Expectant women can apply for pregnancy Medicaid online or at their local state agency. Be prepared with the proper documentation.

Learning one obscure eligibility rule about household size can help you avoid being denied because you make too much money. Your unborn babies count as an extra person!

Once onboard, Medicaid covers many expenses, including prenatal care, ultrasounds, genetic testing, childbirth, newborn infants, dental work, vision, and more.

However, locating providers that accept Medicaid for a specific service is not always easy. Arm yourself with a strategy to find the support you need.

Applying for Pregnancy Medicaid

Applying for pregnancy Medicaid can start by completing an online web form, or by contacting your local state agency. But also having complete documentation on hand is critical to your success.

You can begin an online application at the healthcare.gov website, which will forward your request to the appropriate local office – if you qualify. Or, you can skip this step and go straight to your local agency.

Make sure to gather documentation to verify essential details such as medical proof of pregnancy, age, citizenship, identity, marital status, household size, and income.

Denial Reasons

A pregnant woman can be denied Medicaid if she makes too much money – given her household size and citizenship status. Therefore, pay close attention to the eligibility requirements so you can complete the application correctly to avoid rejection or unnecessary delays.

Household Size

The understating of household size is a frequent mistake that leads to unnecessary denials. It is easy to overlook one very obscure rule. Medicaid counts the mother and unborn child as at least two people, and sometimes three or four if you are carrying twins or triplets.[1]

Each state sets its own rules for income limits. Typically, they express the upper-bound as a percentage of the Federal Poverty Level (FPL), which grows in proportion to your household size.[2]

Household Size 2020 FPL
1 $12,490
2 $16,910
3 $21,330
4 $25,750
Additional Add $4,420

Income Limits

Making too much money (based on household size) is the primary reason that Medicaid might deny the application of a pregnant woman. The maximum income that makes you ineligible depends on the state where you live. Therefore, you must contact your local agency to find out if you qualify.

Federal law sets the lowest percentage at 138% of FPL. However, many states set higher ceilings, and some expand access via Children’s Health Insurance (CHIP), as illustrated by this chart of sample guidelines.[3]

Medicaid CHIP-Funded
California 213% 322%
Texas 203% 207%
Florida 196%
New York 223%
Pennsylvania 220%
Illinois 213% 213%
Ohio 205%
Georgia 225%
North Carolina 201%

Buying private coverage (with possible help from government subsidies) is the primary alternative if your earnings exceed these limits. Bear in mind that you may have to delay coverage until the annual open enrollment – unless you experience a qualifying life event.

Citizenship

Your citizenship status also determines Medicaid eligibility and could be grounds for an application denial depending on the state where you reside, household income, and the length of time you have been in this country.[4]

  • Illegal (undocumented or unauthorized) immigrants who are pregnant can enroll in limited coverage for emergency medical services across the USA
  • Non-citizen refugees, asylees, and other humanitarian immigrants can start anytime during the first seven years of residence
  • All legal non-citizens (qualified immigrants) can enroll following five years of residency nationwide, and if pregnant in 23 of the 50 states without a delay
  • Non-immigrant visa holders include tourists, students, and visitors on business who intend to reside indefinitely are legal non-citizens

Have Insurance

Most women can get pregnancy Medicaid if they already have private health insurance either through work or in the individual marketplace. Having existing coverage is not a valid denial reason.

It often makes sense to use Medicaid as secondary insurance during your pregnancy. Many private plans have significant cost-sharing features such as high deductibles, co-insurance, copayments, or skinny networks. Expectant women often over-utilize healthcare and hit the maximum out-of-pocket for the year.

Secondary coverage fills this gaping hole that most low-income earners cannot afford to close by themselves.

Approval Timing

The length of time it takes to get approved for Medicaid when you are pregnant depends on your level of preparation, the state where you live, and the local agency reviewing your application.

  • Arriving at the agency office with all necessary documentation (age, citizenship, identity, marital status, household size, and income) speeds up the process.
  • Presumptive Eligibility (available in 30 states) enables hospitals and community health centers to extend immediate coverage to pregnant women temporarily[5]
  • Each local agency has different workloads and systems, which affect the time needed to render a decision

Losing Coverage

It is possible to lose Medicaid while pregnant. But, this is highly unlikely, and you would have an easy avenue to continue coverage on the private marketplace if you did.

Each state sets rules for redeterminations that ensure that public resources go to those who need them. Typically, they might re-examine eligibility at set periods, such as 12 or 24 months.

Most women will give birth long before a scheduled redetermination. However, those who began coverage before conception could lose the benefits if the update shows that income increased above the limits.

Fortunately, loss of Medicaid is a qualifying life event, which allows you to begin a new private plan (with government subsidies) during a special enrollment period.

Services Pregnancy Medicaid Covers

Figuring out what services pregnancy Medicaid covers requires detective work because each state makes its own rules, and four possible programs enter the equation.

  1. Three plans cover ten Essential Health Benefits
    1. Regular program for low-income women available coast-to-coast
    2. Expansion coverage for higher-income earners in 36 states
    3. Children’s Health Insurance Plan (CHIP) treats an unborn baby as a low-income person in many regions
  2. Limited Emergency Medicaid pays for maternity-related medical conditions, family planning services, issues that might complicate a gestation

Prenatal Care

Pregnancy Medicaid covers most standard prenatal care services nationwide across all four programs. However, as is always the case, many states set different policies for other forms of treatment.[6]

  • Prenatal vitamins
    • Prescription: 50
    • Over-the-counter: 45
  • Birthing Classes: 17
  • Substance abuse treatment: 48
  • Home visits: 37

Ultrasounds

Pregnancy Medicaid prenatal care coverage seems to pay for at least one 2D ultrasound across the country, although each state may set a different maximum.

Any plan is more likely to pay for multiple 2D sonograms after first detecting a fetal abnormality or a health risk to the mother. Therefore, medical issues could determine how many scans to expect your plan to cover,

The case for at least one 3D ultrasound breaks on medical necessity.

  • 3D Ultrasound images performed only to determine gender or to provide detailed pictures for parents to hang on their refrigerator are not covered
  • Your plan may pay for 3D ultrasounds involving a detailed anatomic examination after identifying specific fetal abnormalities[7]
    • Amniotic band syndrome
    • Single umbilical artery
    • Serum or sonographic markers of aneuploidy
    • Anatomic aberrations
    • Obesity complicating pregnancy
    • Exposure to Zika virus
    • Mother has a bicornuate uterus

4D ultrasound images include the movement of the baby in your womb. Expect the medically necessary standard to be even stricter when adding this fourth dimension to a scan.

Genetic Testing

Our educated guess as to whether Medicaid covers prenatal genetic testing and counseling relies on all three factors, the program, the reason for the protocol, and where you live.

We cannot find any data supporting the number of states that will cover non-invasive prenatal testing (NIPT) – although some do such as California. A simple blood test drawn from the mother’s arm provides a reliable early indicator of the status of your baby.[8]

  • RH blood type
  • Gender (male or female)
  • Possible chromosomal disorders
    • Trisomy 21 (Down syndrome)
    • Trisomy 18 (Edwards syndrome)
    • Trisomy 13 (Patau syndrome)

However, a NIPT result showing evidence of a chromosomal disorder can flip an invasive screening into the medically necessary column – increasing the odds that your plan will pay for a follow-up test – even if your state does not cover the service under normal circumstances.

  • Amniocentesis: 48
  • Chronic Villus Sampling (CVS): 47
  • Genetic counseling: 40

Labor and Delivery

Medicaid should support labor and delivery in a hospital setting nationwide, regardless of the type of plan because childbirth is a medical emergency. The typical length of your hospital stay is 24 hours for a vaginal birth, 3 to 4 days for Cesarean Section surgery, and longer if mom experiences postpartum complications.

However, mothers choosing alternate methods face more uncertainty about the rules in their state.

  • Water Birth: unknown
  • Home Birth: 30
  • Birthing Centers: 41
  • Midwives (Doula): 4
    • Kentucky
    • Minnesota
    • Mississippi
    • Oregon

Baby after Birth

Pregnancy Medicaid covers the mother and newborn baby for a minimum of 60 days after birth. Infants confined to Neonatal Intensive Care (NICU) are typically medically necessary and included in the coverage.

The length of time that postpartum coverage continues after the initial 60-day period depends on household income and rules in your state.

  • Low-income women qualifying for regular or expansion Medicaid can last indefinitely
  • Mid-income families can enroll their infant in CHIP which could last up until age 19 if eligible

Dental

Determining whether your pregnancy Medicaid plan will cover dental work is tricky. In addition to the four program types and regional variations, your age and medical necessity also enter the equation.

Regular Medicaid pays for elective dental care for adults over the age of 21 in 38 states. However, the number covering different services varies quite a bit.

  • Preventive: 27
  • Restorative: 26
  • Periodontal: 19
  • Dentures: 26
  • Oral Surgery: 24
  • Orthodontia (Braces): 1

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 in all 50 states. At a minimum, EPSDT dental services include relief of pain and infections, restoration of teeth, and maintenance of oral health.[9]

Because Medicaid acts as a health insurance policy, your plan may pay for medically necessary dental work across the country. The definition of medically necessary can include oral care arising from non-biting accidents, certain diseases, and treatments deemed integral to other services included in the plan.

Vision

Finding out if your pregnancy Medicaid plan covers vision services such as eye exams, contacts, glasses, and surgeries follows a similar pattern. Your regional rules, enrolled program, age, and medically necessary treatments again play a factor.

Medicaid pays for medically necessary Optometry and Ophthalmology care coast-to-coast. Medically necessary care diagnoses or treats an illness, injury, condition, or disease of the eye or its symptoms.

Regular plans cover exams, contact lenses, and eyeglasses to diagnose and correct refractive vision errors in adults over the age of 21 in 38 states.

EPSDT (under 21) plans may pay for the screening, diagnosis, and treatment of childhood eye conditions such as Amblyopia, Strabismus, Refractive Errors, and Binocular Vision Disorders.

Providers Accepting Medicaid Patients

Online directories are the best resource for locating providers that accept Medicaid patients in your local area. Many states work with private insurance companies, who issue and manage compliant plans.

Therefore, step one means identifying the private company and name of the plan you enrolled in through your regional agency office. In step two, find the online provider directory managed by the private company, and select the appropriate plan.

Finally, use some of these techniques to narrow down your list.

  1. Search by the commonly used specialty name for the type of participating provider you need. For example, enter “Medical Imaging” instead of “Ultrasound.”
  2. Compile a list of local providers in less common specialties such as birthing centers and midwives, and then search by their names after entering your zip code.

OB-GYN

Finding a list of OB-GYN doctors accepting Medicaid patients close to your residence should be straightforward. Most online provider directories will include Obstetrics and or Gynecology clinics as a searchable specialty.

Also, you can narrow your search if you need higher-level care by looking for these OB-GYN sub-specialties.

  • Gynecologic Oncology
  • Maternal-Fetal Medicine (Perinatology)
  • Reproductive Endocrinology and Infertility
  • Urogynecology/Reconstructive Pelvic Surgery

Baby Doctors

Finding local baby doctors accepting Medicaid should prove simple for most patients needing standardized care. Select the Pediatrician specialty in the online provider directory and narrow your search by zip code.

However, parents with very sick infants may need focused care from a participating pediatrician trained in a specific area. Look for doctors in one of these fields.

  • Adolescent Medicine
  • Neonatology
  • Other Pediatric Sub-Specialties
    • Cardiology
    • Hematology/Oncology
    • Surgery
    • Emergency Medicine and Critical Care
    • Hospice and Palliative Medicine
    • Pulmonology

Dentists

Finding dentists that accept your pregnancy Medicaid plan will prove most challenging due to the restrictions on the type of oral care covered. Remember that most states limit the services to exams, cleanings, fillings, gum treatment, and some emergencies.

Therefore, narrowing your search by general dentistry, and periodontists will prove most fruitful. Do not waste your time looking for participating orthodontists.

Meanwhile, searching for participating oral surgeons makes the most sense if you have a medical emergency caused by an accident or disease.

Footnoted Sources:

[1] CMS Household Size

[2] Federal Poverty Level

[3] KFF Income Limits

[4] MACPAC Citizenship

[5] Presumptive Eligibility

[6] KFF Perinatal Benefits

[7] Aetna 3D Ultrasound Requirements

[8] What to Expect – NIPT

[9] EPSDT Benefits