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Page 16 – FAQs

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. For example, an individual submits an application for Medicaid four months after giving birth. The agency determines the individual is eligible for Medicaid and enrolls the individual. The individual is not entitled to extended and continuous postpartum coverage through the end of a 12-month postpartum period, however, because the individual was not enrolled in Medicaid while pregnant.

Q8. Is an individual entitled to an additional 12-month postpartum period in Medicaid or CHIP if they become pregnant during the extended postpartum period?

A8. Yes. An individual who becomes pregnant during an initial extended postpartum period and therefore is enrolled in Medicaid or CHIP during such pregnancy would be entitled to an extended 12-month postpartum period following the end of the subsequent pregnancy. The individual in this case would receive continuous coverage through the end of 12th month after the subsequent pregnancy ends consistent with section 1902(e)(16) or 2107(e)(1)(J) of the Act.

For example, Emily is enrolled in Medicaid while pregnant. Her pregnancy ends in May 2022, and an extended 12-month postpartum coverage period begins. Seven months later, Emily becomes pregnant again in December 2022, while she is still eligible for and enrolled in coverage. Emily’s subsequent pregnancy ends in September 2023. At that point, a new 12- month extended postpartum period will begin, and Emily will remain continuously eligible through the end of the subsequent extended postpartum period (through September 2024). In September 2024, the state will need to conduct a redetermination of eligibility and determine whether Emily remains eligible for Medicaid under the same or another eligibility group.

Q9: Do individuals who qualify as medically needy with a spenddown while pregnant have to continue to meet their spenddown each budget period to be eligible for the coverage available under the 12-month postpartum option?

A9: No. An individual who attained Medicaid eligibility through a spenddown while pregnant is eligible for the extended postpartum coverage even if the individual does not have sufficient incurred medical or remedial care expenses to meet their spenddown in any subsequent budget period during the pregnancy or extended postpartum period. For example, if a pregnant individual applies for Medicaid in January in a state that has adopted the 12-month postpartum option and covers medically needy individuals, and the individual establishes eligibility by meeting their spenddown in February, the state must maintain the individual’s Medicaid coverage through the remainder of the individual’s pregnancy and the end of the month in which the 12-month postpartum period ends. The individual will not have to meet a spenddown again until the end of continuous 12-month postpartum period.

Q10. Are individuals eligible for extended postpartum coverage if they enroll in Medicaid during their postpartum period but were pregnant during a period of retroactive eligibility?

A10. Yes, individuals who received Medicaid services and met Medicaid eligibility requirements while pregnant during a period of retroactive eligibility must be provided extended postpartum coverage.