Medicaid can deny coverage to pregnant women for several reasons. Learn about the guidelines before completing an application to avoid needless rejection.
Medicaid is a publicly-funded program designed as a safety net for low-income families, disabled individuals, senior citizens with few resources, and pregnant women.
The government must have a cutoff point because it cannot offer taxpayer-supported benefits to every applicant. The primary eligibility criteria are household income levels compared to size, citizenship, and residency status.
As always, the devil is in the details. Pay close attention to boost your approval odds and file an appeal if you find errors in your initial application.
What To Do If Denied Medicaid While Pregnant
Medicaid can deny coverage to pregnant women, so you should learn what to do if this happens to you: file an appeal after making corrections to four common mistakes:
- Overstating expected income
- Understating household size
- Omitting crucial documents
- Ignoring medically needy pathways
Relax if you are pregnant without insurance but don’t qualify for Medicaid – even after filing an appeal. You have plenty of other low-cost options with government support.
Recount Annual Income
Verifying that you counted your annual income correctly is the first thing you want to do if denied Medicaid while pregnant. It is easy to overstate the earnings component of FPL because the rules are confusing.
Follow these two income reporting rules carefully without overstating.
- Enter your expected household income, not past earnings
- Estimate your Modified Adjusted Gross Income (MAGI)
|Include in MAGI||Exclude from MAGI|
|Federal taxable wages||Child support|
|Tips||Supplemental Security Income (SSI)|
|Self-employment||COVID Economic Stimulus|
|Investment Earnings||Workers Compensation|
|Social Security Disability (SSDI)||Veterans Disability Payments|
|Rent and Royalties||Loan proceeds|
Alimony counts towards MAGI for divorces and separations finalized before January 1, 2019. Women divorced or separated on or after this date do not include alimony in their total.
Recount Household Size
Verifying that you counted your household size correctly is the second thing you should do if denied Medicaid while pregnant. It is easy to understate this component of PFL because the rules are confusing.
Follow these two household size rules carefully without understating.
- Count expected tax filer, spouse, and dependent children
- Include the number of your unborn babies
Eligibility Income Chart
The third thing to do if denied Medicaid while pregnant is to consult the income eligibility chart published by your state while remembering that household size determines the cutoff.
The Federal Poverty Level (FPL) increases yearly and includes the two components explored in detail above (expected household MAGI and size). Each state expresses eligibility as a percentage of FPL.
Supply Missing Documents
The fourth thing to do if denied Medicaid while pregnant is to verify that you submitted the appropriate documents establishing that you reside in the application state and are legally in the country.
First, you must prove that you live in the state where you are applying. Did you include a recent document from a third party listing your home address (driver’s license, utility bill, or credit card statement from the last ninety days)?
Second, you may have to prove that you are in the United States legally. Did your initial application include a birth certificate or passport if born in the US? If born outside of the country, you must provide a certificate of citizenship or naturalization.
File an appeal if your initial application did not include these documents.
Explore Medically Needy
The fifth thing to do if denied Medicaid while pregnant is to research whether your state supports a medically needy option. Women who make too much money to qualify can “spend down” their earnings by subtracting medical bills for prenatal care and other healthcare services.
States can establish a medically needy pathway, allowing more applicants to qualify. Once enrolled in the program, Medicaid will reimburse any excess costs incurred to become eligible.
Can You Lose Medicaid While Pregnant?
Medicaid can deny your initial application and drop your coverage while pregnant if you no longer meet the income guidelines. This reality is becoming more common as states resume redeterminations after pausing them during the COVID emergency.
You can get Medicaid while wedded and pregnant and lose coverage by getting married. How can both of these statements be simultaneously true?
States base Medicaid eligibility on your household’s Federal Poverty Level (FPL) percentage. Your marital status is not part of the criteria but can influence the determination indirectly as the FPL includes two factors.
- Additional household member
- MAGI of the husband
For example, the FPL increases the income threshold by $5,140 for each additional household member in 2023. States then inflate this figure by a percentage when determining Medicaid eligibility (see chart above).
The impact of marriage on eligibility varies based on where you live, as illustrated by these two extremes.
|State||FPL %||Incremental Marital Earnings|
You can lose Medicaid while pregnant if your state processes a redetermination of your case and finds that you no longer qualify. However, you still have good options.
The loss of Medicaid is a qualifying life event, meaning you can enroll in a private health insurance program immediately. The federal government will even help you lower the monthly costs through premium tax credits if your household lives below 400% of FPL.
Many women lose Medicaid two months after childbirth as states tighten the qualifying criteria once they are no longer pregnant. Once again, you still have good options.
- Babies born to women on Medicaid are automatically eligible for one year regardless of the family income.
- The birth of a baby is a qualifying life event, meaning you can enroll in a private health insurance program immediately and might be eligible for premium tax credits.