It is very difficult to know exactly what Medicaid covers during pregnancy, for labor and delivery, and after the birth of your baby – or for how long.

Medicaid has several programs that cover maternity care differently. In addition, each state has unique rules for who qualifies, the services its plans pay for, and which ones they do not.

Explore the five-part outline found below to discover what your Medicaid plan might deny or approve.

Before-Birth Services Paid by Medicaid

Determining what Medicaid covers during pregnancy for perinatal medical conditions is also very difficult. The three main programs and each individual state rule set can apply in unique ways to prenatal care, ultrasounds, genetic testing, and high-risk pregnancies.

Ultrasounds

Our informed speculation as to whether your Medicaid plan pays for ultrasound pictures, and how many, relies on both the program and medical necessity. The plan is most likely to pay for multiple sonograms during pregnancy after first detecting a fetal abnormality or a health risk to the mother.

RegularLimitedEmergency
3D Ultrasound *LMN
4D Ultrasound *LMN
Gender UltrasoundNNN
Downs Syndrome Ultrasound **YYN

* Most likely covered to track a fetal abnormality detected by another test

** After detecting Downs Syndrome via chorionic villus sampling (CVS)

Prenatal Care

Medicaid pays for prenatal care very differently depending primarily on the specific program. Your state and the medical necessity of a given service are less important factors in our educated guesses in this section.

The limited pregnancy program shines the most with prenatal care. Many states expand the types of perinatal services reimbursed in the plan beyond what is medically necessary. In addition, members have no cost-sharing responsibilities (deductible, co-insurance, copayments).

Private health insurance plans will show greater consistency. If you require greater certainty, enrolling in one of these plans could bring better peace of mind.

The emergency plan does not cover any prenatal care.

RegularLimitedEmergency
Pregnancy Test*YNN
Gynecologist VisitsYYN
Birthing ClassesLMN
Prescription Prenatal VitaminsYYN
OTC Prenatal Vitamins**LMN
Prenatal Massage***LMN
Maternity support beltLMN
Prenatal YogaLMN

* Positive test needed to enroll in the limited plan

** May cover generic vitamins sold over the counter

*** Massage that alleviates severe pain only

Genetic Testing

Our educated guesses as to whether Medicaid pays for prenatal genetic testing and counseling during pregnancy rely on all three factors, the program, the reason for the protocol, and the state where you live.

RegularLimitedEmergency
DNA – paternity testNNN
Genetic testing for cancerMNN
Alpha-fetoprotein test (AFP)LMN
Chorionic villus sampling (CVS)LMN
AmniocentesisLMN
Umbilical blood samplingLMN
Quad screeningLMN

The insurance company administering your plan is most likely to deem genetic testing as medically necessary when your gynecologist suspects an inheritable disease.

The state where you live is also an important factor as not every version supports genetic testing and the contract language often varies. For example, the number supporting each ministration is not uniform.

  • 46 reimburse amniocentesis
  • 42 reimburse CVS
  • 36 reimburse genetic counseling

High-Risk Pregnancy

Our informed speculation is most confident about whether Medicaid pays for high-risk pregnancy. A woman experiencing high-risk complications often has a medically necessary condition or emergency. This means that all three programs are more likely to cover ectopic pregnancy, miscarriage and the resulting dilation and curettage (D&C).

Non-emergency reimbursed medical services might comprise 3D ultrasounds to monitor a high-risk pregnancy. False labor could fall into this category as well. In these cases, only the regular and limited programs would apply.

Childbirth Costs Paid by Medicaid

Determining what Medicaid covers for labor and delivery depends mostly on the type of service in question, who performs them, and why. The regular, limited, and emergency programs each pay for the normal birth of your baby in a hospital in all 50 states.

However, the devil is in the details. Your plan is more likely to pay for medically necessary services that fall outside a normal labor and delivery.

Labor & Delivery

  • Labor induction is often reimbursed when mom is overdue, the baby is too big, and the mother or the baby has a pre-existing health condition.
  • Out of state labor will qualify for reimbursement only if an emergency arises while traveling before your due date. If you live near the border, it is best to play it safe and choose an in-state hospital to deliver your baby.
  • Epidurals often qualify for reimbursement. However, some anesthesiologist offices routinely balance bill all out-of-network patients. Do your homework.
  • Elective C-sections are planned scheduled surgeries. They qualify for reimbursement only when a safe vaginal delivery is not possible.
  • Tummy tucks after a C-section is a cosmetic procedure designed to improve appearance and are never reimbursed.

Hospital and NICU

All three Medicaid programs will pay for hospital bills for the delivery room, at least one overnight stay, and meals (food). This holds true in all 50 states.

Neonatal Intensive Care Unit (NICU) charges are medically necessary for severely underweight or premature infants and those experiencing an illness or injury. This is most common with twins and triplets.

Birthing Centers

The state where you live determines whether Medicaid will pay for labor and delivery in a birthing center, or a water birth performed at home supervised by a doula, midwife, or a licensed doctor. The number covering each type of location and provider gives an indication.

  • Certified nurse midwives – 21 reimburse these practitioners who completed postgraduate studies and work with a board-certified obstetrician.
  • Direct access midwives – 7 reimburse the practitioners who do not have a nursing background.
  • Doulas – 7 reimburse labor support services and coaches
  • Birthing centers – 10 do not reimburse
  • Home births – 10 do not reimburse

Once you give birth to your baby, the variation in Medicaid coverage changes quickly – as you will shortly see.

After Birth of Baby Medicaid Coverage

Determining what types of services Medicaid covers for mom and her baby after birth is also very tricky. The type of program is once again very important – and plays a big role in estimating how long the benefits last.

How Long

Our educated guess for how long Medicaid covers mom and her baby after birth depends on the program that applies. The rules regarding the length of postpartum care are consistent across 47 states, which make the analysis uniform except for these three.

  • Hawaii – 30 days
  • Montana – determined monthly
  • Tennessee – 45 days
ProgramMotherBaby
RegularIndefiniteIndefinite
Limited60 days1 year
EmergencyNoneNone

Postpartum Expenses

Our informed speculation around the types of postpartum expenses that Medicaid pays for relies on medical necessity. The most common questions center on baby expenses, maternity leave, breast pumps, and tubal ligation.

Baby Expenses

Most Medicaid programs pay for the medically necessary expenses of your baby after birth for one year. Your doctor may need to provide documentation to establish medical necessity. However, do not expect it to cover everything.

  • Baby diapers are not reimbursed during the incontinence phase
  • Baby formula is not reimbursed for healthy infants. Enteral formulas for tube feeding often are reimbursed in 18
  • Circumcision is reimbursed in 32
  • Baby cranial helmets are reimbursed if needed to treat positional plagiocephaly or craniosynostosis
  • Babysitting expenses are not reimbursable. However, most offer financial assistance for childcare for low-income families.

Maternity Leave

Medicaid does not pay for maternity leave. It reimburses doctors, hospitals, and medical device companies. However, it does not replace income while mom is unable to work.

Supplemental insurance covers maternity leave. Five states automatically enroll all workers in a program. The five are California, Hawaii, New Jersey, New York, and Rhode Island. In the 45 others, you must purchase a private policy prior to conception.

Breast Pumps

Medicaid does not pay for breastfeeding and lactation support in every state. Contact your plan administrator to see if you can get these services free.

  • Breastfeeding education – 22
  • Breast pump rentals – 29
  • Lactation consulting – 9

Tubal Ligation

Medicaid pays for tubal ligation under both the regular and limited programs in 49 states. In Texas, only participants in the limited option have access to this benefit.

However, women must sign a tubal ligation consent form 30 days prior to the surgery. Therefore, women need to sign the consent form before delivery if she wants to complete the procedure during her hospital stay. Those on the limited plan have a short window of time to make an important decision about a permanent form of sterilization.

Tubal ligation reversal is not reimbursed by Medicaid or any other private insurance plan. Many women change their minds after the surgery. Make sure this is what you really want to be done.

Other Services Covered by Pregnancy Medicaid?

First, we address what other medical services Medicaid might cover during pregnancy in your state. If you qualify for the regular program, you automatically qualify for the limited option as well. Which is the better choice for you?

  • The regular plan pays for medical conditions unrelated to pregnancy
  • The limited plan reimburses dental and vision more frequently

Dental Work

Forecasting whether Medicaid pays for dental work for pregnant women is complicated. First, we have a fourth program to introduce, and then we have to consider the category of care as well.

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is the fourth program. EPSDT provides comprehensive care for children under the age of 21 who already participate in Medicaid. Expectant dependents under the age of 21 automatically receive dental services for the relief of pain and infections, restoration of teeth, and maintenance of dental health. This applies in all 50 states.

Regular Medicaid pays for dental work based on the category of care. Each state sets its own rules for the primary treatment categories.

  • Emergency – control bleeding, prevent pain, and eliminate acute infection
  • Preventive – checkups and exams plus cleanings
  • Restorative – fillings and root canals
  • Periodontal – treatment of gingivitis and gum diseases
  • Oral Surgery – wisdom teeth removal, jaw surgery, etc.
  • Orthodontia  – braces in Oregon and the District of Columbia (DC)

Five states that otherwise restrict dental coverage expand access for pregnant women. These are Louisiana, Missouri, Nevada, Oklahoma, and Oregon.

Vision Care

Speculating about whether Medicaid pays for vision care for pregnant women is tricky for similar reasons. The EPSDT option again comes into play, the categories available vary by state, and some expand vision coverage in their limited program.

The EPSDT program provides diagnosis and treatment for defects in vision, including eyeglasses for expectant dependents under the age of 21.

Regular Medicaid pays for vision care based on category. Once again, each state sets its own rules. Medically necessary care is more widespread than simple optical corrections.

  • Eye Exams – 12 do not cover
  • Eyeglasses – often reimbursed to correct refractive errors
  • Contact lenses – only when disease related
  • Eye surgeries – only to treat diseases

Three states that otherwise restrict vision coverage expand access for pregnant women. These are California, Oregon, and Utah.

Medical Services

Determining whether Medicaid covers any particular medical service during pregnancy depends on the program and the underlying condition. It is impossible to address every scenario definitively for many reasons.

  1. There are three different programs. Each handles claims in a unique way.
  2. Each state establishes its own rules. What is true in one may be false in another.
  3. Medically necessary services are a key concept. Any plan is more likely to pay for a protocol that prevents, diagnoses, or treats a medical condition, or its symptoms.

Therefore, we can only make educated guesses. Always contact the insurance company administering your plan for a final determination. In the meantime, we will use codes to represent our informed speculation about each possible service.

  • Y = Yes
  • N = No
  • L = Less likely
  • M = More likely
RegularLimitedEmergency
ChiropracticMLN
DermatologyMLN
Emergency roomYLM
Flu shotsYLN
Gallbladder surgeryYLM
Hemorrhoid removalYLN
Mental healthYLN
Physical therapyYLN
Prescription medicationsYLN
Regular doctor visitsYNN

Our first set of informed speculation refers to Medicaid coverage for non-pregnancy related medical conditions. The odds are best for an emergency that could complicate a pregnancy. The odds are worst for unrelated non-emergency conditions.

Denials and Eligibility Rules for Maternity Medicaid

Before we can determine what Medicaid covers for maternity care you have to determine which program applies to your situation and if you qualify. Four different plans (using generic names – each state uses distinctive labels) have unique requirements and provide vastly different coverage levels.

Denial Reasons

Pregnant women can be denied by Medicaid in three specific areas.

  1. Women who earn too much money do not qualify
  2. The administrator can deny claims for services not covered under the plan
  3. Doctors who do not participate in the plan can deny non-emergency treatment

Request an individual health insurance quote if Medicaid denied coverage because you earn too much money. You may still be eligible for premium assistance if your household income is below 400% of the federal poverty level. You can enroll any time of the year with immediate maternity coverage – if you experienced a qualifying life event.

  1. Recently lost group coverage
  2. Moved out of the service area of an existing plan
  3. Newly married to the father

Regular Medicaid

Regular Medicaid acts like traditional health insurance and must cover the ten essential health benefits. The ten essential benefits reimburse family planning services, maternity, hospitalizations, newborn care, and more.

Regular Medicaid has eligibility criteria that consider income and/or resource limits that vary by state. They can and often do take coverage away through the redetermination process – when finances improve.

  • Broadest coverage
  • Strictest qualifications

Presumptive Eligibility

Presumptive eligibility Medicaid provides low-income pregnant women with immediate temporary access to ambulatory perinatal services. Ambulatory refers to walk-in or outpatient facilities such as physician offices, urgent care centers, imaging centers, health clinics, etc. It is available in thirty-three states as of February 2017.

  • Narrowest coverage
  • Loosest requirements

They will take presumptive eligibility Medicaid away once they finish processing the application. If approved, they will automatically enroll you in the limited pregnancy program. If denied, they will suggest that you purchase a Marketplace plan during open enrollment.

Limited Pregnancy

Limited pregnancy Medicaid offers coverage for maternity-related medical conditions, family planning services, and conditions that might complicate a pregnancy – with no cost-sharing such as copayments, coinsurance, or deductible.

  • Narrower coverage
  • Lowest cost sharing
  • Looser requirements

Women with a pre-existing pregnancy can begin at any time. They must provide positive proof of conception when completing the application, and meet the income criteria.

Therefore, Medicaid can turn down or deny a pregnant woman whose household income is too high. However, if approved, they cannot take away coverage until 60 days after delivery – even if you no longer meet the income threshold.

Emergency Medicaid

Emergency Medicaid is available to legal immigrants in the country for less than five years, and undocumented aliens experiencing a medical crisis. The emergency program covers labor and delivery only.

  • Very narrow coverage
  • Very specific requirements

Apply for emergency pregnancy Medicaid by contacting a local social services agency. Doctors and hospitals that accept Medicaid can often assist with enrollment in many states.

Sources

Posted 02/13/17 5:09 PM by Kevin Haney MBA