Immigrant Medicaid Policy in POEM for Equity States

Written By Annabelle Ng
3/21/2024

Immigrant Medicaid Policy in POEM for Equity States 

The postpartum period is a crucial time for new parents and their babies, but many pregnant immigrants are left out of recent Medicaid postpartum extensions. Under the recent American Rescue Plan Act, states can now opt to extend Medicaid coverage to cover a full 12 months after childbirth beyond the minimum 60 days, but pregnant immigrants are often ineligible due to variations in state eligibility rules. Here we illustrate the implications of existing state Medicaid eligibility rules towards pregnant immigrants on who will gain access to 12-month postpartum extensions and who will be left behind in New York, New Jersey, and Texas—three states with large immigrant populations and contrasting eligibility guidelines for Pregnancy Medicaid. We have studied these states extensively as part of our POEM for Equity project.

Examining the Cases of New York, New Jersey, and Texas

Under the American Rescue Plan Act, New York, New Jersey and Texas have all implemented 12-month Medicaid postpartum coverage extensions, with Texas being the most recent (March 1, 2024). Despite all three states adopting 12-month postpartum extensions, there is significant variation in eligibility, as well as covered services and benefits with regards to immigrant groups. Here we outline differences.  

New York

Prior to the pandemic, all pregnant NY residents who were lawfully present (i.e., even those below the five-year bar) with incomes up to 223% of the federal poverty level (FPL) were eligible for Pregnancy Medicaid for a 12-month period from the date of enrollment. Undocumented persons with incomes up to 223% FPL also received Pregnancy Medicaid through state-only funds, but their coverage expired 60 days after delivery. When the pandemic hit in March 2020 and Congress passed the Families First Coronavirus Response Act (FFCRA), all NY Medicaid enrollees became continuously enrolled until the end of the Public Health Emergency (PHE), which lapsed in March 2023. In 2022, the State Executive Budget formally extended Medicaid coverage to 12-month postpartum for all individuals regardless of immigration status. In June 2023, New York received approval from CMS to implement the extension.

New Jersey

Prior to the pandemic, all lawfully present pregnant NJ residents, including those under the five-year bar, with incomes up to 194% FPL were eligible for Pregnancy Medicaid, and those with incomes between 194% and 205% FPL were eligible for similar benefits under the CHIP Pregnant Woman option. After FFCRA passed and until the PHE lapsed, all lawfully present pregnant people covered by Pregnancy Medicaid were eligible for continuous coverage. Lawfully present, CHIP Pregnant Woman enrollees may have been eligible for continuous coverage as indicated by the state’s COVID-19 Section 1115(a) demonstration. In late 2021, NJ formally extended postpartum coverage for both Medicaid and CHIP enrollees when they implemented a 12-month extension via Section 1115 waiver.  

For undocumented immigrants, New Jersey uses state-only funds to provide outpatient prenatal coverage with an income limit of 205% FPL through the New Jersey Supplemental Prenatal and Contraceptive Program. However, these funds are limited and may run out. In addition, this program does not cover postpartum services, and individuals must apply for Emergency Medicaid to cover labor and delivery costs. Undocumented immigrants were not eligible for continuous coverage before, nor during FFCRA, and continue to be ineligible now post-FFCRA. 

Texas

Lawfully present pregnant Texas residents must meet the five-year bar and have incomes at or below 203% FPL to be eligible for Pregnancy Medicaid. During the PHE, Pregnancy Medicaid enrollees were continuously enrolled; otherwise, coverage ended 60 days postpartum. Since 2020, Texas has used state funds to provide a limited postpartum services package through the Healthy Women Texas Plus program, including pelvic exams, screening for post-partum depression, birth control and screening and treatment for diabetes, high blood pressure and cholesterol. This program enrolls eligible postpartum individuals once their Pregnancy Medicaid coverage ends up to 12 months following enrollment; and thus is available only to citizens and lawfully resident immigrants over the five-year bar. With the implementation of Texas’ 12-month postpartum Medicaid extension on March 1, 2024, Pregnancy Medicaid enrollees will now receive full-benefit postpartum coverage.  

For recent (i.e., under the five-year bar) and undocumented immigrants, Texas has implemented the unborn child option, called the CHIP Perinatal program, which has a slightly higher upper income limit of 207% FPL. The CHIP Perinatal program provides limited prenatal coverage and only two postpartum visits regardless of immigration status. For individuals with incomes at or below 203% FPL—the majority of enrollees—labor and delivery services are provided through Emergency Medicaid. 

Conclusion

Differences between New York, New Jersey, and Texas underscore how eligibility for 12-month postpartum coverage under Medicaid is impacted by historic policies affecting immigrant access to federally funded Medicaid programs.