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

Summary

A State can choose to add pregnancy-related health coverage for certain low-income pregnant women to its children’s health plan by amending that plan. To do this, the State must meet income rules: pregnant women must be eligible at a level that is at least 185% of the poverty line (or higher if that’s already what the State uses), and children under 19 must be covered at least to 200% of the poverty line. The State cannot lower the effective income cutoff for pregnant women below what it used on February 4, 2009, and it cannot cover higher-income pregnant women while skipping lower-income ones. The pregnancy help must be given the same way and under the same protections as child health coverage, including rules on cost sharing and a cap on family annual cost sharing. No benefits can be denied for preexisting conditions or delayed by waiting periods. The State may not use enrollment caps, waiting lists, or procedures that delay enrollment for targeted low-income children. Definitions and special rules: “Pregnancy-related assistance” means the same kinds of services the plan gives children, but for the pregnancy period. A “targeted low-income pregnant woman” is a woman who is pregnant (and through the 60-day postpartum period, or 12 months in certain cases), whose family income is above 185% of poverty but not above the child coverage limit, and who meets the same non-income rules a child would. If a woman covered at birth has a baby, that child is treated as already applied and eligible from birth until age 1, using the mother’s eligibility ID unless the State issues a new one. A State may also choose to use presumptive eligibility rules for pregnant women like those in Medicaid and can keep using other authorities it already has.