Postpartum Coverage Frequently Asked Questions (Provider)

Who is eligible for extended postpartum coverage?

Any beneficiary who is enrolled in a NC Medicaid program that covers pregnancy-related services.

Will beneficiaries automatically be enrolled in the postpartum benefit? Will a new application be needed for Medicaid for Pregnant Women (MPW) to transition to full Medicaid?

All eligible beneficiaries will receive a full 12 months of coverage. Beneficiaries do not need to submit a new application, but must notify their caseworker at their local Department of Social Services of the following:

• when the beneficiary becomes pregnant
• if the due date changes
• when the pregnancy ends

Is the coverage triggered at the end of the pregnancy and not just the birth of the baby?  

The postpartum period is calculated based on the expected due date.

The 12-month postpartum period is included at authorization. If the pregnancy ends for any reason, sooner or later, than expected, the 12-month postpartum period will be adjusted. The beneficiary must report the end of pregnancy within 10 days. 

Can anyone who has given birth in the last 12-months get the benefit until they are 12 months postpartum?

A beneficiary must be pregnant or in her 60-day postpartum period on or after April 1, 2022.

Who should the beneficiary contact at the end of their pregnancy?

The beneficiary’s caseworker at their local Department of Social Services (DSS) must be notified the pregnancy has ended. Providers can also report the birth of a child. DSS can receive reports from providers, hospitals or family.

Are beneficiaries still required to notify their local Department of Social Services of changes in income, family size, etc. within the 12-month period? Are updates still needed even though they will not affect coverage? 

Recipients should report all changes to their local DSS within 10 days. 

Are there materials we can use for the postpartum coverage and patient responsibility to notify DSS? It would help our office staff to receive training. 

Provider and Beneficiary fact sheets are available. The Provider fact sheet can be found here.

Are prior authorizations required by health plans for postpartum visits? 

No, there are no PA requirements for the postpartum period.

Is there a one-page “declare pregnancy” form for beneficiaries on NC Medicaid Direct we could have them complete to send to local Department of Social Services? 

There is no declaration form to attest to pregnancy for NC Medicaid Direct. The beneficiary needs to call their local DSS to report the pregnancy with the estimated due date. 

If a member is incarcerated in the state prison and released during her 12-month period, will she be eligible for services? 

Yes, her Medicaid is suspended during the period of incarceration and is only eligible for inpatient hospitalization. Upon release, if she is still in her 12-month postpartum period, her Medicaid will be unsuspended.

If the pregnancy ends in an abortion, will postpartum coverage be affected?

The beneficiary is entitled to coverage through the end of the month of the 12-month postpartum period, if the pregnancy ends for any reason.

With Medicaid postpartum coverage extended, beneficiaries need to transition to a PCP. Some local Health Departments do not offer primary care services. Is there an agency requirement for beneficiaries to transition to another PCP? Should the beneficiary contact their local DSS to change their Advanced Medical Home (AMH)? Will the county be required to make a formal referral to a primary care provider?  

DSS does not need to be contacted as they do not assign a pregnancy medical home, only a primary care provider. MPW beneficiaries do not choose a primary care provider, but a PCP is mandatory to enroll with the health plans.

The postpartum documents instruct agencies and beneficiaries that they must contact their local DSS caseworker to advise when
1.     the beneficiary becomes pregnant 
2.     the pregnancy ends 

What would happen if the caseworker were to change the AMH prior to the postpartum visit?

The DSS caseworker does not assign a pregnancy medical home. This is not related to eligibility and is not entered into NC FAST.

How will DSS know to transition the client to another Medical Home for the 12-month extension? What flexibility is offered to the beneficiary in choosing a new AMH if her OB provider does not offer primary care.

The local DSS does not assign a pregnancy medical home. Only in NC Medicaid Direct do they assign a primary care provider, but MPW is mandatory to enroll with NC Medicaid Managed Care.

Is the OB provider expected to manage the client’s care for the full 12 months of postpartum care?

The expectation is that beneficiaries should continue to have access to “full Medicaid” benefits and receive care for services that they need. If a beneficiary has postpartum care needs that would be best served by the OB, the beneficiary has access to those needed services.

At what week postpartum will the beneficiary who is assigned to an OB provider for antenatal care be transitioned to a primary care provider (PCP) for the rest of the 12-month postpartum period? 

The PCP the beneficiary is enrolled with will manage the beneficiary’s care, there is no information that the caseworker will need to enter in NC FAST.

Will the beneficiary be able to choose her PCP after her postpartum visit? 

The beneficiary can work with her health plan or NC Medicaid Direct to choose her PCP.

What role is the OB provider expected to play in transitioning the beneficiary to primary care?

The beneficiary is enrolled with a NC Medicaid Managed Care health plan and should contact them to transition her care.