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What is Medicaid?
Medicaid provides government-sponsored health insurance that helps millions of low-income Americans access necessary healthcare. This support is particularly vital during pregnancy.
Medicaid, along with the Children’s Health Insurance Program (CHIP), finances nearly half of all births across the United States. Without these programs, many pregnant individuals and their newborns would face substantial barriers to essential healthcare services.
How Medicaid Helps During Pregnancy
Medicaid is a health insurance program jointly funded by federal and state governments. It provides free or low-cost health coverage to eligible individuals and families who have no medical insurance or inadequate coverage.
Eligible groups include:
- Low-income families
- Children
- Pregnant people
- Older adults
- Individuals with disabilities
Since Medicaid operates as a partnership between federal and state governments, specific rules, eligibility requirements, and covered services vary by state, though all states must follow federal guidelines.
Medicaid serves as the single largest payer for pregnancy-related services nationwide. Federal law requires all states to provide Medicaid coverage to qualified pregnant women who meet income and other eligibility criteria.
Every state offers Medicaid or a similar program specifically designed to ensure pregnant individuals can access adequate prenatal care before birth and postpartum care after delivery.
Children’s Health Insurance Program (CHIP)
CHIP works alongside Medicaid to provide low-cost health coverage primarily for children in families whose income is too high to qualify for Medicaid but who may struggle to afford private health insurance.
In some states, CHIP also extends coverage directly to pregnant individuals or offers specific pathways like the CHIP Perinatal program or the “unborn child” option (also known as From-Conception-to-End-of-Pregnancy or FCEP) which covers pregnancy-related care for the fetus.
Together, Medicaid and CHIP form a critical foundation for maternal and child health in the U.S.
Healthcare Benefits for Pregnant Individuals
Medicaid coverage during pregnancy is comprehensive, generally covering services deemed “necessary for the health of a pregnant woman and fetus, or that have become necessary as a result of the woman having been pregnant.”
While states have some flexibility in defining the exact scope of services, federal guidance encourages broad coverage. The vast majority of states provide the full standard Medicaid benefit package to pregnant beneficiaries.
Importantly, federal Medicaid law prohibits states from charging pregnant individuals deductibles, copayments, or similar cost-sharing for services related to the pregnancy or conditions that might complicate it.
Prenatal Care
Accessing care early and regularly during pregnancy is vital for monitoring the health of both the mother and the developing baby. Medicaid covers a wide array of essential prenatal services:
Regular Check-ups: Includes routine visits with doctors or other qualified providers like Certified Nurse Midwives.
Prenatal Vitamins: Coverage typically includes essential vitamins like folic acid, often extending to over-the-counter versions.
Screenings and Tests: Includes various laboratory tests, screening for genetic conditions (like amniocentesis and chorionic villus sampling in most states), monitoring for gestational diabetes and preeclampsia, and other necessary diagnostic services. Coverage for genetic counseling itself may vary or be limited.
Ultrasounds: Important for monitoring fetal development, though some states may limit the number covered (e.g., two or three) unless additional scans are deemed medically necessary.
Counseling and Education: This can include childbirth and parenting education classes (covered in less than half of states), breastfeeding support and counseling, and mandatory coverage for tobacco cessation counseling for pregnant women.
Care for Complicating Conditions: Medicaid covers services needed to manage health conditions that could complicate the pregnancy, such as hypertension, diabetes, mental health conditions, or substance use disorders (SUD).
Labor and Delivery
Medicaid covers the costs associated with labor and delivery, ensuring access to necessary care during childbirth:
Hospital Services: Includes both inpatient (overnight stays) and outpatient hospital services related to labor and delivery.
Provider Services: Covers services provided by physicians and Certified Nurse Midwives, which is a mandatory benefit category.
Birth Settings:
- Freestanding Birth Centers: Services in these facilities are covered if the state licenses or recognizes them.
- Home Births: Coverage varies, with about half of states covering planned home births.
Labor and delivery costs are explicitly listed as covered services in program descriptions.
Postpartum Care
Care doesn’t end at delivery. Medicaid provides coverage for essential postpartum services:
Postpartum Check-ups: Covers visits to monitor recovery after childbirth. Most states report having no limits on the number of covered postpartum visits.
Family Planning Services: Includes counseling and access to contraception, which is a mandatory Medicaid benefit.
Breastfeeding Support: Coverage often includes counseling and supplies like breast pumps. However, comprehensive support (classes, pumps, consultations) is covered by only about one-third of states.
Mental Health and SUD Treatment: Recognizing the importance of mental well-being postpartum, Medicaid covers mental health services and treatment for substance use disorders. The recent push to extend postpartum coverage duration specifically aims to improve continuity of care for these conditions.
Treatment for Complications: Covers care needed for any health issues arising from the pregnancy or delivery.
The increasing inclusion of services like mental health care, SUD treatment, comprehensive family planning, and breastfeeding support reflects a growing understanding that maternal health encompasses more than just the physical events of pregnancy and birth.
Optional Services
Beyond the core benefits, states have the option to cover additional services that can support maternal health, though availability varies widely:
Comprehensive Dental Care: While basic dental health is important during pregnancy, full dental service coverage is an optional Medicaid benefit.
Doula Services: Support from a doula during labor and delivery is covered by only a handful of states, although interest in adding this benefit is growing.
Transportation: Some states may offer assistance with transportation to medical appointments.
Home Visits: Optional programs may provide home visits during or after pregnancy for medical care, counseling, or infant care assistance.
Healthcare Benefits for Your Newborn
Ensuring a healthy start for newborns is a primary goal of Medicaid and CHIP. A key feature facilitating this is “deemed eligibility.”
Deemed Eligibility: Automatic Coverage for Baby
Babies born to mothers who are enrolled in Medicaid or, in most cases, CHIP at the time of the baby’s birth are automatically (“deemed”) eligible for Medicaid coverage starting from their date of birth.
This means families do not need to submit a separate application for the newborn to get coverage immediately. This automatic enrollment prevents dangerous gaps in coverage during the critical first days and weeks of life.
Initially, the mother’s Medicaid identification number might even serve as the baby’s ID number to ensure immediate access to care and prompt payment for services.
Duration of Newborn Coverage
This deemed eligibility for newborns typically lasts for a full year, until the baby’s first birthday. Importantly, this coverage continues for the entire year even if the family’s income or circumstances change during that time.
Before the year of deemed eligibility ends, the state Medicaid agency is required to review the child’s situation to see if they remain eligible for Medicaid or CHIP under other criteria, facilitating a smooth transition if possible.
Covered Services for Baby (EPSDT)
Newborns covered by Medicaid or CHIP receive a comprehensive set of benefits, largely defined by the mandatory Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit that applies to all enrolled children up to age 21. EPSDT ensures access to a wide range of preventive and treatment services crucial for healthy development:
Well-Baby Checkups: Regular visits with a pediatrician or other provider according to the schedule recommended by the American Academy of Pediatrics (AAP) and Bright Futures (e.g., visits at 3-5 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months).
Immunizations (Vaccines): Covers all routine vaccinations recommended by the Centers for Disease Control and Prevention (CDC) to protect against serious childhood diseases.
Screenings: Includes tests to detect potential problems early, such as developmental screenings, hearing and vision screenings, newborn blood screenings (for conditions like Phenylketonuria (PKU) and sickle cell disease), and lead screenings.
Diagnostic Services: If a screening identifies a potential issue, further diagnostic tests are covered to confirm the condition.
Treatment: Covers medically necessary treatment for any physical or mental health conditions, illnesses, or defects discovered, including medical care, dental services, vision care, hearing services, and mental health services.
Other Services: Also includes necessary hospital care (inpatient and outpatient), prescription drugs, laboratory tests, and X-rays.
The combination of automatic deemed eligibility and the comprehensive EPSDT benefit package creates a powerful system designed to give newborns covered by Medicaid/CHIP a strong foundation. It removes initial administrative hurdles for families and ensures access to a broad range of preventive services and necessary treatments throughout the critical first year of life.
How Long Does Postpartum Coverage Last?
Understanding the duration of Medicaid coverage after pregnancy ends is crucial, as significant health needs can persist well beyond delivery.
The Standard 60-Day Rule
For many years, the standard federal requirement was for states to continue Medicaid coverage for individuals whose eligibility was based on pregnancy through the end of the month in which the 60th day after the end of the pregnancy occurred.
This 60-day postpartum period applied regardless of any changes in income during that time, providing a short window of continuous coverage immediately after birth.
The Postpartum “Coverage Cliff”
While helpful, this 60-day limit created what many experts called a “coverage cliff.” Research and data revealed that a substantial portion of pregnancy-related complications and deaths occur after this 60-day window closes.
One analysis indicated that one-third of such deaths happen between one week and one year postpartum. Individuals could lose their health coverage precisely when they still needed ongoing medical care, management of chronic conditions exacerbated by pregnancy, or treatment for postpartum depression or other complications.
This risk was particularly high in states that had not expanded Medicaid under the Affordable Care Act, as many postpartum individuals might not qualify for Medicaid under other eligibility categories (like low-income parent or adult) once their pregnancy-related eligibility ended.
The 12-Month Postpartum Coverage Extension Option
Recognizing the dangers of the coverage cliff and the ongoing maternal mortality crisis in the U.S., a major policy change was enacted. The American Rescue Plan Act of 2021 (ARP) gave states a new option to extend continuous Medicaid and CHIP eligibility for postpartum individuals from the standard 60 days to a full 12 months after the end of pregnancy.
This option, which took effect in April 2022, was later made permanent by the Consolidated Appropriations Act of 2023 (CAA).
Goals and Impact of the Extension
The primary goals of offering this 12-month continuous coverage period are to:
- Reduce preventable pregnancy-related deaths and severe maternal morbidity (illness)
- Improve continuity of care for chronic conditions like diabetes, hypertension, heart conditions, mental health disorders, and substance use disorders
- Enhance individuals’ engagement with the healthcare system during the critical first year after birth
- Help address stark racial and ethnic disparities in maternal health outcomes, as Black and American Indian/Alaska Native individuals experience significantly higher rates of mortality and morbidity
State Adoption of the 12-Month Option
This option has been met with widespread adoption by states across the country. As of early 2025, the vast majority of states and the District of Columbia have implemented or are planning to implement this 12-month postpartum coverage extension.
This rapid uptake signifies a major policy shift driven by the urgent need to improve maternal health outcomes and reflects a growing consensus that healthcare needs extend well beyond 60 days postpartum.
To check the current status of postpartum coverage duration in a specific state, resources like the KFF Medicaid Postpartum Coverage Extension Tracker are available.
Who is Eligible for Pregnancy Medicaid?
Eligibility for Medicaid during pregnancy depends on several factors, and while there are federal minimum requirements, the specifics can vary significantly from state to state. The main criteria generally considered are:
- Income: Based on the household’s Modified Adjusted Gross Income (MAGI)
- Residency: Must live in the state where applying
- Citizenship or Immigration Status: Must generally be a U.S. citizen or fall into specific categories of lawfully present immigrants
Income Requirements
Federal Minimum: Federal law requires states to cover pregnant individuals with household incomes up to at least 138% of the Federal Poverty Level (FPL) (this combines a 133% FPL standard with a standard 5% income disregard).
State Variations (Often Higher): Crucially, most states have chosen to set their income limits for pregnant individuals significantly higher than this federal minimum. Many states cover pregnant individuals with incomes exceeding 185% or even 200% FPL.
You can find state-specific income limits through resources provided by organizations like the Kaiser Family Foundation (KFF) or the Medicaid and CHIP Payment and Access Commission (MACPAC).
Other Pathways: Some states offer programs like CHIP Perinatal for those whose income is slightly above the Medicaid limit but still below a certain threshold. Additionally, some states have “medically needy” or “spend-down” programs that can help individuals qualify if their income is too high but they have substantial medical expenses that reduce their available income.
Residency
Applicants must be residents of the state in which they are applying for Medicaid coverage.
Citizenship and Immigration Status
General Rule: Typically, Medicaid eligibility is limited to U.S. citizens and certain “qualified non-citizens,” such as Lawful Permanent Residents (LPRs, or green card holders), refugees, and asylees.
The 5-Year Waiting Period: Many qualified non-citizens (including LPRs) are subject to a 5-year waiting period after obtaining their qualifying immigration status before they can become eligible for Medicaid or CHIP.
Important Exception for Pregnant Individuals and Children: Recognizing the importance of prenatal and child health, federal law (specifically the Children’s Health Insurance Program Reauthorization Act of 2009, or CHIPRA) gives states the option to waive this 5-year waiting period for lawfully residing pregnant individuals and children.
A large number of states (over 35, plus recent additions) have adopted this option, significantly expanding access for immigrant communities who are lawfully present but haven’t met the 5-year requirement.
FCEP/”Unborn Child” Option: Some states utilize the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option (previously called the “unborn child” option) to provide prenatal care and delivery coverage through CHIP, based on the fetus’s eligibility, sometimes regardless of the mother’s immigration status.
Emergency Medicaid: Even immigrants who do not meet the criteria for full Medicaid may be eligible for Emergency Medicaid to cover labor and delivery services. If the baby is born in the U.S., the baby is a citizen and typically qualifies for deemed newborn coverage for the first year.
Public Charge: It is important to know that applying for or receiving Medicaid or CHIP (or Marketplace savings) does not make an individual a “public charge” and does not negatively impact their immigration status or path to citizenship.
Overall, the eligibility rules for Medicaid during pregnancy are often more generous compared to those for other non-disabled adults. The higher income thresholds used by most states and the specific federal options allowing coverage for certain immigrant groups reflect a clear policy emphasis on ensuring access to crucial maternity care.
State Differences Matter: Finding Your State’s Rules
While this article provides a general overview based on federal guidelines and common practices, it is absolutely essential to understand that Medicaid and CHIP programs are administered by each individual state. This means there can be significant variations across state lines regarding:
- Income Eligibility Levels: The exact FPL percentage cutoff for pregnant individuals varies widely
- Specific Benefits Covered: While mandatory benefits are consistent, the scope of optional benefits (like dental, doula services, home visits) differs
- Postpartum Coverage Duration: Whether a state has adopted the 12-month extension or maintains the 60-day period (though most have extended)
- Rules for Immigrants: Whether the state has waived the 5-year waiting period for lawfully present pregnant individuals
- Program Names: States often have unique names for their Medicaid and CHIP programs
- Delivery Systems: Some states use managed care organizations (MCOs) to deliver services, while others use a fee-for-service model
This high degree of state-level variation creates a complex system for potential beneficiaries. National information provides a helpful starting point, but it cannot substitute for understanding the specific rules in your own state.
Finding Your State’s Medicaid Agency
The best source for accurate, up-to-date information about your state’s Medicaid and CHIP programs, including specific eligibility rules, covered benefits, and how to apply, is your official state Medicaid agency.
You can find contact information and website links for every state and territory Medicaid agency through the official U.S. government Medicaid website:
Visit the Beneficiary Resources page on Medicaid.gov:
- Scroll down to the section titled “STATE MEDICAID LINKS”
- Find your state in the list to get direct links to the agency website and often phone numbers for assistance
Example of State Variation: Texas CHIP Perinatal
To illustrate how states tailor programs, consider the CHIP Perinatal program in Texas. This program is specifically designed for the unborn children of pregnant women who cannot get regular Medicaid (often because their income is slightly too high or due to their immigration status) and who do not have other health insurance.
CHIP Perinatal provides coverage for prenatal care (visits, vitamins, some tests), labor and delivery, and two postpartum visits for the mother. After the baby is born, the baby transitions to either regular Medicaid or CHIP, depending on the family’s income, receiving comprehensive benefits including checkups and immunizations.
This Texas-specific program highlights why checking your state’s unique offerings is critical.
How to Apply for Pregnancy Medicaid
Applying for Medicaid or CHIP during pregnancy is designed to be accessible, with multiple ways to apply and features to ensure timely care.
When to Apply
You can apply for Medicaid or CHIP at any time of the year – there are no restricted enrollment periods like those for some private insurance. It is highly recommended to apply as soon as you know or suspect you are pregnant. Early application helps ensure you can access vital prenatal care from the beginning of your pregnancy.
Where to Apply
There are several ways to submit an application:
Through the Health Insurance Marketplace: Visit HealthCare.gov. When you fill out a Marketplace application, it will assess your eligibility for both Marketplace plans (with potential cost savings) and Medicaid/CHIP. If it looks like you or someone in your household might qualify for Medicaid or CHIP, the Marketplace will securely send your information to your state agency, which will then contact you to complete the enrollment process.
Directly Through Your State Medicaid Agency: You can apply directly with your state’s agency. Use the link provided earlier to find your state agency’s website and contact information. Applications can typically be submitted online, by phone, by mail, or in person at a local office.
At Clinics, Hospitals, or Health Centers: Some healthcare providers, hospitals, or community health centers may be able to help you apply or may even be designated as “qualified providers” who can grant Presumptive Eligibility on the spot.
Required Documentation
While specific requirements vary by state, you will generally need to provide documents to verify your eligibility. Be prepared to submit copies of:
- Proof of Pregnancy: Often a statement from a doctor or clinic
- Proof of Income: Recent pay stubs, tax returns, or letters from employers
- Proof of Citizenship or Immigration Status: Such as a birth certificate, passport, or immigration documents (e.g., Green Card)
- Proof of Residency: A utility bill, lease agreement, or driver’s license showing your state address
- Social Security Number(s): For applicants who have one or are eligible for one (proof of application may suffice)
Always check with your state Medicaid agency for their exact documentation requirements.
Presumptive Eligibility (PE)
Because timely prenatal care is so important, many states offer Presumptive Eligibility (PE) for pregnant individuals. PE allows certain healthcare providers (like clinics or hospitals) to grant temporary Medicaid coverage on the same day based on basic information like income, pregnancy status, and residency, before the full application is processed.
The purpose of PE is to eliminate delays and allow individuals to start receiving necessary prenatal care immediately while their formal application is pending. This temporary coverage typically lasts for a limited period (often up to 60 days) during which the individual must complete the full Medicaid application process for coverage to continue. PE is a state option, so it’s not available in every state.
Application Assistance
If you need help completing the application, assistance is available:
- Contact your state Medicaid agency directly via phone or visit a local office
- Utilize Navigators, Certified Application Counselors (CACs), or other enrollment assisters often found through the Health Insurance Marketplace (HealthCare.gov) or community organizations
- Ask for help at local health clinics, hospitals, or federally qualified health centers
Retroactive Coverage
In many cases, Medicaid can cover medical bills for eligible services received in the three months prior to the month you apply, provided you met the eligibility requirements during that time. You may need to specifically ask for this retroactive coverage when you apply.
Processing Time
Applications for pregnant individuals are often given priority. While processing times vary, a determination might be made within roughly 2 to 4 weeks. Presumptive Eligibility helps bridge any gap during this processing period.
The availability of multiple application pathways (Marketplace, state, provider), combined with safety net features like Presumptive Eligibility and retroactive coverage, demonstrates an effort to make the system accessible.
Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.