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Page 21 – 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, Jane submitted an application on January 10, 2022, and was determined eligible for and enrolled in the group for pregnant individuals with verified income equal to 50 percent of the federal poverty level (FPL) in a state that has adopted the extended postpartum coverage option. Her effective date of coverage is January 1, 2022, and her 12-month eligibility period extends through December 31, 2020. Jane’s pregnancy ends on August 16, 2022, her 60-day postpartum period ends October 31, 2022, and her 12-month postpartum period ends August 31, 2023. The state’s income standard for parents and caretaker relatives is 65 percent FPL.

Because Jane is eligible for extended postpartum coverage, the state does not need to redetermine eligibility at the end of Jane’s 60-day postpartum period or complete a renewal of eligibility until the end of her 12-month postpartum period (August 31, 2023), and she may remain enrolled in the group for pregnant individuals through the remainder of her extended postpartum period. However, if the state does not have any information indicating Jane’s income has changed since application when she reaches the end of the 60-day postpartum period (October 31, 2022), it is permissible for the state to shift Jane’s coverage to the eligibility group for parents and caretaker relatives effective November 1, 2022. The state will need to complete Jane’s next regular renewal at the end of her extended postpartum period. Federal Financial Participation

Q21. What FMAP applies to individuals enrolled in the adult group who become pregnant?

A21. States are not required to track the pregnancy status of beneficiaries enrolled in the adult group and are not required to move them to the eligibility group for pregnant individuals if the state becomes aware of their pregnancy. Beneficiaries who become pregnant must be given the option of moving to the pregnancy-related coverage category. States must inform beneficiaries of the differences in coverage between the adult group and pregnancy-related coverage (including any differences in benefits, premiums, and cost sharing), and if the state covers any additional benefits for pregnant individuals under 42 C.F.R. § 440.250(p) not provided to other individuals eligible under the state plan, such benefits also must be provided to pregnant individuals enrolled in the adult group in an alternative benefit package. If an individual enrolled in the adult group who becomes pregnant does not elect to switch groups and remains enrolled in the adult group, the individual’s status for FMAP purposes (as newly eligible or not) is unchanged until such time the individual is determined eligible for another group, which would in no case be sooner than the end of the 12-month postpartum period.

Q22. Is increased FMAP related to the adult group available to states for individuals covered in the extended postpartum coverage option who might otherwise qualify for the adult group?

A22. Yes. Increased FMAP is available for beneficiaries receiving coverage during an extended 12-month postpartum period who would meet the requirements for coverage in the adult group described in 42 C.F.R. § 435.119 and the definition of “newly eligible” in 42 C.F.R. §433.204(a)(1).