01/18/2024
Summary:
- This manual release provides updates to policy for the postpartum coverage period, which is being increased to 12 months for eligible mothers;
- Clarifies the expanded medical certification period for women receiving postpartum coverage; and
- Provides guidance for the requirement of cooperation with child support for pregnant women.
State Statute 305 ILCS 5/5-2
Effective April 2021, enhancements to postpartum coverage have been made to help reduce maternal morbidity and mortality in Illinois by providing additional health care access and care coordination support to new mothers during the entire medically vulnerable postpartum period.
Updates to Postpartum Coverage
The following updates have been made to postpartum coverage:
- eligibility is extended for pregnant women from 60 days to a maximum of 12 months per pregnancy, and
- pregnant women will remain in the pregnant women category of eligibility throughout the entire 12-month postpartum period.
This change increases access to:
- needed care, follow-up visits, and
- medications when health issues arise during the postpartum period.
Note: The postpartum period also applies to an eligible woman who is not pregnant at application, but whose pregnancy ended:
- in the month of application, or
- in one of the 3 months (backdate months) before the month of application.
Continuous Eligibility (CE)
Continuous eligibility for the postpartum period will prevent mothers from having to switch providers during a medically vulnerable time and avoid:
- gaps in follow-up care due to different provider networks, and
- disruption in courses of treatment during the postpartum period.
Once a pregnant woman is determined eligible for postpartum coverage, she remains eligible regardless of changes in income or living arrangement for 12 months beginning with the month after the month the pregnancy ended. They are eligible unless they:
- move out of the State of Illinois;
- were incorrectly determined eligible in the first place;
- are deceased; or
- request cancellation.
Note: Do not remove/delete the Expected Date of Delivery (EDD) from IES. Removing or deleting the EDD will allow CE to end and interrupt postpartum coverage. See IES Wizard: 'End a Pregnancy Record'.
Type of Assistance (TOA)
Allowing women to enroll in the pregnant women TOA throughout the entire 12-month postpartum period ensures their health care needs are met throughout the postpartum period regardless of the source of coverage at delivery. The postpartum coverage will allow the State's Medicaid Managed Care Organization (MCO) to provide care coordination for women during the postpartum period.
Extended postpartum coverage provides full Medicaid benefits for eligible customers under the following TOAs:
- Pregnant (Moms and Babies),
- Newborn (Moms and Babies),
- All Kids Assist (PT), and
- AABD (PT).
Medical Certification Period
Certification periods are modified to accommodate the new 12-month postpartum period. Postpartum care provides up to 12 months of coverage starting with the first day of the month following the month after the pregnancy ends. Pregnant women are assigned a 12 month certification period when reporting their pregnancy. Upon the end of the pregnancy, these women are assigned a 12-month postpartum certification period. The Pregnancy End Date field is used by the system to determine the postpartum period. See IES Wizard: 'End a Pregnancy Record'.
Note: Pregnant women may have a certification period up to 24 months for each pregnancy.
Example: Mrs. Smith applies on August 14, 2021. EDD = April 8, 2022. Mrs. Smith is approved for Mom and Babies effective August 1, 2021.
- Initial certification period = 8/1/2021 - 7/31/2022.
Mrs. Smith reports on April 24, 2022 that the baby was born on April 18, 2022.
- Postpartum certification period = 5/1/2022 - 4/30/2023.
Mrs. Smith's certification period for her pregnancy (including her postpartum coverage) = 8/1/2021 - 4/30/2023 (21 months of continuous coverage).
Redetermination
Pregnant women are redetermined at the end of their postpartum period. Eligibility factors are reviewed to determine if the pregnant woman is eligible for the Form A or Form B process.
IES reviews the Pregnancy End Date field on the Pregnancy Details Screen to see if a date has been entered. If the Pregnancy End Date is populated, the normal Form A/B redetermination process continues. If Pregnancy End Date is not entered, the customer receives Form B.
If the Form B is not returned by the due date, the Pregnancy End Date is set to the pregnancy due date. The postpartum period is not approved in this scenario and the following case comment is entered: Per JIRA ILIES-259643, customer did not provide pregnancy end date. Pregnancy End Date field populated with the Estimated Delivery Date (EDD)." The pregnant woman is reviewed for eligibility for any other program.
If Form B was returned without the end date entered by the customer, the Pregnancy End Date is set to the Pregnancy Due Date. The postpartum period is not approved in this scenario and the following case comment will be entered: Per JIRA ILIES-259643, customer did not provide pregnancy end date. Pregnancy End Date field populated with the Estimated Delivery Date (EDD)." The pregnant woman is reviewed for eligibility for any other program.
Note: Updating the postpartum period to 12 months might cause misaligned certification periods. These EDGs are reviewed for alignment at the earliest opportunity.
Cooperation with Child Support Services (CSS)
Pregnant women are not required to cooperate with CSS when applying for or receiving medical coverage. The entry of the estimated date of delivery (EDD) allows pregnant women to continue receiving uninterrupted medical coverage while being sanctioned for TANF benefits. Women that have their medical benefits paused due to a CSS sanction will begin to receive medical when she reports her pregnancy. Women that apply for medical coverage and are pregnant will not have their medical denied due to noncooperation. HFS Form 1611 Notice of Failure to Cooperate is completed by the Department of Child Support Services (DCSS) and sent to the office assigned to the case. Form 1611 provides the findings of customer's cooperation in the child support process (see PM 24-02-03). HFS Form 493 Change in Case/Non-Custodial Parent Status is completed by the DCSS and sent to the office assigned to the case. Form 493 provides updated information concerning a change in the cooperation of a client.
Note: TANF benefits may be sanctioned for pregnant women (see Policy Memo:TANF Sanction Policy Changes dated 12/20/2019).
MANUAL REVISIONS
[signed copy on file]
Dulce M. Quintero
Secretary-Designate, Illinois Department of Human Services
Elizabeth Whitehorn
Director, Illinois Department of Healthcare and Family Services
