Acknowledgements: The authors thank state officials from Mississippi, Kentucky, Wyoming, Washington, and Maryland who reviewed a draft of this publication. This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
Ensuring Sustainability and Reach of COVID-19 Vaccine Distribution
As part of a comprehensive effort to support state leaders as they navigate the COVID-19 response, the Duke-Margolis Center for Health Policy and the National Academy for State Health Policy (NASHP) convened a meeting in July 2021 with a geographically diverse set of state officials and national experts to share best practices and innovative approaches to increase COVID-19 vaccinations.
Though the landscape continues to evolve rapidly, the participants discussed several themes that remain relevant given the current state of the pandemic. Participating state officials discussed strategies to reach unvaccinated individuals and policy and operational shifts to living with COVID-19 as a constant rather than a crisis.
This issue brief includes a summary of the meeting discussion as well as additional details on specific state approaches, including:
- Identifying reasons for hesitancy and identifying effective, culturally responsive messaging to reach all populations
- Enhancing targeted partnership and outreach and including trusted messengers
- Reducing barriers to vaccine access in primary care settings
- Engaging communities and providing easy access
- Using financial strategies to incentivize vaccine uptake
- Navigating political and legal issues
- Improving the use of data to increase equitable access to vaccines
Partnering with Tribal Nations for COVID-19 Vaccinations: A Case Study of Alaska
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Alaska’s vaccination outreach to Alaska Natives exemplifies a co-leadership model that prioritizes health equity and acknowledges historical trauma associated with previous public health emergencies. State and tribal leaders co-led the COVID-19 vaccination effort, including allocation, distribution, funding, and communication.
- As a result of the state and tribal partnership, Alaska Native communities have received vaccinations at rates equal to, and in many cases, above that of the average for all Alaskans.
- This brief is part of a series of work between NASHP, NGA, and the Duke-Margolis Center on health equity during COVID-19.
- Related: A Case Study of the Virginia COVID-19 Equity Leadership Task Force and Health Equity Working Group
State Strategies to Increase COVID-19 and Routine Immunizations in Advance of Back-to-School
Amidst changes in the COVID-19 landscape, including navigating surges due to new variants, states are working with local partners to prepare for and implement back-to-school plans, while also anticipating the need to adapt as the school year progresses.
As of August 2021, children ages 12+ are eligible to get vaccinated against COVID-19. Children under 12 are not yet eligible, but authorities anticipate approval by the US Food and Drug Administration (FDA) for a COVID-19 vaccine for children under 12 (5-11 years old expected first) in early to mid-winter. The FDA granted full approval for Pfizer-BioNTech’s COVID-19 vaccine for 16+, and Moderna and Johnson & Johnson are working on finalizing their applications for full approval. This full approval will likely lead to additional actions by states, local governments, employers, universities and others to provide education and encouragement to get vaccinated.
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These factors along with an evolving set of vaccine mandates and mandate bans complicates public health mitigation plans, not only for vaccinating but for the full complement of tools that reduce spread, including health education, masking requirements, testing, and contact tracing. Additionally, intention to vaccinate and access to vaccines vary widely across the unvaccinated, with vaccination status of eligible children closely mirroring that of their parents.
Health and education officials simultaneously are planning for flu vaccinations and prioritizing catch up for routine childhood immunizations, required in many states for school, which lagged significantly during the pandemic as families followed social isolation and socially distanced recommendations.
NASHP convened a group of state officials from across the country to exchange strategies and creative approaches to navigating this environment in various demographic, political and policy environments. This brief summarizes key themes around accelerating routine vaccination rates and increasing access to the COVID-19 vaccine among eligible youth, including making vaccines convenient, using data to target resources and effectively engage partners, partnering to increase access and address intent, and prioritizing equity.
Making Vaccines Convenient for Families
Making vaccines available at locations that align with individuals’ daily routines enables those who may have limited time or resources due to childcare responsibilities, transportation, and other barriers to become vaccinated against COVID-19. Such convenience is critical to promoting widespread access generally and is an important tool in advancing equitable access for school-age children who rely on caregivers.
Convenience can be achieved by making vaccines available in community settings. To target adolescents and their families, some states are offering vaccine clinics at schools, ensuring that families can have ready access in a community hub and trusted location. Several states are pursuing strategies to ensure people “stumble into” opportunities to vaccinate, through pop up clinics in highly populated places (such as transit centers), on school grounds, or other at popular community events to allow for families to get vaccinated together, like at state fairs (such as Wyoming’s Frontier Days), or sporting events. This type of broad access in community enjoys the benefit of enhanced vaccine confidence when delivered in collaboration with trusted sources.
Another key method for reaching unvaccinated populations is to engage community providers and ensure they are willing and able to administer COVID-19 vaccines, which is particularly important for those living in underserved or rural areas. Most Americans trust doctors, nurses, and pharmacists, especially their own, and states are leveraging this trust and engaging these providers in both COVID-19 and routine vaccination efforts. Early in the pandemic, Kentucky state officials partnered with the Kentucky Board of Pharmacy to encourage pharmacist participation in delivering COVID-19 and routine vaccines. The Department of Public Health, the Kentucky Immunization Registry Coordinator, and the Emergency Preparedness Pharmacist from the Kentucky Pharmacists Association enrolled community and independent pharmacies to participate in the state’s vaccination program to reach underserved populations. Pharmacies are now one third of enrolled COVID-19 vaccine providers in the state, with 482 participating locations.
Prior to the delta surge, states had closed most mass vaccine sites in favor of local clinics, individual demand for vaccines had plateaued, and officials began managing excess doses about to expire. However, many community providers remained reluctant to provide COVID-19 vaccines for several reasons, including being unable to use large quantities of vaccines. To address these challenges, a number of state health officials established distribution programs – breaking down large palettes of vaccine sent by the federal government into small quantities to be distributed to providers. This approach is key to reaching underserved populations through trusted health care providers. For example, the Virginia Department of Health (VDH) federally funded Small Shipment Redistribution Program allows medical providers to order doses using VDH’s vaccine management platform, and a network of distribution centers across the state are used to store and distribute doses to clinics. Mississippi set up a Pfizer vaccine distribution site at County Health Departments using CDC supplemental funds and deployed pharmacists to distribute smaller doses (minimum of 6) to local providers, clinics, pharmacies, and homeless shelters, allowing for broader access to individuals. Kentucky doubled the size of their COVID-19 Vaccine and VFC (Vaccines For Children) program field representative workforce to redistribute doses around the state directly to providers.
Encouraging Vaccines Holistically
States are also taking advantage of the CDC guidance allowing COVID-19 and routine vaccines to be co-administered and are co-locating vaccination clinics. Many states are focusing messaging campaigns to educate individuals and families about the importance of getting all appropriate vaccines, including the COVID-19 vaccine, flu vaccine, and other routine childhood vaccines.
Mississippi uses an opt-out model to encourage higher compliance for recommended routine vaccinations. For example, to exempt their children from receiving the HPV vaccine, parents are provided education and must sign a document acknowledging the health risks of not receiving the immunization. This model helped increase county HPV immunization rates from 45% to 71% between 2018 and 2019, and officials are considering extending this model to other routine vaccinations.
Data to Identify Need and Share with Partners
States identify having comprehensive data as a critical step in their ability to target strategies to increase routine vaccinations and COVID-19 vaccinations. All states use immunization information systems (IIS) to collect and communicate immunization data, but access to and use of the data varies. For example, some state’s IIS are connected to hospital electronic health records (EHR), and other states share data between IIS and Medicaid data systems. Some data sharing occurs regularly and automatically, and some require manual matching, which is a common challenge as this is more time-consuming for staff who may already be working at maximum capacity. It can be useful to increase data sharing and analytic capacity for states to allow connected EHRs and Medicaid data systems, as Medicaid serves as a healthcare provider for so many children.
States cited IIS data sharing as critical to identifying students who have not yet been vaccinated. The EHR and Medicaid connection is a key component to this strategy; having as much data as possible can help inform vaccination rates by enabling better targeting. Some states allow schools and school nurses the ability to pull data from the IIS so they can identify which students need their vaccines and target communication strategies based on this information.
Partnerships to Increase Access and Address Intent
Engaging trusted community leaders as messengers is essential to increasing vaccine intent. States are enlisting various community partners to help them engage more individuals in vaccination efforts. Vaccine intent varies across different demographic groups, and states can partner with school staff, healthcare professionals, and community and faith leaders to tailor vaccination engagement approaches.
Schools are important partners when it comes to hosting vaccine clinics and educating families about the importance of getting vaccinated. Mississippi and Kentucky designed school-based programs that bring vaccines to students who are eligible for the COVID-19 vaccine. Mississippi’s Adopt-a-School model incentivizes medical providers to coordinate on-site vaccination clinics at schools by paying participating providers $75 per shot. The Adopt-a-School program is part of Mississippi’s Covid-19 Community Vaccination Program, which is funded through a Center for Disease Control and Prevention (CDC) immunizations grant. The Kentucky Department for Public Health is contracting with a private vendor to host mobile vaccine clinics at schools. The state reimburses this vendor $80 per shot using FEMA (Federal Emergency Management Agency) funding. Other states are exploring partnerships between FQHCs and schools as well as public health and school nurses to organize school-based vaccine clinics.
Several other states are partnering with schools to circulate vaccine messaging and encourage students to get vaccinated. One state is collaborating with the American Academy of Pediatrics (AAP) chapters, school nurse organizations, and health and education departments to distribute information to students and families about vaccines. Other state officials from Kentucky and Maryland emphasized the important role of athletic departments in incentivizing vaccinations, as some schools do not allow unvaccinated students to participate in sports and ensuring the ability to take part in school athletic events is highly motivating.
State public health agencies can also engage more individuals by integrating vaccine efforts into the healthcare system. State health departments partner with primary care providers (PCPs), pharmacists, Medicaid agencies, and managed care organizations (MCOs) to educate individuals about COVID-19 vaccines and incentivize vaccinations. For example, one state’s Medicaid agency sent a fax blast to Medicaid-participating pharmacies to help encourage vaccinations. Another state official cited their state’s partnership with MCOs, where the MCOs helped organize community vaccination events and partnered with providers to increase vaccine availability. Other MCOs are offering financial incentives to their patients who get the COVID-19 vaccine. Trusted medical providers have a unique role in counseling and educating individuals about the safety of vaccines. Several states are leveraging this trust in doctors and creating initiatives that encourage providers to administer both COVID-19 and routine immunizations at doctor’s visits. For example, Wyoming is organizing a series of webinars for providers, giving them the opportunity to ask questions and work through challenges together.
Consistent Outreach and Messaging is Critical
States highlighted the value of a governor’s role in messaging through use of the bully pulpit including publicly vaccinating their eligible children. Still, most noted that effective outreach to those who remain unvaccinated requires tailored messaging to specific audiences and thoughtful assessment of population-specific barriers to vaccine information and uptake. Wyoming, for example, launched a multi-pronged messaging campaign to address vaccination holistically (including COVID, influenza and routine vaccinations). The campaign is tailored to the needs of various populations such as American Indians and residents in the most rural parts of the state. Intentional use of “choice” language through their provider and consumers educational campaigns has been key. Notably, early in the pandemic, some individuals were getting information about vaccine (and testing) opportunities across state lines which challenged state-specific messages around resources. The state responded through multiple messaging media to bring the right information to state residents.
Maryland is focusing outreach efforts to pockets of the state with a high rate of unvaccinated individuals. They are rolling out a voluntary screening/testing program at schools (reaching approximately 80% to date) with the hope of integrating mobile vaccination clinic opportunities into the program. The state is also aiming to reach areas with high need by leveraging multiple messaging strategies, such as door-to-door canvassing, pop up activities, digital communications, and partnerships with local employers and court systems.
Using an Equity-driven Approach
Given the disparate impact of the pandemic on communities of color, specifically Black, LatinX, and Indigenous groups, states are working to make sure their vaccine distribution strategy is equitable to these populations. Research shows that even though children may not have been impacted by the pandemic at the same rates as adults, the socio-emotional and developmental implications are staggering. And, children are experiencing similarly disproportionate levels of vaccine distribution, highlighting the importance of using an equity-driven approach to close the gaps in vaccine distribution in advance of and during the school year, and to mitigate the effects of the COVID-19 virus, especially with the emergence of the highly contagious Delta variant.
State officials cited their focus on areas with high numbers of unvaccinated people, as well as those vulnerable to infection. States use various data, such as the CDC’s Social Vulnerability Index (SVI), to identify these pockets of need and bring vaccinations to these areas, using a combination of mobile vaccination teams and local providers. Ensuring providers have appropriate educational materials and support to build vaccine confidence with their patients is critical.
State officials acknowledged efforts to engage community-based organizations and faith leaders to support vaccine intent. Kentucky created a COVID-19 vaccine communication toolkit for local trusted leaders to use when engaging with community members. There has also been an increased push from the federal level to address equity in COVID-19 response, including vaccination efforts. For example, the White House has increased public messaging and created the COVID-19 Health Equity Task Force and there has been an increase in equity-related funding from the CDC and HRSA to aid states as they work to use an equity lens on targeted approaches to vaccinate individuals.
Considerations for the Evolving Landscape
Several key themes were discussed without clear policy solutions and represent areas of continued opportunity as the school year begins and the vaccine landscape will continue to evolve:
- Navigating the issue of parental consent: Maintaining policies around consent for vaccination emerged as a major challenge in some states. A small subset of states allows minors 14 and older to consent for their own medical care through policies developed in partnership with provider organizations, such as the American Academy of Pediatrics. Political and policy disagreements with respect to exercising this option around the COVID-19 vaccine has resulted in clearer guidance from some states that parental consent is needed for COVID-19 vaccination separate from routine use of the minor consent option for other services.
- Incentivizing provider participation: Provider reimbursement approaches continue to evolve to incentivize vaccination and engage various provider types and locations. State officials noted further that provider reimbursement approaches should reflect the extended counseling sessions often occurring with unvaccinated people uncertain about their intention.
- Planning for the next milestones in vaccine approval: Several anticipated milestones will renew discussions around vaccine intent, access, and planning, including emergency use authorizations (EUA) for use of vaccines in children under 12 as well as full approval of those vaccines under EUA for adults and older children.
- Integrating pharmacists into vaccination efforts: Many states were eager to identify ways to include pharmacists in the Vaccines for Children (VFC) program specifically (and new adult immunization programs) to broaden the network and reach of vaccine providers, particularly in rural, frontier and otherwise underserved areas.
As students head back to school and state officials and providers continue to promote the importance of routine immunizations and the COVID-19 vaccine for eligible children, NASHP is continuing to follow this topic. For more resources on state policies to support students and families as they transition back to school, click here, and for more information on routine childhood and COVID-19 immunization services and policies, click here.
Advancing Access to Oral Health Care Amidst COVID-19 Recovery
Oral health is central to overall health, yet 34 percent of Americans lack access to affordable dental care, a challenge exacerbated by the COVID-19 pandemic. The pandemic disrupted oral health care in several ways. Early on, dental providers faced office closures and lacked personal protective equipment (PPE). Similarly, school-based dental sealant programs were inaccessible with school closures, limiting preventive care for school-age children from low-income families. These barriers led to an overall decrease in preventative and routine dental procedures. Dental care remains children’s greatest unmet health need during the pandemic, disproportionately affecting households with pandemic-related income and job loss. As a result of COVID-19, a shortage of dental assistants, hygienists and other team members is hindering the dental sector’s ability to recover and resume care.
In June 2021, the National Academy for State Health Policy (NASHP) convened a group of Medicaid and public health state leaders to discuss strategies and considerations for increasing access to oral health services amidst recovery from the COVID-19 pandemic. Participants identified teledentistry, school-linked programs and new federal funding available under the American Rescue Plan Act as key opportunities to increase access to oral health care.
Teledentistry
Participating state officials expressed their interest in increasing access to oral health care by sustaining or building on new teledentistry flexibilities introduced during the pandemic. According to the ADA, teledentistry, like other telehealth services, involves “the use of telehealth systems and methodologies” in dentistry, such as live video interaction, asynchronous or “store and forward” communication, and remote patient monitoring. Adoption of these methods and reimbursement for teledentistry approaches varies by state. Teledentistry can greatly increase access to oral health care, particularly for underserved populations such as communities of color and those living in rural areas.
During the pandemic, 17 states updated their Medicaid teledentistry guidance to allow new provider types to deliver virtual services, expand the scope of services that can be reimbursed through Medicaid, and ease consent restrictions that limited access to teledentistry, among other policy modifications. Considering telehealth policy revisions made during the COVID-19 pandemic, twenty-three states currently have policies in place to allow for delivery and reimbursement of teledentistry, however, challenges remain. For example, state leaders shared concerns about reimbursement for teledental services and limited guidance for providers about scheduling teledentistry visits in tandem with in-person visits. Some states, such as Pennsylvania and Rhode Island, seek to maintain or enhance teledentristry policies enacted during the pandemic to increase access to care for low-income children and adults.
In March 2020, Pennsylvania established guidance defining teledentistry as “two-way, real-time interactive communication” between a patient and dental provider. Accordingly, the Pennsylvania Medicaid program dental fee schedule was updated with billing codes D9995 (“teledentistry – synchronous”) and D0140 (“limited oral evaluation – problem focused”). (The D9995 code is not reimbursable, rather it is used to document teledental visits and must be used in conjunction with D0140 to provide services to patients experiencing dental emergencies). This policy lasted for the duration of the state of emergency in Pennsylvania, ending June 10, 2021. Now, officials seek to make permanent these Medicaid policies for preventive teledentistry through developing guidance on:
- virtual supervision of fluoride varnish application,
- tobacco cessation counseling,
- oral hygiene instructions and nutritional counseling,
- limited problem-focused evaluations,
- integration of different settings of care delivery, and
- care coordination for follow up to in-person visits as needed.
Rhode Island is in the process of establishing Medicaid guidance for teledentistry to expand dental services, particularly for children. At the beginning of the COVID-19 pandemic, the Rhode Island Department of Health released guidance allowing providers to bill telehealth services to Medicaid. This allowed dental providers to bill for a care coordination phone call (D9992) and schedule emergency video consultations with patients (D9310). This guidance expired on July 6, 2021, but the Rhode Island legislature recently passed an update to the Telemedicine Coverage Act, which expands telemedicine coverage requirements for Medicaid and private insurers, requires reimbursement rates for telemedicine services to match in-person rates, and ensures that dentists providing teledentistry services be held to the same standards of care that would apply in an in-person setting. Work to communicate reimbursable services to dental providers is in progress.
As states identify approaches to expand the use of teledentistry, many are creating pathways for patients and their caregivers to administer certain preventive procedures under virtual supervision from dental practitioners. As part of a pilot project, Nevada allows parents to apply fluoride varnish for their children under virtual supervision from a licensed dental provider. The Nevada Board of Dental Examiners approved virtual provision of fluoride varnish for individuals under the age of 21 in October 2020. A forthcoming fact sheet will provide more information on Nevada’s fluoride varnish program.
School-linked and School-based Programs
States also are considering how to leverage schools to fill dental care gaps among children. School-based dental sealant programs (SBSPs) provide critical primary and preventive dental care and disproportionately serve low-income students and those living in rural areas. However, according to a 2015 survey, 39 states and the District of Columbia do not have sealant programs in most of their high need schools, and only 5 states have sealant programs in at least 75 percent of high need schools. The Centers for Disease Control and Prevention (CDC) published considerations for SBSPs during the COVID-19 pandemic that includes information on restarting SBSPs. Still, state leaders cited concerns that reestablishing school-based programs will be challenging due to safety concerns, changing guidance, and workforce shortages, and they are searching for other strategies to increase access to dental care for students from low-income households.
To encourage children to visit dental providers in advance of the 2021-2022 school year, Smile, California, the California Medi-Cal Dental Program’s campaign, is partnering with the Office of Oral Health and Local Oral Health Programs to carry out a Back Tooth School Activation. Campaign partners can access Back Tooth School resources on the Oral Health and School Readiness website. Additionally, although the pandemic has limited students’ ability to receive oral care at school, California is pursuing strategies to screen children at school and refer them to dental providers using an electronic referral system. California’s Dental Transformation Initiative created a pilot program to improve dental health for Medicaid-eligible children. More LA Smiles, run through UCLA, is the largest of these pilot projects and created the LA Dental Registry and Referral System (LADRRS) to connect medical providers in clinical settings with dental providers. To implement a school-linked program, a platform like LADRRS can be modified to include referrals from schools. This system will enable state leaders to target low-income schools and gather data on students’ health.
During the roundtable, state leaders shared concerns about the increased challenges school nurses face as a result of the COVID-19 pandemic. The Colorado Department of Public Health and Environment (CDPHE) collaborated with its Department of Education to train over two-thirds of the state’s school nurses to distribute and respond to home screening tools to identify students with urgent oral health needs. Schools give parents or caregivers the option to fill out an oral health screening form, translated into several languages so that school nurses can address care needs or refer students to dental providers.
Federal Funding Opportunities
States can leverage new and existing federal funding opportunities in the wake of COVID-19 to improve oral health access. The American Rescue Plan Act (ARPA) provides significant funding to states and localities to assist in COVID-19 recovery. The Act includes $8.5 billion for a provider relief fund targeted for rural Medicare and Medicaid providers. There are also $500 million in emergency grants for rural health to cover costs associated with increased telehealth capabilities and lost revenue from COVID-19.
ARPA also includes funding for health centers through the Health Resources and Services Administration Health Center Program that serve an important role in the dental safety net. The law allocates $7.6 billion to the Department of Health and Human Services for health centers and includes allowable funding uses with implications for oral health.
For example, four health centers in Rhode Island will use a portion of these funds to pay for community health workers’ engagement in oral health and case management.
Conclusion
Moving forward, states can involve oral health policymakers in planning discussions for allocating newly available federal dollars. As states engage in health transformation efforts, oral health stakeholders can assist states in considering how to integrate dental and medical care to address overall health by leveraging technology, schools and federal resources.
Acknowledgement: The authors thank state officials from California, Rhode Island, Colorado, Pennsylvania, Minnesota, and North Carolina who reviewed a draft of this publication. Additionally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number U2MOA394670100, National Organizations of State and Local Officials. This information, content, or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
State Approaches to Extending Medicaid Coverage Beyond 60 Days Postpartum
States have an increasing interest in extending Medicaid coverage from 60 days to 12 months postpartum, driven by states’ priorities for ensuring continuity of coverage and addressing the maternal mortality crisis. To extend this coverage, states can request approval from the Centers for Medicare and Medicaid Services (CMS) under Medicaid Section 1115 demonstrations. Through a new provision included in the American Rescue Plan Act (ARPA), states can now also extend postpartum coverage through a Medicaid state plan option (SPA). Under the SPA option, states must provide full benefits during and throughout the 12-month postpartum period. If a state covers pregnant people through the Children’s Health Insurance Program (CHIP), it must also elect to extend coverage through CHIP. This state plan option is only available for a five-year period starting April 1, 2022.
As described in more detail below, two states – Illinois and Missouri – recently received approval from the Biden Administration for the extension of Medicaid postpartum coverage. Washington State has enacted legislation to extend Medicaid postpartum coverage and will submit a SPA to CMS for this authority. There are another 33 states that have introduced legislation or enacted legislation to seek federal authority to extend Medicaid coverage to 12 months postpartum. Some states are seeking a full coverage extension for all eligible pregnant people, while other states are defining specific eligibility groups, benefit coverage, and length of the extension (i.e., six-months postpartum).
The maternal mortality crisis continues to be a significant challenge across states. More than half of pregnancy-related deaths occur during the postpartum period, or the period following birth, and 12 percent occur after six-weeks postpartum. Black women are three to four times more likely to die from a preventable pregnancy-related complication compared to non-Hispanic white women; women of color also experience higher rates of uninsurance compared to white non-Hispanic women. Lapses in or loss of coverage may exacerbate existing chronic conditions, such as depression and hypertension, which can contribute to poor maternal health outcomes. Churn, or moving between insurance plans or becoming uninsured, can also pose a serious risk to pregnant people by disrupting care and potentially exacerbating existing health conditions. Higher rates of churn and uninsurance among pregnant women are found in states that have not expanded Medicaid under the ACA.
Extending Medicaid postpartum coverage is a key strategy to address maternal mortality and loss of coverage. Currently, Medicaid coverage for pregnant people lasts until 60 days postpartum and individuals are typically disenrolled on the last day of the month. After this period, postpartum people may:
- requalify for Medicaid if they live in a state that has expanded Medicaid and they meet expansion eligibility criteria, including the income requirements,
- requalify for Medicaid if they are a parent with a dependent child and meet eligibility criteria, including the income and age requirements,
- seek private coverage through the individual marketplace, which generally includes premiums and higher out-of-pocket spending compared to Medicaid, or
- become uninsured.
The following describes three states’ efforts to extend postpartum coverage through a Medicaid section 1115 waiver or through a state plan option, as allowed under ARPA.
In May of 2021, CMS approved Illinois’ request to expand full Medicaid coverage from 60 days to 12 months postpartum under a Medicaid Section 1115 demonstration. The goal of this extension of coverage is to reduce health disparities and strengthen continuity of coverage by allowing mothers to stay with their existing providers, prevent gaps in insurance coverage, and provide access to needed care, including behavioral health services and services to manage chronic conditions, such as diabetes and hypertension, during the full postpartum period.
In 2018, Missouri enacted a law allowing the state to seek federal authority to extend Missouri HealthNet (Medicaid) benefits for postpartum women who are diagnosed with a substance use disorder (SUD) within 60 days of giving birth. The state submitted an 1115 Demonstration waiver, which was approved by CMS in March 2021. Women who meet the criteria of the Missouri Targeted Benefits for Pregnant Women Demonstration program will be eligible for SUD treatment, as well as treatment for mental health conditions related to SUD for up to twelve months following delivery. The intent is to improve access to quality treatment for SUD, and mental health conditions related to SUD, for women who recently gave birth. Anticipated results include increased adherence to and retention of SUD treatment plans; reduction in SUD-related hospitalizations and emergency room visits; strengthened safeguards for the health of women and children during the postpartum period and first year of the newborn’s life; and improvement in health outcomes for women and children.
In May 2021, Washington State enacted a law to extend Medicaid postpartum/post-pregnancy coverage to 12 months, with an implementation date of June 2022. The state plans to submit a SPA to CMS, as allowed under ARPA. Under the law, the state will also provide coverage for undocumented individuals who do not qualify for Medicaid coverage but whom are in the window of up to 12 months postpartum. The law will also provide coverage to individuals who had any end of pregnancy outcome.
Promoting continuity of coverage is a critical strategy for addressing the maternal mortality crisis. NASHP expects states to continue pursuing postpartum coverage extensions, particularly through the state plan option under ARPA. For more information on state actions to extend postpartum coverage, visit NASHP’s Extending Postpartum Coverage Tracker, which is updated monthly.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
