Women often ask whether Medicaid covers a particular service (health, dental, or vision) during pregnancy and shortly after birth. The correct answer depends on four specific pathways you might have and whether your residency state includes the benefit.
Emergency Medicaid pays for critical care for undocumented immigrants, while limited pregnancy Medicaid restricts many healthcare services.
Full-Scope Medicaid provides comprehensive healthcare benefits, while CHIP provides inclusive care for some mothers with higher incomes.
Disclaimer: your managed care organization is the final authority regarding possible claim payments for any service. What follows is a breakdown of what is likely to occur given many parameters.
Services Unrelated to Pregnancy
Medicaid sometimes expands coverage for services unrelated to pregnancy or treatments typically not addressed by healthcare plans.
In these cases, the full-scope and CHIP pathways are more likely to provide these benefits. At the same time, the limited and emergency programs have restrictions – with some notable exceptions.
Before starting, it is critical to keep two thoughts in mind.
- A pregnant woman can be denied Medicaid if she makes too much money or cannot document her legal immigration status
- Pregnant women who make too much to qualify for Medicaid could still be eligible for subsidies to purchase private insurance
- Services Unrelated to Pregnancy
- Medicaid Prenatal Care
- Medicaid Childbirth Coverage
- Medicaid After Birth of Baby
Medicaid sometimes covers dental care during pregnancy, even though these services typically fall outside of the healthcare umbrella. Pregnancy hormones can make women more susceptible to gum disorders such as gingivitis, making proper oral care is critical to mom and her baby’s health.
However, your age, state, and pathway determine the coverage for dental care.
Teeth & Gums
Teenage girls and women under the age of 21 in the full-scope pathway automatically enjoy primary dental care while pregnant as a minimum requirement under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.
- Relief of pain and infections
- Restoration of teeth
- Maintenance of oral health
Women older than 21 enrolled in the full-scope pathway will have varying levels of Medicaid funded oral care based on rules in their residency state.
- Emergency services to stop bleeding or pain: 50
- Restorative care: 23
- Dental implants: 0
- Root Canal: 23
- Crowns: 23
- Dentures: 23
- Periodontal treatment: 19
- Deep cleaning
- Gum surgery
- Oral & Maxillofacial Surgery: 25
- Wisdom teeth removal
- Jaw surgery
Women older than 21 enrolled in the Limited-Pregnancy pathway could enjoy access to dental care otherwise denied to adults if they reside in Louisiana, Missouri, Nevada, or Oklahoma.
Medicaid coverage for dental braces depends on the age, state, and pathway of the pregnant woman. Orthodontic braces can take years to straighten crooked teeth while a normal gestation ends after only nine months.
Both Emergency and Limited Pregnancy pathways offer temporary benefits and are unlikely to fund any orthodontic work that takes years to complete.
However, the full-scope and CHIP plans might fund orthodontic braces under several different scenarios.
- Medically necessary braces for across the country
- Non-biting accidents (adults)
- Congenital deformities (teens)
- Braces to correct a handicapping malocclusion
- Teenagers across the country
- Adults over 21 in Oregon and D.C.
Medicaid sometimes covers vision for pregnant women. With services affecting eyesight, the rules diverge for medically necessary ophthalmology and optometry (correcting refractive errors).
Plus, women enrolled in the emergency program should not expect benefits unless the eye condition happens suddenly with severe symptoms. Those in the limited program might also find similar restrictions and should contact their managed care organization.
Medicaid is more likely to pay for vision services for pregnant women provided by an ophthalmologist across the country with less variation by pathway. These treatments are often medically necessary because they address diseases of the eye.
An ophthalmologist performs eye surgeries that treat illnesses such as Diabetes, Grave’s Disease, Keratoconus, Multiple Sclerosis, and others. Other procedures may repair injuries to your iris, pupil, sclera, retina, optic nerve, cornea, conjunctiva, lids, etc.
Medicaid is less likely to pay for optometry during pregnancy because the correction of refractive errors falls outside of the healthcare umbrella.
An optometrist is a non-medical practitioner who performs eye exams and vision tests, detects orbital abnormalities, and prescribes corrective lenses and medications.
Each state enacts unique rules for optometry coverage under the full-scope pathway. Plus, the limited and emergency programs are more likely to restrict benefits in this arena – except when states do the opposite.
Medicaid sometimes covers vision exams to detect refractive errors under the full-scope pathway. With exams, the rules change by age and state.
- Pregnant teens receive eye exams through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program
- Pregnant adults could enjoy vision exams based on their residency state and the time since their last test
- No coverage: 14
- Once annually: 30
- Every three years: 6
Medicaid may fund prescription eyeglasses following a similar pattern as with exams for refractive errors – with one notable exception. The state of California adds the benefit for pregnant women only.
Medicaid rarely pays for contact lenses to correct refractive errors because eyeglasses are the least expensive alternative. Contacts fall into the cosmetic category in most cases.
However, the full-scope pathway might honor claims for medically necessary contacts that address the symptoms of a disease such as Keratoconus.
Medicaid Prenatal Care
Medicaid coverage for prenatal care provides another opportunity to illustrate the four pathways’ differences and how each state determines what services to include.
Right away, we know that the emergency pathway will not pay for prenatal care because preventive services are non-urgent by definition.
For the remaining three plans (Limited, Full-Scope, CHIP), each state sets rules for coverage, and the service must be medically necessary: treat a condition and or its symptoms.
Medicaid is likely to cover many prescription drugs during pregnancy because the mother’s health connects with her baby’s. Of course, this holds for the full-scope, limited, and CHIP programs only, and each state makes specific rules.
Medicaid pays for prenatal vitamins in all fifty states because the extra folic acid and other nutrients promote healthy fetal development. However, at least four require a prescription from a licensed physician.
Medicaid is more likely to cover prescription diabetes medications (Metformin, Glucophage, Glumetza, or Insulin) because pregnancy can affect how your cells use sugar.
Increases in hormone levels can lead to gestational diabetes that can affect your baby’s health and lead to chronic disease after birth for the mother
Prescription drugs for diabetes are typically medically necessary.
Tests & Scans
Our three Medicaid plans (Limited, Full-Scope, and CHIP) are likely to pay for medically necessary prenatal tests and scans designed to detect abnormalities that might benefit from early intervention.
The Medicaid coverage guidelines for prenatal ultrasounds grow stricter for each new measurement dimension (depth and movement) added to the scan because of the least expensive alternative rule.
Medicaid pays for at least one 2D pregnancy ultrasound across the country, although each state may set a different maximum. Any plan is more likely to pay for multiple 2D sonograms after detecting a fetal abnormality or a health risk to the mother.
Medicaid pays for 3D ultrasounds when adding the depth dimension is medically necessary: detailed anatomic examination after identifying specific fetal abnormalities.
- 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
Medicaid is unlikely to pay for the more expensive 4D ultrasound because an obstetrician rarely needs to track the baby’s movement in your womb to diagnose a medical problem.
Medicaid is likely to include prenatal genetic testing in most but not all states because the DNA samples provide an early warning for possible chromosomal disorders.
- Trisomy 21 (Down syndrome)
- Trisomy 18 (Edwards syndrome)
- Trisomy 13 (Patau syndrome)
Most states pay for the testing component (Amniocentesis, Chronic Villus Sampling, or NIPT), but a handful does not support genetic counseling services.
Medicaid is more likely to pay for ambulatory blood pressure monitors during pregnancy because preeclampsia is a severe medical condition that affects the baby and mother’s health.
Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal and can lead to liver and kidney damage.
Therefore, women diagnosed with preeclampsia can expect their plan to deem blood pressure monitors as medically necessary in many cases
Our four Medicaid plans are more likely to diverge on whether they pay for prenatal women visiting selected healthcare providers. Here, the reason for the appointment plays a critical role in determining coverage.
Our three Medicaid plans (Full-Scope, Limited, and CHIP) are likely to honor claims for prenatal visits with your obstetrician or gynecologist (OB-GYN).
An OB-GYN has specialized expertise in female reproductive health and childbirth. This type of preventive care is typically medically necessary during pregnancy.
Limited-Pregnancy Medicaid is less likely to pay for visits to the dermatologist because many skin conditions do not directly affect an unborn baby’s health.
Limited means restricted, and your plan could draw a line with dermatology visits unrelated to hormonal changes during pregnancy. However, full-scope and CHIP plans might honor claims for all skin conditions.
Medicaid includes visits to the Chiropractor during pregnancy when medically necessary in roughly half of the country. Prenatal chiropractic care can relieve pain associated with misalignments of the pelvis and spine caused by your growing belly.
However, approximately twenty-four states do not honor claims for chiropractic visits for any reason – even when medically necessary.
Medicaid coverage for emergency room visits during pregnancy is full of gray areas because of the many possible medical reasons and pathways. Also, because the ER is the most expensive alternative, many states impose reimbursement caps for non-urgent situations.
- Many women visit the emergency room for routine care unrelated to pregnancy. In this case, Emergency and Limited Medicaid are less likely to honor restricted claims.
- All types of Medicaid (including Emergency plans for undocumented immigrants) are most likely to cover pregnant women visiting the ER for acute care that happens suddenly with severe symptoms – even when unrelated to her pregnancy.
Medicaid Childbirth Coverage
All four Medicaid pathways cover most childbirth services because labor and delivery are both medically necessary and urgent (happens suddenly with severe symptoms). Therefore, we can bundle the Emergency version for undocumented immigrants with Limited, Full-Scope, and CHIP plans in this section.
Medicaid is likely to pay for an ambulance ride to the hospital for a pregnant woman when the transportation is medically necessary: the use of any other vehicle could endanger her health.
For example, women in active labor might need an ambulance ride, while someone with a scheduled C-section could take a personal car.
All four forms of Medicaid are likely to pay for an epidural during childbirth because the contraction pains often arrive suddenly, are intense, and could prolong labor and delivery.
An epidural is typically medically necessary because it blocks pain (a symptom).
Medicaid coverage for the various childbirth settings depends on your residency state and the type of plan. Therefore, verify benefits through the private company administering your program before your due date to avoid unpleasant surprises.
- Hospital labor and delivery and C-sections apply nationwide because this setting is the medical standard of care
- Alternative settings for labor and delivery apply less frequently as each state makes different decisions about how to handle non-standard locations
- Water Birth: unknown
- Home Birth: 26
- Birthing Centers: 40
- Midwives (Doula): 5
Medicaid After Birth of Baby
Our four Medicaid plans address postpartum issues quite differently. The coverage might end shortly after the birth of your baby, which could impact possible benefits for tubal ligation, circumcision, and breast pumps.
Our four Medicaid plans show the most diversity when it comes to how long the coverage continues after your baby’s birth. One size does not fit all in this situation, and the answer can differ for both mom and infant.
- Emergency benefits for undocumented immigrants end immediately for the mother once she recovers from childbirth. The same holds for the baby unless her residency state supports alien children: California, Illinois, Massachusetts, New York, Oregon, and Washington
- Limited benefits end sixty days after birth for both mom and her infant. If eligible based on income, full-scale or CHIP could extend up to age 19 for your newborn
- Full-Scale coverage continues indefinitely after birth for both mom and her babies provided she passes periodic redeterminations
- CHIP benefits also continue indefinitely after birth for babies and their mom as long as their household incomes stay below the slightly higher limits
Medicaid often pays for tubal ligation surgery for women who want permanent sterilization shortly after having a baby. In general, you must meet several criteria if you want your tubes tied for free.
- At least 21 years old
- Not mentally incompetent
- Signed an informed consent form
- Wait at least 30 days but not more than 180 days after the consent – unless you meet an exception rule
- Premature birth
- Emergency abdominal surgery
In other words, Women covered under the Emergency and Limited pathways should sign consent forms before their due date if they want a tubal ligation because their coverage ends shortly after.
However, be 100% sure you do not want another baby because Medicaid rarely pays for tubal ligation reversal.
Medicaid coverage for the circumcision of male infants shortly after birth is all over the map because the cutting of healthy foreskin has questionable health benefits. Plus, groups campaign against public funding for a surgical procedure associated with religious beliefs.
For example, circumcision coverage for the remaining pathways (Full-Scope, Limited, CHIP) will vary by state because pressure groups succeeded in eliminating the benefit. Currently, eighteen states do not include this procedure.
After the birth of your baby, Medicaid coverage for breast pumps is also all over the map because the states create many different rules about infants’ feeding and nutrition.
Breast pump coverage could fall into one of four categories.
- Double electric
- Manual only
- Rental vs. purchase
- Prescription required
- Inverted nipples
- Preterm birth
As a fallback to Medicaid, your local WIC (Women Infant Children) program might provide support for breast pumps.