of 5 percent. We need to position the state to take advantage of this match should the federal legislation pass. The managed care organizations would want to make sure that the costs for this coverage is included in the managed care rates.

Persons Testifying (Ways & Means): PRO: Senator Emily Randall, Prime Sponsor; Judy Kimelman, American College of Obstetricians and Gynecologists; Maria Huang, Washington Chapter of the American Academy of Pediatrics; Cori Domschot, MomsRising; Molly Firth, Perigee Fund; Chris Bandoli, Association of Washington Healthcare Plans.

Persons Signed In To Testify But Not Testifying (Ways & Means): No one.