Rica Trigs:

The American Heart Association appreciates the opportunity to submit comments on the Oklahoma Health Care Authority’s (OHCA) proposed emergency rules to increase Income Standard for Pregnant Women and Extend Postpartum Coverage.

The American Heart Association (AHA) believes everyone, including Medicaid enrollees, should have access to quality and affordable health coverage. As the nation’s oldest and largest organization dedicated to fighting heart disease and stroke, the AHA represents over 100 million patients with cardiovascular disease (CVD) including many who rely on Medicaid as their primary source of care. Nationally, about 1 in 10 adults with Medicaid coverage are estimated to have some form of CVD, with 6 in 10 having multiple chronic conditions.

The AHA is committed to ensuring that Oklahoma’s Medicaid program provides quality and affordable healthcare coverage and would like to offer the following comments.

Extended Postpartum Coverage and Increasing Eligibility The American Heart Association supports Oklahoma’s proposed revisions to expand postpartum coverage from sixty days to twelve months and expand Medicaid eligibility for full-scope pregnancy benefits by increasing the income standard from 133% of the Federal Poverty Level (FPL) to 210% FPL, without an increased cost burden. Oklahoma’s proposal will help to prevent gaps in healthcare coverage for low-income women during the postpartum period, helping patients to better manage serious and chronic health conditions. The need to increase coverage during this period is clear. Improving postpartum coverage is an important component of reducing maternal mortality in Oklahoma. According to research from the Centers for Disease Control and Prevention (CDC), an estimated three out of five pregnancy-related deaths are preventable.  Access to a regular source of healthcare is important for conditions to be caught early and negative health outcomes to be avoided if possible. Access to care during the postpartum period is especially important for women with serious and chronic conditions that can impact maternal health outcomes, as well as for women who develop such conditions during their pregnancies. 

Extending postpartum coverage and increasing income eligibility requirements is also important to reducing health disparities. State policy changes to streamline eligibility and enrollment for this population will add stability and comprehensive coverage during a time of great need, with negative maternal outcomes disproportionately affecting women of color.  Nationally, Medicaid covers 43% of births in the United States, including 60% of births to Hispanic women, 65% of births to African American women, and 67% of births to American Indian or Alaskan Native women.  Extending postpartum coverage and increasing income eligibility is therefore a critical opportunity to improve access to care and reduce pregnancy-related deaths in communities of color.

Thank you for the opportunity to provide comments.

Emma Morris:

Oklahoma Policy Institute – a nonpartisan, nonprofit think tank focused on equitable and fiscally responsible state policy – appreciates the opportunity to comment on this proposed rule change. We strongly support the proposed changes to increase the income eligibility level for pregnant women from 138% FPL to 210% FPL and to expand the postpartum coverage period from two to twelve months. These changes will improve health outcomes for new mothers and infants, something that is particularly needed in a state with a history of poor health outcomes.

We have a few questions about the proposal:

1. Will members who are in the pregnancy category throughout pregnancy and the 12 month postpartum period be required to cooperate with the child support services requirement? We would suggest that these members not be asked to comply with this requirement until after the 12 month postpartum period ends. The cooperation requirement can discourage people from seeking coverage, which would adversely impact maternal health.

2. Will there be any “look back period” to re-enroll members who give birth before the postpartum period extension goes into effect? For example, if someone gave birth in October 2022, is there any plan to re-enroll them into postpartum coverage from the implementation of the 12-month extension until October 2023? The agency’s commitment to reprocessing nearly 100,000 members and automatically enrolling them into Medicaid expansion suggests that the agency has the ability to reprocess the applications of members who recently gave birth. This would help connect Oklahomans who are likely uninsured to vital and potentially life-saving coverage during the vulnerable postpartum period.

3. Part 16 states that pregnant and postpartum members will continue to be allowed 32 units of services from a maternal and infant licensed clinical social worker. With the current 60 days of postpartum coverage, enrollees are allowed 32 units of service. With the extension to 12 months postpartum coverage, should more units of service be allowed for the extra 10 months of coverage? Does OHCA believe that this will be enough units even throughout the extra ten months of coverage? Will members be able to access more units if it is deemed medically necessary?

4. The American Rescue Plan Act affords states the option to expand postpartum coverage from two to twelve months using a State Plan Amendment through 2027. Does OHCA plan to ensure this coverage extension continues when the American Rescue Plan Act’s SPA option ends, as part of the agency’s goal of better health outcomes?

Thank you for the opportunity to provide comments. 

OHCA Response:

Thank you for your comment. The OHCA takes every comment under advisement and review. 

Per 42 C.F.R. Section 433.145, pregnant women are exempt from cooperating with child support. Additionally, there will be no look-back period. However, if the member loses eligibility at the end of the 60-day post-partum period and, once the State implements this change, they could be eligible for the additional postpartum period, the member can reapply within 3 months of their eligibility ending. If within those 3 months they received SoonerCare-covered services and met SoonerCare eligibility requirements, they would then be retro-actively eligible for post-partum coverage, and it would continue until the end of their 12 months post-partum period. 

Furthermore, extending the postpartum period to 12 months is not a new category of benefit rather it is an extension of coverage that provides continuous eligibility. The benefits postpartum members receive will be according to the plan they are eligible for – this could be either the Health Adult Program or full-scope pregnancy-related Title XIX benefits.

Finally, this new coverage option afforded through the American Rescue Plan Act was made permanent with the passing of the 2023 Consolidated Appropriations Act.

Steven Goldman:

The CMS guidance on the Post-Partum 12-month Medicaid Extension notes:

".. under the extended postpartum coverage option, individuals are entitled to the extended postpartum coverage **regardless of the reason the pregnancy ends**."

(emphasis added; CMS SHO 21-007, Dec. 7, 2021, page 3)

Similar wording does not seem to be in OHCA rules, but likely should be added. There may be concern that only a "live birth" would qualify a woman for the 12-month extension in Oklahoma.

Would OHCA please clarify whether there are any restrictions based on how, when or why a pregnancy ends which would affect eligibility for the 12-month extension?

[This comment comes as a private citizen, not connected to any other group or employer]

OHCA Response:

Thank you for your comment. The OHCA takes every comment under advisement and review. The OHCA rules have been amended to add "regardless of the reason" at 317:30-3-57(31) behind "after the pregnancy ends" to address the concern.