What are the Medicaid eligibility rules for pregnant women under 42 CFR 435.116? Answer in under 100 words.

Details / How it works

Basis and Scope. This section implements sections 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I), (IV), and (IX), and 1931(b) and (d) of the Social Security Act. The state Medicaid agency must provide Medicaid to pregnant women whose household income is at or below the income standard established in the State plan.

Income Standard. The agency must establish the income standard in its State plan. The minimum income standard is the higher of (i) 133 percent of the Federal Poverty Level (FPL) for the applicable family size, or (ii) a higher income standard up to 185 percent FPL if the state had established such a standard as of December 19, 1989 (or had authorizing legislation by July 1, 1989). The maximum income standard is the higher of (i) the highest effective income level in effect under the State plan for coverage of pregnant women as of March 23, 2010 or December 31, 2013 (whichever is higher, converted to a MAGI-equivalent standard), or (ii) 185 percent FPL.

Covered Services. Pregnant women are entitled to full Medicaid coverage, consisting of all services required under § 440.210(a)(1) and all optional services the state covers under § 440.225 and § 440.250(p). However, for pregnant women whose income exceeds the applicable income limit established in the State plan, the agency may provide only pregnancy-related services, which are consistent with § 440.210(a)(2) and § 440.250(p).

Numbers & thresholds

Exceptions & edge cases

Pregnancy-related services only. If a pregnant woman's income exceeds the applicable income limit established by the agency (which ranges between the AFDC-derived minimum and the maximum income limit), she is not eligible for full Medicaid coverage. Instead, the state may provide only pregnancy-related services as described in § 440.210(a)(2) and § 440.250(p). This limit is based on the state's historical AFDC standard converted to MAGI.

State discretion to set higher income standards. The regulation permits states to adopt income standards anywhere within the defined minimum and maximum ranges. The minimum is tied to 133% FPL or historical state choices, while the maximum is tied to 185% FPL or the state's highest historical coverage level.