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Page 6 – State Health Official

CHIP regulations at 42 C.F.R § 457.342 allow for two exceptions to continuous eligibility in addition to those in 42 C.F.R. § 435.926(d): (1) non-payment of premiums, and (2) becoming eligible for Medicaid. However, section 2107(e)(1)(J) of the Act, which applies 1902(e)(5) and (16) of the Act to CHIP, explicitly requires that individuals who were eligible while pregnant remain eligible under the state plan through the end of the 12th month after the end of the pregnancy regardless of any changes. Therefore, the additional exceptions to continuous eligibility at 42 C.F.R § 457.342 do not apply during the pregnancy and extended postpartum period under the option provided under section 2107(e)(1)(J) of the Act.11

Renewals for Individuals Eligible for Extended Postpartum Coverage

For individuals first enrolled at the end of their pregnancy, the regular renewal required under 42 C.F.R. § 435.916 may coincide with the end of the extended 12-month postpartum period. For most, however, the 12-month postpartum period will end after their regularly-scheduled renewal date. The availability of continuous coverage for 12 months post-pregnancy under the extended postpartum coverage option renders any regular renewal scheduled before the end of the 12- month postpartum period unnecessary. Rather, the Medicaid and CHIP agency must conduct the renewal at the end of the individual’s extended 12-month postpartum period in accordance with renewal regulations at 42 C.F.R. §§ 435.916 and 457.343.12 Because agencies do not need to complete renewals or redeterminations based on changes in circumstances until the end of the extended postpartum period, beneficiaries remain enrolled in the eligibility group in which the beneficiary was enrolled during pregnancy through the end of the 12-month postpartum period.

We recognize that, absent a state’s election to provide 12 months of continuous postpartum coverage, some individuals enrolled in the group for pregnant individuals would be redetermined as eligible for the adult group at the end of the 60-day postpartum period and meet the definition of “newly eligible” in 42 C.F.R. § 433.204(a)(1) for purposes of claiming the increased federal medical assistance percentage (FMAP) described in section 1905(y) of the Act. The availability of increased FMAP for such individuals is discussed below.

Benefits

States electing the extended postpartum coverage option must provide full benefits to all pregnant and postpartum individuals, as described at sections 1902(e)(16)(B) and 2107(e)(1)(J) of the Act. There may be some beneficiaries who become pregnant after enrolling in the adult group described in section 1902(a)(10)(A)(i)(VIII) of the Act and 42 C.F.R. § 435.119. Coverage provided under an Alternative Benefit Plan (ABP) under section 1937 of the Act is considered full benefits for purposes of the extended postpartum option. States must inform beneficiaries of any differences in coverage between the ABP and the benefits available to

11 While eligibility for Medicaid is not an exception to continuous eligibility during pregnancy and the extended postpartum period under ARP, it may be beneficial for a pregnant or postpartum individual to request voluntary termination of CHIP eligibility to enroll in Medicaid. As such, beneficiaries who become Medicaid eligible need to be informed about the differences between the programs, including cost sharing, benefits, provider networks, and their eligibility for extended postpartum coverage, so they can make an informed decision. 12 See CMCS Informational Bulletin “Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements,” (December 2020) for more information on making accurate redeterminations of eligibility. Available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf

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.