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.

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. 

Yvonne Myers:

On behalf of the Citizen Potawatomi Nation and as a consultant who promotes access to care, I want to go on record as stating the importance of reinstating the income eligibility back to 185% FPL (210% MAGI) back to the level is was in Oklahoma prior to implementation of the ACA Marketplace.

Based on communications with OHCA staff, it is my understanding that you plan to do a "look back" for those individuals whose pregnancy ended in 2022 and reinstate the balance of the 12 months post partum benefit for 2023.   This is very important.

It is also important that these members stay under the Pregnancy benefit category and are not subject to cooperation with child support requirements.   Under the pregnancy benefit, cooperation with child support is not required.

As I believe it is the intent, I do want to stress the importance of the 12 months apply to the end of pregnancy regardless of whether the pregnancy ends as a result of a live birth, stillbirth, miscarriage, etc.     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)   This intent should be the same for Oklahoma.

Again, increasing the income eligibility for make the full scope of services available for pregnant women available is extremely positive.

I respectfully submit my comments and requests for your approval.

OHCA Response:

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

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 that 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.

Per 42 CFR 433.145 pregnant women are exempt from cooperating with child support.

The 12-months post-partum coverage is granted, regardless of how the pregnancy ends. The rules are amended to add “regardless of the reason” at 30-3-57(31) behind “after the pregnancy ends”.