Robust Implementation of Medicaid Postpartum Extensions Key to Maintaining Maternal Health Momentum 

In 2024, there were 18.7 maternal deaths per 100,000 live births, with Black and Native women at significantly higher risk of maternal mortality. Medicaid is at the forefront of addressing the US maternal health crisis given that it covers 4 in 10 births nationwide, nearly two-thirds of births to Black women, and more than one-quarter of births to Native women.  

State Medicaid programs are working to drive innovation in maternity care with approaches such as covering doula and midwifery services and incorporating requirements to improve maternal health outcomes in their managed care organization contracts. Extending Medicaid through the postpartum period is another important way that states are now supporting mothers’ access to needed health care. Because most pregnancy-related deaths occur in the critical year following pregnancy, and are preventable, postpartum extensions have the potential to reduce maternal mortality. Yet, successful ongoing implementation of the coverage extensions will require extra attention given recent federal funding cuts and eligibility changes to Medicaid.   

Bipartisan Federal Laws Opened the Door  

Two recent bipartisan laws — the American Rescue Plan Act of 2021 and Consolidated Appropriations Act, 2023 — allowed states to permanently extend postpartum Medicaid coverage for 12 months after the end of pregnancy. Before this change many women with Medicaid-covered births became uninsured when pregnancy-related coverage expired 60 days after the end of pregnancy, with many facing unmet needs and worries about medical bills. All states except for Arkansas and Wisconsin have since extended pregnancy-related Medicaid coverage for a full year postpartum. 

An analysis of Medicaid claims data from 2018, prior to widespread adoption of extensions, found that more than three-quarters of new mothers who had full-year Medicaid coverage in the postpartum year had at least one outpatient visit between 61 days and 12 months postpartum, with higher utilization among those with diagnosed physical or behavioral health conditions or pregnancy/delivery complications. This suggests that extended postpartum Medicaid could help more women meet health care needs that arise after the 60-day period of traditional pregnancy-related coverage.  

Assessing Implementation 

In prior work, we assessed early implementation of postpartum Medicaid extensions nationally and in Georgia. Speaking with maternal health experts, health care providers, state Medicaid officials, managed care plan representatives, and consumer advocates, one consistent message came through loud and clear: Postpartum extensions are seen as a critical forward step in the fight to end the maternal health crisis, but much work remains to realize their full benefits.  

Interviewees were encouraged and energized by the opportunity to better engage and support Medicaid enrollees throughout the birth cycle — from pregnancy and delivery through the critical postpartum year. State officials noted the extended postpartum coverage reinforced and complemented maternal health initiatives underway, such as community doula projects and innovative maternal care models. Several managed care plans reported expanding supports and care coordination services in the 12-month postpartum period.  

In Georgia, we also interviewed mothers with postpartum Medicaid, who expressed deep appreciation for the extended coverage and the ability to get health care without facing out-of-pocket costs. 

Realizing the Benefits Will Require Sustained Investments  

Our studies also identified several implementation challenges related to communications, eligibility systems, and access barriers that could dampen the positive effects of postpartum extensions. And such challenges may be even more formidable in the coming years, as Medicaid undergoes substantial changes required by the 2025 budget reconciliation law. Pregnancy-related coverage isn’t directly affected by the law, but provisions such as new eligibility restrictions for legally present immigrants as well as work requirements and more frequent eligibility checks for Medicaid expansion enrollees could make it harder for women of reproductive age to enroll in and maintain Medicaid. Moreover, the law will reduce federal Medicaid spending by about a trillion dollars over 10 years and redirect much of state Medicaid agencies’ capacity and resources to implementation of new policies, which could lessen focus on maternal health. 

The anticipated challenges increase the need for action to support Medicaid maternal health initiatives. State health policymakers, Medicaid agencies, managed care plans, health care providers, and other maternal health stakeholders could consider the following actions: 

• Raising awareness of extended Medicaid postpartum coverage and benefits. Our findings align with those from other research, suggesting that enrollees, health care providers, and other providers serving pregnant and parenting women (such as home visitors or providers in the federal Women, Infants, and Children nutrition program) may not be aware of extended postpartum Medicaid. The forthcoming changes to Medicaid eligibility could lead to further confusion and misinformation, so it is crucial that eligibility staff, community health workers, clinicians, and others who interact with low-income pregnant and postpartum women understand and pass on the information that they remain entitled to coverage. Importantly, communications should clearly note that the full range of health care services are covered throughout the postpartum year, including care unrelated to pregnancy—such as specialist visits for behavioral health, dental care, and medications—since we heard of confusion on that point.  
• Ensuring correct functioning of eligibility systems and enrollment processes. The recent Medicaid unwinding experience highlighted deficiencies in state eligibility systems, and a recent lawsuit in Florida alleges that postpartum enrollees were disenrolled from Medicaid despite being eligible for 12 months of coverage. Our interviews with postpartum enrollees in Georgia also found that some members were disenrolled from the program inappropriately both during pregnancy and postpartum periods. Ensuring that state eligibility systems and administrative procedures maintain coverage for pregnant and postpartum women will be even more critical since new restrictions under the 2025 budget law could make eligibility systems more complex and vulnerable to errors. It will also be important to target assistance to enrollees transitioning out of 12-month postpartum coverage to ensure they are equipped to maintain Medicaid or other health insurance, where possible.  
• Supporting and monitoring utilization of care from pregnancy through 12-months postpartum. Our interviewees frequently pointed out persistent barriers to obtaining health care. A common challenge — provider shortages — may become more acute if states reduce provider payment rates or hospitals reduce services or close due to fiscal strains. Funding cuts might lead some states to contemplate cuts to benefits such as doula programs and perinatal care coordination, or even to drop postpartum extensions. Because new Medicaid policies could destabilize Medicaid programs and delivery systems, it is now even more important to protect benefits and access to perinatal services. Close monitoring of Medicaid utilization data could help inform approaches to care. More research is also needed on the impacts of extended postpartum Medicaid; only a handful of states that used Section 1115 waiver authority are required to conduct formal evaluations, and it will be important to develop robust evidence of the policy’s impacts on a range of outcomes and variation across states and beneficiaries.  

Even though new Medicaid policies under the 2025 budget law do not directly threaten postpartum extensions, they could lead to incorrect information and confusion among enrollees and providers, stress eligibility systems, further weaken delivery systems, and strain state budgets — exacerbating existing implementation challenges. Medicaid’s momentum on maternal health could stall, if not reverse. State policymakers, providers, health plans, advocates, philanthropy and community-based organizations working together could help ensure this tumultuous time in Medicaid’s history does not undermine critical maternal health investments made in recent years.