42 U.S.C. § 1397ll: Optional coverage of…

Summary

States can choose to add pregnancy-related health coverage for certain low-income pregnant women to their child health plan. To do that, the state must meet income rules: pregnant women must be eligible at no less than 185 percent of the poverty line (or the higher percent the state already uses) and that level cannot be lower than whatever was in effect on July 1, 2008. Children under 19 must have eligibility at least 200 percent of the poverty line. The state cannot set the CHIP income level for pregnant women lower than the Medicaid level that was in effect on February 4, 2009. The state may not cover higher-income pregnant women while leaving out lower-income ones. The pregnancy help must follow the same rules as child health assistance, including no exclusions for preexisting conditions or waiting periods, the same cost-sharing protections and annual family limits, and no enrollment caps, waiting lists, or delays for children. A state that chooses this option can also let pregnant women get presumptive eligibility the way Medicaid does. “Pregnancy-related assistance” means the same benefits a child gets during the pregnancy and the postpartum time. A “targeted low-income pregnant woman” is a woman who is pregnant and through the end of the month after the 60-day postpartum period (or, in certain cases, through a 12-month period), whose family income is above 185 percent (or the higher percent the state uses) but not higher than the state’s child eligibility level, and who meets the same basic eligibility rules as children. If a woman receiving this help gives birth, her baby is automatically treated as applied for and eligible for child health or Medicaid until the child turns 1 year old, and the baby uses the mother’s eligibility ID for claims unless the state gives a new number. States may also use other approved options or waivers to offer these services and can continue postpartum services through the 60-day month if the mother otherwise qualifies.

Title 42, §1397ll

The Public Health and Welfare, Source: USLM XML via OLRC

(a)In general

Subject to the succeeding provisions of this section, a State may elect through an amendment to its State child health plan under section 1397bb of this title to provide pregnancy-related assistance under such plan for targeted low-income pregnant women.

(b)Conditions

A State may only elect the option under subsection (a) if the following conditions are satisfied:

(1)Minimum income eligibility levels for pregnant women and children

The State has established an income eligibility level—

(A)for pregnant women under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1396a of this title that is at least 185 percent (or such higher percent as the State has in effect with regard to pregnant women under this subchapter) of the poverty line applicable to a family of the size involved, but in no case lower than the percent in effect under any such subsection as of July 1, 2008; and

(B)for children under 19 years of age under this subchapter (or subchapter XIX) that is at least 200 percent of the poverty line applicable to a family of the size involved.

(2)No CHIP income eligibility level for pregnant women lower than the State’s Medicaid level

The State does not apply an effective income level for pregnant women under the State plan amendment that is lower than the effective income level (expressed as a percent of the poverty line and considering applicable income disregards) specified under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), or (l)(1)(A) of section 1396a of this title, on February 4, 2009, to be eligible for medical assistance as a pregnant woman.

(3)No coverage for higher income pregnant women without covering lower income pregnant women

The State does not provide coverage for pregnant women with higher family income without covering pregnant women with a lower family income.

(4)Application of requirements for coverage of targeted low-income children

The State provides pregnancy-related assistance for targeted low-income pregnant women in the same manner, and subject to the same requirements under section 1397cc(c) of this title, as the State provides child health assistance for targeted low-income children under the State child health plan, and in addition to providing child health assistance for such women.

(5)No preexisting condition exclusion or waiting period

The State does not apply any exclusion of benefits for pregnancy-related assistance based on any preexisting condition or any waiting period (including any waiting period imposed to carry out section 1397bb(b)(3)(C) of this title) for receipt of such assistance.

(6)Application of cost-sharing protection

The State provides pregnancy-related assistance to a targeted low-income woman consistent with the cost-sharing protections under section 1397cc(e) of this title and applies the limitation on total annual aggregate cost sharing imposed under paragraph (3)(B) of such section to the family of such a woman.

(7)No waiting list for children

The State does not impose, with respect to the enrollment under the State child health plan of targeted low-income children during the quarter, any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment.

(c)Option to provide presumptive eligibility

A State that elects the option under subsection (a) and satisfies the conditions described in subsection (b) may elect to apply section 1396r–1 of this title (relating to presumptive eligibility for pregnant women) to the State child health plan in the same manner as such section applies to the State plan under subchapter XIX.

(d)Definitions

For purposes of this section: (1) Pregnancy-related assistance

(2)Targeted low-income pregnant woman

The term “targeted low-income pregnant woman” means an individual—

(A)during pregnancy and through the end of the month in which the 60-day period, or, in the case that subparagraph (A) of section 1396a(e)(16) of this title applies to the State child health plan (or waiver of such plan), pursuant to section 1397gg(e)(1) of this title, the 12-month period, (beginning on the last day of her pregnancy) ends;

(B)whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this subchapter for a targeted low-income child; and

(C)who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of section 1397jj(b) of this title in the same manner as a child applying for child health assistance would have to satisfy such requirements.

(e)Automatic enrollment for children born to women receiving pregnancy-related assistance

If a child is born to a targeted low-income pregnant woman who was receiving pregnancy-related assistance under this section on the date of the child’s birth, the child shall be deemed to have applied for child health assistance under the State child health plan and to have been found eligible for such assistance under such plan or to have applied for medical assistance under subchapter XIX and to have been found eligible for such assistance under such subchapter, as appropriate, on the date of such birth and to remain eligible for such assistance until the child attains 1 year of age. During the period in which a child is deemed under the preceding sentence to be eligible for child health or medical assistance, the child health or medical assistance eligibility identification number of the mother shall also serve as the identification number of the child, and all claims shall be submitted and paid under such number (unless the State issues a separate identification number for the child before such period expires).

(f)States providing assistance through other options

(1)Continuation of other options for providing assistance

The option to provide assistance in accordance with the preceding subsections of this section shall not limit any other option for a State to provide—

(A)child health assistance through the application of section 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) of title 42, Code of Federal Regulations (as in effect after the final rule adopted by the Secretary and set forth at 67 Fed. Reg. 61956–61974 (October 2, 2002)), or

(B)pregnancy-related services through the application of any waiver authority (as in effect on June 1, 2008).

(2)Clarification of authority to provide postpartum services

Any State that provides child health assistance under any authority described in paragraph (1) may continue to provide such assistance, as well as postpartum services, through the end of the month in which the 60-day period (beginning on the last day of the pregnancy) ends, in the same manner as such assistance and postpartum services would be provided if provided under the State plan under subchapter XIX, but only if the mother would otherwise satisfy the eligibility requirements that apply under the State child health plan (other than with respect to age) during such period.

(3)No inference

Nothing in this subsection shall be construed—

(A)to infer congressional intent regarding the legality or illegality of the content of the sections specified in paragraph (1)(A); or

(B)to modify the authority to provide pregnancy-related services under a waiver specified in paragraph (1)(B).

Notes & Related Subsidiaries

Editorial Notes

Amendments

2021—Subsec. (d)(2)(A). Pub. L. 117–2 inserted “, or, in the case that subparagraph (A) of section 1396a(e)(16) of this title applies to the State child health plan (or waiver of such plan), pursuant to section 1397gg (e)(1) of this title, the 12-month period,” after “60-day period”. 2020—Subsec. (b)(4). Pub. L. 116–127 inserted “under section 1397cc(c) of this title” after “same requirements”.

Statutory Notes and Related Subsidiaries

Effective Date

Section effective Apr. 1, 2009, and applicable to child health assistance and medical assistance provided on or after that date, with certain exceptions, see section 3 of Pub. L. 111–3, set out as a note under section 1396 of this title.

§1397ll Optional Coverage of Targeted Low-income Pregnant Women Through a State Plan Amendment