Medicaid Coverage of Pregnancy-Related Services: Findings from a 2021 State Survey

Introduction

The Medicaid program finances more than four in ten (42%) births in the United States, and more than half of births in several states. In recent years, policymakers have devoted new attention to maternal health in response to rising rates of pregnancy-related deaths and the substantially higher rates experienced by Black and American Indian and Alaska Native (AIAN) people. This is a particular concern for the Medicaid program, which finances approximately two-thirds of births among Black and AIAN individuals nationally.

The range of pregnancy-related services that states cover is shaped by many factors, with federal law setting the following baseline requirements that states must follow:

• Income eligibility—All states must provide Medicaid coverage for pregnant individuals with incomes up to 138% of the federal poverty level (FPL), but many states set their eligibility thresholds considerably higher than the federal minimum requirement. The federal standard requires that coverage last through 60 days postpartum, but states have options to extend the postpartum coverage period, which is discussed more later in this report.
• Cost-sharing—States are prohibited from imposing cost sharing requirements on beneficiaries for pregnancy-related services.
• Benefits—Federal law does not generally define the services that states must cover for pregnant beneficiaries, beyond inpatient and outpatient hospital care, leaving states with discretion to determine the scope of services that they will offer. However, states that have expanded eligibility under the Affordable Care Act must cover services that fall under the federal requirements for coverage of preventive services established by the ACA. This includes many prenatal screening tests, folic acid supplements, and breastfeeding services .

While federal law establishes a floor for benefits and eligibility, states have significant latitude to set income eligibility levels, define specific maternity care services, and apply utilization controls such as prior authorization and preferred drug lists (PDL). To understand how states cover reproductive health services under Medicaid, KFF (Kaiser Family Foundation) and Health Management Associates (HMA) conducted a survey of states between June 2021 and October 2021 about the status of Medicaid benefit policies across the nation. This report presents findings on states’ coverage of maternity care services under Medicaid as of July 2021. Forty-one states and the District of Columbia responded to the survey. States that did not respond to the survey are: Arkansas, Georgia, Kentucky, Minnesota, Nebraska, New Hampshire, New Mexico, Ohio, and South Dakota. Key themes from the survey findings are summarized in Figure 1. A companion report with findings on coverage of family planning benefits is available here.

Key Findings

Prenatal and Delivery Services

• All responding states cover prenatal visits, vitamins and ultrasounds, but some impose utilization controls on these services. Coverage for other prenatal and delivery services, such as group prenatal care, varied. Standard prenatal care includes a slate of services such as prenatal visits, vitamins, and ultrasounds. Ten states reported limits on the number of ultrasounds they would cover, and six states have a preferred drug list for coverage of certain brands of prenatal vitamins. Group prenatal care, a newer model of prenatal visits, is only covered in 12 of the responding states.
• Most of the responding states are taking steps to prevent and monitor preeclampsia and gestational diabetes. Most responding states (31 of 41) cover blood pressure monitors for home use as a pregnancy-related service, but only nine states reported covering scales to monitor weight gain during pregnancy. The majority of states also reported covering continuous glucose monitors and nutritional counseling to support pregnant people with gestational diabetes.
• More than half of responding states cover home births under Medicaid. While clinicians, maternal health researchers, and birthing parents have been discussing home births for decades, interest has grown since the start of the COVID pandemic. Of the 25 states that cover home births, several have prior authorization requirements or require that the birth be attended by a physician or nurse midwife.

Counseling and Support Services

• State coverage varies for support services typically provided outside the medical setting. For example, fewer than half of responding states reported that they cover childbirth and parenting classes. Conversely, most states reported covering home visiting services during and after pregnancy, but some limit services to high-risk beneficiaries.
• Most of the responding states cover dental services for pregnant Medicaid enrollees, however, five of these states limit coverage to emergency dental services and do not cover preventive dental care. There is some evidence that pregnant people are at higher risk for periodontal disease during pregnancy and that a mother’s dental health status is linked to her child’s future dental health.
• While just three of the survey states reported covering doula services as of July 2021, several more states are considering adding doula coverage or are testing pilot programs. Indiana, New Jersey, and Oregon reported that they were covering doula services as of July 1, 2021. Minnesota, which did not respond to this survey, also covers doula services through their state Medicaid program. Several other states said that they have plans to begin coverage in 2022 or are considering adding doula benefits in the future.
• Most states cover services for pregnant and postpartum individuals with substance use disorder (SUD) beyond federally-required minimum benefits. Federal law requires that states cover Medication Assistance Treatment (MAT) for pregnant and postpartum people with SUD. However, a variety of other services, including residential and inpatient treatment, may be recommended for people with SUD. Of the 42 responding states, 36 reported offering expanded SUD benefits beyond the required benefit of MAT. Additionally, eight states mentioned they are developing initiatives to address substance use or mental health services for pregnant or postpartum beneficiaries.
• The majority of states do not offer any coverage for fertility assistance services. Coverage for fertility care is a major gap in Medicaid. Just 11 states cover diagnostic testing related to fertility for women, and some of those states limit coverage to medical diagnoses. Furthermore, while states are required to cover most prescription medications under Medicaid, there is an exception that allows states to exclude coverage for fertility medications. Just four states (CA, IL, NY, WI) reported coverage of fertility medications.

Breastfeeding and Postpartum Services

• The full array of breastfeeding services and supports– classes, pumps, lactation consultations–are covered by about one-third of the states under Medicaid. Several states indicated that breastfeeding education, such as an instructor led class, is covered as part of an office visit or global maternity fee, rather than through a separate reimbursement. Lactation consultation services are more commonly covered in the hospital setting, compared to outpatient and home visits after discharge. Most states cover manual and electric breast pumps, but some require prior authorization. In total, 15 of the survey states reported Medicaid coverage for all of the breastfeeding supports we asked about: educational classes, lactation consultations in the hospital, outpatient, and home settings, and electric and manual breast pumps.
• The majority of responding states (35 of 41) reported no limits on the number of covered postpartum visits. Seven of the states that responded to the survey reported limits on the number of postpartum visits or on reimbursements for postpartum visits. ACOG and other professional organizations recommend that postpartum individuals have contact with their obstetric care providers within the first three weeks postpartum, with ongoing care as needed through one year after pregnancy. Several states have extended the postpartum period beyond 60 days or are considering extending Medicaid pregnancy eligibility through 12 months postpartum as allowed by an option in the federal American Rescue Plan Act (ARPA).

New Directions

Several states are considering efforts to enhance maternity benefits, particularly extending the postpartum coverage period, adding doula benefits, and developing targeted initiatives to address substance use disorders for pregnant and postpartum beneficiaries. Under federal Medicaid rules, pregnancy-related coverage lasts through 60 days postpartum, but in recent years, there has been interest in extending coverage through the first year postpartum among policymakers at the federal and state levels. Extending postpartum Medicaid coverage was the most commonly reported new initiative that states are considering with regard to maternal health. KFF is tracking state activity on this policy, and the most up to date information is available in this tracker.

While few states had doula benefit in place as of July 2021, at least 11 other states are considering adding coverage for doula benefits, including four states reporting they planned to begin coverage by the end of 2022. A number of states also reported that they are trying to strengthen care for pregnant and postpartum beneficiaries with substance use disorders, with a focus on improving access to treatment services.