WikiLeaks Document Release http://wikileaks.org/wiki/CRS-RS22785 February 2, 2009 Congressional Research Service Report RS22785 SCHIP Coverage for Pregnant Women and Unborn Children Evelyne P. Baumrucker, Domestic Social Policy Division January 8, 2008 Abstract. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 6 states used the 1115 waiver authority and 12 states extended coverage through unborn child SPAs (Rhode Island extends coverage to pregnant women through both authorities). This report summarizes the variation in pregnancy coverage and the financing streams associated with such coverage among these states. Order Code RS22785 January 8, 2008 SCHIP Coverage for Pregnant Women and Unborn Children Evelyne P. Baumrucker Analyst in Health Care Financing Domestic Social Policy Division Summary The State Children's Health Insurance Program (SCHIP) does not include http://wikileaks.org/wiki/CRS-RS22785 pregnancy status among its eligibility criteria and does not cover individuals over age 18. Under SCHIP, states can cover pregnant women aged 19 and older in one of three ways: (1) states may apply for waivers of program rules to extend coverage to adults such as pregnant women (§1115 waiver authority); (2) states may provide health benefits coverage, including prenatal care and delivery services, to unborn children through an SCHIP state plan amendment (SPA) as permitted through regulation;1 or (3) states may offer a "family coverage option" that allows them to provide coverage under a group health plan that may include maternity care to adult females in eligible families.2 As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 6 states used the §1115 waiver authority and 12 states extended coverage through unborn child SPAs (Rhode Island extends coverage to pregnant women through both authorities). This report summarizes the variation in pregnancy coverage and the financing streams associated with such coverage among these states. This report will be updated as state activity warrants. Background States that choose to cover pregnant women through the §1115 waiver authority must submit a proposal to the Centers for Medicare and Medicaid Services (CMS) for approval. 1 Federal Register, vol. 67, no. 191, Wednesday, October 2, 2002, Rules and Regulations. 2 Section 2105(c)(3) of the Social Security Act allows states to cover entire families including parents if the purchase of family coverage is cost-effective when compared with the cost of covering only the targeted low-income children in the families involved, and would not substitute for other health insurance coverage. E-mail correspondence (from June 7, 2007) with Kathleen Farrell, the CMS Director of the SCHIP program, indicates that New Jersey and Massachusetts are the only states with operational family coverage variance programs. CRS-2 States with approved §1115 demonstration programs define the available pregnancy- related services in their waiver terms and conditions agreements. States that opt to extend SCHIP coverage to unborn children must submit an SPA to CMS for approval specifying the pregnancy-related services. Under the SCHIP SPA option, covered services must be related to the pregnancy or to conditions that could complicate the pregnancy, including those for diagnosis or treatment of illnesses or medical conditions that might threaten the health of the unborn child. Care after delivery for the mother, such as postpartum services, is generally not covered as part of the title XXI SPA option. Although CMS requires the care to be directed at the unborn child, the SCHIP unborn child SPA option effectively enables states to provide prenatal care to pregnant women including those with incomes at or above the Medicaid income eligibility thresholds and for individuals who do not qualify for Medicaid (or SCHIP) for other reasons, such as immigration status3 or incarceration.4 Finally, for the family coverage option, pregnancy-related benefits are those offered by participating private health plans. Summary of State Variation in Pregnancy Coverage Under SCHIP http://wikileaks.org/wiki/CRS-RS22785 Table 1 summarizes the variation in pregnancy coverage among states with §1115 waivers and those using the SCHIP unborn child SPA option. As of October 2007, 17 states offered pregnancy-related services using SCHIP funds. Of those, 12 states extended coverage through unborn child SCHIP SPAs and 6 states used the §1115 waiver authority (Rhode Island extends coverage to pregnant women through both authorities). The highest upper-income eligibility thresholds for pregnant women and/or unborn children under SCHIP was 300% FPL in California. Seven states established upper-income limits at 200% FPL. Four states exceeded 200% FPL, and six states set maximum income levels below 200% FPL. Of the 12 states that offer pregnancy-related services to unborn children under the SCHIP SPAs, all but Tennessee extended coverage to the unborn children of undocumented aliens who otherwise would not have access to federally funded pregnancy-related services, except through emergency Medicaid.5 Two states used SCHIP SPAs to extend coverage to the unborn children of incarcerated women who are otherwise ineligible for SCHIP coverage. Covered services under the §1115 waiver programs and the SCHIP SPAs generally consisted of comprehensive pregnancy-related services including prenatal care, labor and delivery services, and access to some form of coverage during the postpartum period. However, the length of coverage (e.g., prenatal period through labor and delivery, or prenatal period through 60 days postpartum period) and financing streams for the care 3 Section 1903(v) of the Social Security Act. 4 Section 2110(b)(2)(A) of the Social Security Act. 5 Illegal immigrants are barred from Medicaid and SCHIP eligibility; legal immigrants who have not been granted lawful permanent residency status are ineligible for Medicaid or SCHIP for five years. Such women who otherwise qualify but for their documentation status have access to emergency care under Medicaid, which includes labor and delivery costs (Section 1903(v) of the Social Security Act). CRS-3 associated with each of these pregnancy phases varied across states. For example, some states offered coverage from conception through 60 days postpartum care (financed with SCHIP funds), whereas others segmented the coverage to include prenatal care (financed with SCHIP funds), labor and delivery (financed with emergency Medicaid funds), and postpartum care (financed with state-only funds). In these states, program specialists pointed out that the pregnancy-related care is seamless to the mother despite the administrative complexities required of the state to submit claims under multiple funding streams. Three states indicated that the coverage offered to pregnant women and/or unborn children was comprehensive and not limited to pregnancy-related services. An additional four states specified that the available care included pregnancy-related care and associated health services including, for example, medically necessary dental or mental health benefits as long as the care was necessary to promote the health of the unborn child. Postpartum care differs among states that chose to extend pregnancy coverage under the §1115 waiver authority as compared with those that offered coverage to unborn children under the SCHIP unborn child SPAs. There were 15 states that offered 60 days of postpartum care to at least some of their eligible populations, including each of the 6 http://wikileaks.org/wiki/CRS-RS22785 states that offered pregnancy coverage under the §1115 waiver authority. Among the SCHIP SPA states, five states financed 60 days of postpartum care with state-only funds. Four SCHIP SPA states extended 60 days of postpartum care using SCHIP funds. CMS permitted this financing arrangement despite the fact that the unborn child regulation clearly states that federal SCHIP-financed care ends with the birth of the child. The reason CMS permits this is because the state has a global rate for their pregnancy services that includes the cost of prenatal care, labor and delivery, and 60 days of postpartum care. One SCHIP SPA state provided SCHIP-financed postpartum care through the end of the month that the child was delivered because those services have already been paid for under the monthly managed care capitation payment. Two SCHIP SPA states did not offer any form of care for the mother after the birth of the child except in the case of an emergency during which the mother would have access to emergency Medicaid services. Finally, two states (one §1115 waiver state and one SCHIP SPA state) provided access to extended family planning services and supplies as a part of their postnatal care benefit. CRS-4 Table1. SCHIP Pregnancy Coverage for States with Section 1115 Waivers and SCHIP Unborn Child State Plan Amendments (as of October 2007) Upper- Income Benefit Coverage State Threshold Length of Financing (Award Date) Authority (% FPL) Covered Services Coverage Stream Mother's Coverage After Delivery Financing Stream Arkansas Unborn 200% FPL Separate SCHIP program (SSP) Conception to birth SCHIP No coverage except under Emergency (6/30/04) Child SPA undoc. aliens includes prenatal care, and delivery emergency Medicaid Medicaid services http://wikileaks.org/wiki/CRS-RS22785 Colorado SCHIP 200% FPL Prenatal care, labor and delivery, and Date of application SCHIP 60 days postpartum care SCHIP (9/27/02) §1115 60 days postpartum care (excludes through 60 days HIFA dental care) postpartum California Unborn 0%-200% Prenatal care, labor and delivery, and Conception SCHIP 60 days postpartum care SCHIP (treated as a (3/28/06) Child SPA undoc. aliens 60 days postpartum care through 60 days bundled service) postpartum 300% AIM program offers comprehensive Conception SCHIP uninsured care not just pregnancy related care through 60 days postpartum Illinois Unborn 0%-200% SSP Medicaid look alike benefits Confirmed SCHIP 60 days postpartum care State-only funds (6/11/03) Child SPA undoc. aliens includes prenatal care and associated pregnancy and and health services (excludes HCBS through start of incarcerated waiver services and abortion labor women services) Labor and delivery services Labor through Emergency delivery Medicaid Idaho SCHIP up to 185% Premium assistance for private Confirmed SCHIP pays Defined in participating private SCHIP pays for (6/21/05) §1115 workers in insurance (must cover postpartum pregnancy through for coverage plans premiums only HIFA small care) 60 days postpartum premiums businesses only Louisiana Unborn 0%-200% SSP to provide prenatal care, care Confirmed SCHIP No coverage except emergency Medicaid (4/5/07) Child SPA undoc. aliens related to the pregnancy, and pregnancy through services under Medicaid delivery services delivery CRS-5 Upper- Income Benefit Coverage State Threshold Length of Financing (Award Date) Authority (% FPL) Covered Services Coverage Stream Mother's Coverage After Delivery Financing Stream Massachusetts Unborn 200% SSP prenatal care, associated health Conception SCHIP 60 days postpartum care State funded (9/15/03) Child SPA undoc. aliens services, labor and delivery through birth program and free care pool Michigan Unborn 185% FPL SSP includes prenatal care, Conception SCHIP Labor and delivery and 60 days SCHIP (treated as a (4/17/03) Child SPA undoc. aliens pregnancy-related care, and non- through 60 days postpartum care bundled service) pregnancy related care (up to birth of postpartum child) labor and delivery, and 60 Other health coverage (e.g., broken Emergency arms) Medicaid http://wikileaks.org/wiki/CRS-RS22785 days postpartum care Minnesota Unborn 275% SSP Medicaid look-a-like program Conception SCHIP 60 days postpartum care State-funded (8/6/03) Child SPA undoc. aliens covers pregnancy-related services, through end of the prenatal care, labor and delivery, and month in which the limited postpartum care child was born Nevada SCHIP 133%-185% Medicaid pregnancy -related benefits Conception SCHIP 60 days postpartum care SCHIP (11/2/06) §1115 including prenatal care, related through 60 days HIFA health care, labor and delivery, and postpartum 60 days postpartum care New Jersey Medicaid 0%-200% Presumptive eligibility program Temporary Medicaid Emergency Medicaid for labor and Emergency (1/18/01) and SCHIP includes prenatal care, labor, and eligibility until delivery services only Medicaid §1115 delivery determined eligible HIFA for Medicaid 0%-185% New Jersey Medicaid package Conception Medicaid 60 days full comprehensive Medicaid includes prenatal care, labor and through 60 days Medicaid delivery, and 60 days of full postpartum 186%-200% Medicaid coverage Conception SCHIP SCHIP through 60 days postpartum Rhode Island Unborn 185%-250% Medicaid benefit package includes Conception SCHIP Extended family planning family SCHIP (4/17/03) Child SPA undoc. aliens prenatal care, labor and delivery through labor and services and supplies for 24 months delivery 60 days postpartum care State-only funds CRS-6 Upper- Income Benefit Coverage State Threshold Length of Financing (Award Date) Authority (% FPL) Covered Services Coverage Stream Mother's Coverage After Delivery Financing Stream Rhode Island SCHIP 185%-250% Medicaid benefit package (i.e., Conception SCHIP 60 days postpartum care and SCHIP (1/18/01) §1115 prenatal care, labor and delivery, and through 60 days extended family planning family 60 days postpartum care) postpartum services and supplies for 24 months Virginia SCHIP 133%-185% Full Medicaid benefits (not Conception SCHIP Coverage for the remainder of the SCHIP (6/21/05) §1115 (approved up pregnancy only benefits) through labor and birth month plus 60 days postpartum HIFA to 200%) delivery coverage. Tennessee Unborn 185%-250% SSP Pregnancy-related services Conception SCHIP Coverage through the last day of the SCHIP (treated as a http://wikileaks.org/wiki/CRS-RS22785 (10/3/07) Child State including prenatal care, labor and through 60 days month that 60 day post partum bundled service) Plan Option delivery, and 60 days postpartum post partum period occurs care Texas Unborn 200% SSP to provide prenatal care, labor and delivery, and 2 postpartum visits Care ends at the end of the month SCHIP (6/2/06) Child SPA undoc. aliens during which the child is born. There are no public benefits after that except if the mother qualifies for emergency Medicaid services. Washington Unborn 185% SSP, Benefits includes prenatal care Conception and SCHIP 60 days postpartum care state-only funds (9/22/03) Child SPA undoc. aliens and associated health services through start of labor and delivery Labor and delivery Labor and delivery Emergency Medicaid Wisconsin Unborn 185% SSP Badger Care prenatal program Conception SCHIP 60 days postpartum care allowed for SCHIP (treated as a (5/7/07) Child SPA undoc. provides for prenatal coverage through 60 days all but undocumented aliens bundled service) aliens, and including cost of labor and delivery postpartum uninsured and 60 days postpartum care and/or Undocumented aliens emergency Emergency incarcerated Medicaid only Medicaid women Sources: Section 1115 waiver terms and conditions documents, SCHIP unborn child state plan amendments, and conversations with state officials. Notes: SPA means State Plan Amendment, HIFA means Section 1115 Health Insurance Flexibility and Accountability Waiver, AIM stands for Access for Infants and Mothers program, HCBS stands for Medicaid Section 1915(c) Home and Community-Based Waiver, SSP means SCHIP Separate State Program, and a Medicaid look-a-like program is a Separate SCHIP Program with a benefit package that looks like Medicaid, but may exclude, for example, certain services.