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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

SHO# 21-007 RE: Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP)

December 7, 2021

Dear State Health Official:

Medicaid is the largest single payer of pregnancy-related services and covers over 42 percent of births nationally.1 The Children’s Health Insurance Program (CHIP) also covers pregnant adolescents and, in some states, low-income pregnant individuals with income over the Medicaid income limit. Together, Medicaid and CHIP play a critical role in ensuring access to care for pregnant and postpartum individuals, improving the quality of maternal health care, and addressing disparities in health outcomes and pregnant and postpartum care. Sections 9812 and 9822 of the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2) give states a new option to provide 12 months of extended postpartum coverage to pregnant individuals enrolled in Medicaid and CHIP beginning April 1, 2022. The purpose of this State Health Official (SHO) letter is to provide guidance to states on implementation of this new state option.

The newly extended postpartum coverage option offers states an opportunity to provide care that can reduce pregnancy-related deaths and severe maternal morbidity and improve continuity of care for chronic conditions such as diabetes, hypertension, cardiac conditions, substance use disorder, and depression. More than half of pregnancy-related deaths occur in the 12-month postpartum period, and 12 percent occur after six weeks postpartum. Significant and persistent disparities exist in pregnancy-related morbidity and mortality. Black and American Indian/Alaska Native individuals are up to five times more likely than White individuals to die from pregnancy-related complications and more likely to have a preventable death.2 There are also disparities in rates of postpartum follow-up care for conditions associated with morbidity and mortality. Black individuals who had gestational diabetes were found to have among the lowest postpartum diabetes screening rates despite having the highest risk for progression to chronic diabetes.3 More generally, individuals who have a lower level of education, individuals who are Black or Hispanic, and individuals with co-existing morbidities, such as mental health

1 Medicaid covers 42.1 percent of births nationally; National Center for Health Statistics, Birth Data (updated June 14, 2021). Available at https://www.cdc.gov/nchs/nvss/births htm. 2 Petersen, E. E., N.L. Davis, D. Goodman, et al. “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017.” Morbidity and Mortality Weekly Report, vol. 68, no. 18, 2019, pp. 423–429. Exact rates differ by demographic data. 3 Herrick, C. J., Puri, R., Rahaman, R., Hardi, A., Stewart, K., & Colditz, G. A. (2020). Maternal Race/Ethnicity and Postpartum Diabetes Screening: A Systematic Review and Meta-Analysis. Journal of women's health (2002), 29(5), 609–621. Available at https://doi.org/10.1089/jwh.2019.8081.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.