Page 18

Page 18 – 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. in circumstances that may affect eligibility such as a change in household composition, a change in categorical eligibility (e.g., reaching an age milestone, eligibility conferred through receipt of other program benefits). States must ensure that individuals eligible for extended postpartum coverage, who would otherwise lose eligibility due to a change in circumstances, remain enrolled in Medicaid or CHIP until the end of the 12-month postpartum period, unless: (1) the individual requests voluntary termination, (2) the individual ceases to be a state resident, (3) the agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual, or (4) the individual dies.

Q13. Does the ARP require states to provide continuous eligibility to pregnant individuals in Medicaid regardless of changes in circumstances, even if the state does not extend postpartum coverage?

A13. In states that do not extend postpartum coverage, pregnant individuals enrolled in Medicaid are entitled to continuous eligibility through the last day of the month in which a 60- day period, beginning on the last day of pregnancy, ends, regardless of changes in income that would otherwise result in a loss of eligibility, as required at 42 C.F.R. § 435.170. States that provide postpartum coverage consistent with 42 C.F.R. § 435.170 must act on changes in circumstances that may affect eligibility, other than changes in income, while the individual is pregnant or in their 60-day postpartum period. In states that do not provide extended postpartum coverage, we believe changes in circumstances that may affect eligibility for pregnant and postpartum individuals are rare, and may include, for example, a change affecting categorical eligibility or a change in immigration status.

Q14. Does the ARP require states to provide continuous eligibility to pregnant individuals enrolled in a separate CHIP if the state does not adopt the option to provide 12 months of extended postpartum coverage?

A14. No. Section 2107(e)(1)(J) of the Act provides that section 1902(e)(5), which requires continuous eligibility for pregnant individuals in Medicaid, applies to separate CHIPs only if the state has adopted the extended postpartum option in section 1902(e)(16). There is not a continuous eligibility requirement for pregnant individuals enrolled in CHIP unless the state adopts the option in sections 1902(e)(16) and 2107(e)(1)(J) of the Act.

Q15. Are states required to transition individuals enrolled in CHIP who become eligible for Medicaid during the continuous extended postpartum period?

A15. No. Section 2107(e)(1)(J) applies paragraphs 5 and 16 of section 1902(e) of the Act equally to CHIP, which requires that if an individual was eligible for CHIP and receiving services while pregnant, they are entitled to continuous eligibility throughout their pregnancy and postpartum period. Therefore, states must keep individuals enrolled in CHIP for the duration of their pregnancy and extended postpartum period, even if they become eligible for Medicaid, unless one of the allowable exceptions to the continuous eligibility period (as discussed in Q12) is applicable. However, we note that if an individual voluntarily elects to end their CHIP enrollment during their extended postpartum period, the individual would not be entitled to continuous eligibility for the remainder of their 12-month postpartum period in Medicaid. In