This issue brief was drafted by Rachel Fabi with research assistance from Mohini Banerjee, edited by Michael K. Gusmano and Nancy Berlinger, and designed by Mohini Banerjee. Special thanks to expert reviewers Evan A. Ashkin, MD, Associate Professor of Family Medicine, University of North Carolina at Chapel Hill; Kate Bicego, Consumer Assistance Program Manager, Health Care For All, Boston, MA; Caroline Rath, physician assistant, Gouverneur Healthcare Services, New York City; and Eva Turbiner, President and CEO, Zufall Health Center, Dover, NJ. Information about policy mechanisms was compiled using publicly available documents, including Medicaid Provider Manuals for each state; see References. All information is current as of September 12, 2014.
Access to prenatal care for women who are undocumented immigrants varies widely across the United States due to differences in state policies and differing state-level interpretations of federal policies that fund health services for pregnant women. This issue brief provides an overview of this access problem and the consequences of policy-related uncertainty or variation for undocumented patients, their families, and the health care safety-net.
Why is access to prenatal care for undocumented immigrants important?
There is long-established medical consensus that prenatal care is fundamental to reproductive and infant health; however, undocumented immigrants living in the U.S. are significantly less likely to have “adequate” prenatal care, compared to other immigrants and to U.S. born citizens. [1-4] The reasons for this gap include lack of means to pay for prenatal care, lack of access to sources of prenatal care, and mistrust of the health care system.  Other barriers to health care that undocumented immigrants face include difficulties navigating the health care system; linguistic, literacy, and other challenges in communicating about health care needs; inability to take time off from work; misinformation about the immigration-related consequences of using health care services; and perceived and actual risks of encountering immigration authorities or local law enforcement in the course of seeking health care.
The Emergency Medical Treatment and Active Labor Act (EMTALA), which prevents hospitals from turning away uninsured patients in need of emergency treatment, encompasses labor and delivery, and most “emergency” health care services used by undocumented immigrants are related to childbirth. [6-8] State-level Emergency Medicaid programs provide some reimbursement to hospitals for treatment provided under EMTALA. In some states, undocumented immigrants may account for as much as 99% of Emergency Medicaid expenditures; approximately 80% of these costs are related to childbirth or to complications of pregnancy and labor.  Because access under EMTALA is restricted to emergent conditions, it is not a mechanism for access to routine prenatal care that could prevent or monitor pregnancy-related complications.
Lack of access to prenatal care increases the risk of premature birth and low birth-weight, and may be a factor in a range of poor health outcomes experienced by undocumented pregnant women and their babies, including higher rates of labor and delivery complications such as precipitous labor, excessive bleeding, breech presentation, cord prolapse, and fetal distress. [9, 10] These risks and outcomes have consequences for the viability and health of newborns, infant and child development, and the health of mothers, and for costs associated with treating medical conditions that could have be prevented or managed before birth.
What policy provisions may offer access to prenatal care for undocumented immigrants?
1. CHIP Unborn Child Option
As of September 2014, 16 states have implemented a State Plan Amendment (SPA) to the Children’s Health Insurance Program (CHIP), which is jointly supported by federal and state funds. An unborn child may be considered a “targeted low-income child” who is eligible for this program.  This provision would enable an undocumented immigrant to enroll her unborn child in the program so she can obtain coverage for prenatal care and labor and delivery services, in the interest of protecting the child’s future health. Under this provision, services such as prenatal vitamins and ultrasounds may be covered but services perceived as unrelated to pregnancy may not be covered.
2. Presumptive Eligibility for Medicaid (PE)
Presumptive eligibility (PE) is a state-level mechanism that enables pregnant women to obtain immediate temporary Medicaid coverage without having to wait for a Medicaid application to be processed. As of September 12, 2014, PE was available in 30 states, 13 of which explicitly restrict access to women with legal immigration status. Physicians who are “qualified providers” of Medicaid services and eligible to determine PE based on a patient’s self-reported income can provide Medicaid-funded care to any pregnant woman whose self-reported income meets that state’s eligibility threshold. During the time-limited PE period, the woman is expected but not required to submit an application for regular Medicaid coverage. PE coverage typically lasts two months, or until a decision approving the applicant for Medicaid is made. The scope of services covered under PE differs by state; some states cover only ambulatory prenatal care, while others cover the full Medicaid scope of services.
For information on the Hospital Presumptive Eligibility provision of the Patient Protection and Affordable Care Act (ACA), which enables qualified hospitals to determine PE, see References.
3. Other Policy Mechanisms
Expanding eligibility for safety-net health insurance programs to include coverage for low-income pregnant women regardless of immigration status is another way that undocumented women in some jurisdictions can obtain coverage for prenatal care. Three states (New York, Massachusetts, and New Jersey) offer public insurance for the duration of a pregnancy and for two months after delivery. In New York, this coverage is offered as an entitlement program through a state-funded expansion of Medicaid. In Massachusetts, coverage is provided through a state-funded Medicaid expansion, supplemented by the CHIP Unborn Child Option (see above) to cover ambulatory prenatal care services. In New Jersey, Medicaid coverage for prenatal care only is funded through the state budget and offered through community health centers and hospitals subject to the availability of grant funds.
In some cities, undocumented immigrants are eligible for coverage for prenatal care and other health care services through locally-funded programs. In Washington D.C, for example, the D.C. Healthcare Alliance provides insurance coverage for low-income city residents who do not have Medicaid or other insurance.
Beyond these publicly-funded insurance mechanisms, access to prenatal care for undocumented immigrants may also be provided directly by public health clinics and nonprofit organizations (such as Federally Qualified Health Centers) that offer health services for patients without insurance that are available for free or at a sliding-scale fee based on a patient’s ability to pay.
1. American Academy of Pediatrics, Guidelines for Perinatal Care, 7th ed. 2012.
2. ACOG Committee Opinion No. 425: health care for undocumented immigrants. Obstet Gynecol, 2009. 113(1): 251-4.
3. Cohen, G.J., The prenatal visit. Pediatrics, 2009. 124(4): 1227-32.
4. Korinek, K. and K.R. Smith, Prenatal care among immigrant and racial-ethnic minority women in a new immigrant destination: exploring the impact of immigrant legal status. Soc Sci Med, 2011. 72(10): 1695-703.
5. Frisbie, W.P., S. Echevarria, and R.A. Hummer, Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans. Matern Child Health J, 2001. 5(1): 21-33.
6. Federal Funding for Unauthorized Aliens’ Emergency Medical Expenses, in CRS Report For Congress. 2004.
7. United States Congressional Budget Office, The Impact of Unauthorized Immigrants on the Budgets of State and Local Governments. 2007.
8. DuBard, C.A. and M.W. Massing, Trends in emergency Medicaid expenditures for recent and undocumented immigrants. Jama, 2007. 297(10):1085-92.
9. Lu, M.C., et al., Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis. Am J Obstet Gynecol, 2000. 182 (1 Pt 1): 233-9.
10. Reed, M.M., et al., Birth outcomes in Colorado’s undocumented immigrant population. BMC Public Health, 2005. 5: 100.
11. State Children’s Health Insurance Program; Eligility for Prenatal Care and Other Health Services for Unborn Children, F. Register, Editor. 2002: 61956-61974.
State-Level and Local-Level Programs
On immigrants’ eligibility provisions for public benefits, including Medicaid and CHIP, see Overview of Immigrants’ Eligibility for SNAP, TANF, Medicaid, and CHIP, Office of the Assistant Secretary for Planning and Evaluation (March 2012): http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml (accessed on August 27, 2014).
Medicaid Provider Manuals for presumptive eligibility in many states are available on the website of Enroll America, a nonprofit, nonpartisan organization (March 2014): http://www.enrollamerica.org/toolkits/pe/states.html
(accessed on August 20, 2014). See also links below.
For a list of states that had Presumptive Eligibility as of January 2013, see the Kaiser Family Foundation state indicator: http://kff.org/medicaid/state-indicator/presumptive-eligibility/ (accessed on August 27, 2014).
(The chart that accompanies this Issue Brief reflects subsequent changes to this list current as of September 1, 2014)
See also: Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013, Kaiser Commission on Medicaid and the Uninsured (January 2013): http://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf (accessed on August 27, 2014)
On Hospital Presumptive Eligibility, see Implementation of the Affordable Care Act’s Hospital Presumptive Eligibility Option: Considerations for States, Center for Medicare and Medicaid Services (November 2013): http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Learning-Collaborative-State-Toolbox/Downloads/State-Network-CHCS-Implementation-of-the-Affordable-Care-Acts-Hospital-P.pdf (accessed on August 27, 2014); see also The New Hospital Presumptive Eligibility Opportunity. Enroll America. March 10, 2014. http://www.enrollamerica.org/toolkits/pe/home.html (accessed on August 26, 2014).
State Medicaid Provider Manuals and Related State-level Documents
Alabama Medicaid Agency. Provider Manual – Maternity Care – Chapter 24. July 2014.
http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.8_Provider_Manuals_2014/188.8.131.52_July_2014/Jul14_24.pdf (accessed 20 August 2014).
Alaska Department of Health and Social Services. Medicaid. 2012. http://dhss.alaska.gov/dpa/pages/medicaid/default.aspx (accessed 26 August 2014).
Arizona Health Care Cost Containment System. AHCCCS Health Plans. 2014. http://www.azahcccs.gov/applicants/healthplans/healthplans.aspx (accessed 26 August 2014)
Arkansas Department of Human Services. Medical Services Policy Manual, Section B. January 2014. https://ardhs.sharepointsite.net/DHSPolicy/DCOPublishedPolicy/Section%20B-200%20Families%20and%20Individuals%20Group%20(MAGI).pdf (accessed on August 20, 2014).
Access for Infants and Mothers (AIM). AIM Handbook. April 2014. http://www.aim.ca.gov/Publications/AIM_Handbook_en.pdf (accessed on August 20, 2014).
Colorado Department of Health Care Policy & Financing. Medicaid Provider Information Billing Manual. February 2014. 19-20. https://www.colorado.gov/pacific/sites/default/files/GENERAL_PROVIDER_INFORMATIO_0.PDF (accessed on August 20, 2014).
Connecticut Department of Social Services. U.S. Citizenship: What you need to know for your benefits in Medicaid, HUSKY A and HUSKY B. February 2010. http://www.ct.gov/dss/lib/dss/pdfs/0606citizenshiprevised02.10.pdf (accessed on August 20, 2014).
Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance. 31 Del.C. §512: Delaware Medicaid Modified Adjusted Gross Income (MAGI) Eligibility and Benefits State Plan Amendments MAGI-Based Eligibility Groups. December 2013. http://regulations.delaware.gov/register/december2013/final/17%20DE%20Reg%20612%2012-01-13.pdf and http://regulations.delaware.gov/register/december2013/final/Benefits.pdf (accessed on August 20, 2014).
State of Florida Department of Children and Families. Presumptive Medicaid Eligibility for Pregnant Women. January 2014. http://www.dcf.state.fl.us/admin/publications/cfops/165%20Economic%20Self-Sufficiency%20Services%20(CFOP%20165-XX)/CFOP%20165-09,%20Presumptive%20Medicaid%20Eligibility%20for%20Pregnant%20Women.pdf (accessed on August 20, 2014).
Georgia Department of Community Health, Division of Medical Assistance Plans. Part II: Policies and Procedures Affordable Care Act For Presumptive Eligibility Pregnant Women Medicaid. July 2014. https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/PE%20ACA%20Pregnant%20Women%20Medicaid%2002-07-2014%20145016.pdf (accessed on August 20, 2014).
State of Hawaii. My Benefits. 2014, http://mybenefits.hawaii.gov/. (accessed 26 August 2014).
Idaho Department of Health and Welfare. Presumptive Eligibility for Medicaid: Provider Training. January 2014. http://healthandwelfare.idaho.gov/Portals/0/Providers/PresumptiveMedicaid/PresumptiveEligibilityProvidersTraining.pdf (accessed on August 20, 2014).
State of Illinois All Kids. Moms & Babies Programs for Pregnant Women. 2014. http://www.allkids.com/pregnant.html#momsbabies (accessed on August 20, 2014).
State of Indiana Family and Social Services Administration. Presumptive Eligibility for Pregnant Women. 2014. http://member.indianamedicaid.com/media/15344/pe%20brochure_v2.pdf (accessed on August 20, 2014).
Iowa Department of Human Services. All Providers II Member Eligibility. August 2014. https://dhs.iowa.gov/sites/default/files/All-II.pdf (accessed on August 20, 2014).
Kansas Department of Health and Environment. KanCare. 2012-2014. http://www.kancare.ks.gov/ (accessed 26 August 2014).
Kentucky Cabinet for Health and Family Services. Presumptive Eligibility (PE) for Pregnant Women. April 2014. http://chfs.ky.gov/dms/peservice.htm#eligible (accessed on August 20, 2014).
Louisiana Department of Health and Hospitals. Louisiana Medicaid Eligibility Manual (MEM). May 2014. http://new.dhh.louisiana.gov/assets/medicaid/MedicaidEligibilityPolicy/H-3050m.pdf (accessed on August 20, 2014).
Maine Department of Health and Human Services. Mainecare Eligibility Manual. June 2014. http://www.maine.gov/sos/cec/rules/10/144/ch332/144c332-sans-extras.doc (accessed on August 20, 2014).
Maryland Department of Health and Mental Hygiene. Maryland Medical Assistance Programs. February 2014, https://mmcp.dhmh.maryland.gov/SitePages/Home.aspx (accessed 26 August 2014).
Massachusetts Executive Office of Health and Human Services. Member Booklet for Health Coverage and Help Paying Costs. March 2014. http://www.mass.gov/eohhs/docs/masshealth/membappforms/aca-1-english-mb.pdf (accessed on August 20, 2014).
Massachusetts Executive Office of Health and Human Services. MassHealth Regulations, 130 CMR 505.002(D). January 2014.
http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR505.pdf (Accessed on August 27, 2014).
Michigan Department of Community Health. Health Care Programs Eligibility. 2014. http://www.michigan.gov/mdch/0,4612,7-132-2943_4860-35199–,00.html (accessed on August 20, 2014).
Minnesota Department of Human Services. People Who Are Not U.S. Citizens. December 2013. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144099# (accessed on August 20, 2014).
Mississippi Division of Medicaid. Medicaid. 2014. http://www.medicaid.ms.gov/ (accessed on August 27, 2014).
Missouri Department of Social Services. TEMP Eligibility Determination. 2008. http://manuals.momed.com/forms/temp_eligibility_determination.pdf (accessed on August 21, 2014).
See also : Lieb, D. Missouri governor signs health care expansion. St. Louis Post-Dispatch. July 10, 2014.
http://www.stltoday.com/news/special-reports/mohealth/updates/missouri-governor-signs-health-care-expansion/article_035eec6f-1bd0-5b9d-97b6-1d1363b127e4.html (accessed on August 21, 2014).
Montana Department of Health and Human Services. Presumptive Eligibility 2014 Qualified Entity Reference Guide. 2014. http://medicaidprovider.hhs.mt.gov/pdf/presumptive_eligibility/presumptiveEeigibilityreferenceguide%202014.pdf (accessed on August 21, 2014).
Nebraska Department of Health and Human Services. New Adjunct Eligible Program. July 2012. http://dhhs.ne.gov/publichealth/Documents/I-6-2012_New_Adjunct_Eligible_Program.pdf (accessed on August 21, 2014).
The Undocumented and the Unborn. April 23, 2013. The New York Times. http://www.nytimes.com/2012/04/24/opinion/undocumented-immigrants-and-the-unborn.html (accessed on August 21, 2014).
Nevada Department of Health and Human Services. Division of Health Care Financing and Policy. https://dhcfp.nv.gov/index.htm (accessed 26 August 2014).
New Hampshire Department of Health and Human Services. Application for Medicaid Presumptive Eligibility (PE). 2014. http://www.dhhs.nh.gov/dfa/presumptive/documents/dfa-821.pdf (accessed on August 21, 2014).
New Jersey Department of Human Services. Medicaid Communication No. 11-07: New Jersey Supplemental Prenatal Care Program (NJSPCP). July 2011. http://www.state.nj.us/humanservices/dmahs/info/resources/medicaid/2011/11-07_New_Jersey_Supplemental_Prenatal_Care_Program_NJSPCP.pdf (accessed on August 21, 2014).
New Jersey Administrative Code. 10:72-3.10: New Jersey Care Special Medicaid Programs Manual. 18 August 2014.
https://web.lexisnexis.com/research/retrieve?_m=fa48f5c6040d70cb38009b6c3e923ada&csvc=toc2doc&cform=tocslim&_fmtstr=FULL&docnum=1&_startdoc=1&wchp=dGLzVzB-zSkAb&_md5=b1be9ccbb51b271b7fb8183803b176eb (accessed on August 26, 2014).
New Mexico Administrative Code. 8.291.400: Eligibility Requirements. 2014. http://www.nmcpr.state.nm.us/nmac/parts/title08/08.291.0400.htm (accessed on August 21, 2014).
New Mexico Human Services Department. Presumptive Eligibility (PE) Applicant Information Form. May 2014. https://nmmedicaid.acs-inc.com/static/PDFs/PE%20Forms/MAD011.pdf (accessed on August 21, 2014).
New York State Department of Health. New York State Medicaid Update, Prenatal Care Special Edition. February 2010. https://www.health.ny.gov/health_care/medicaid/program/update/2010/2010-02_special_edition.htm (accessed on August 21, 2014).
North Carolina Department of Health and Human Services. Family and Children’s Medicaid MA-3245 Presumptive Eligibility for Pregnant Women. March 2012. http://info.dhhs.state.nc.us/olm/manuals/dma/fcm/man/ma3245-01.htm (accessed on August 21, 2014).
North Carolina Department of Health and Human Services. Presumptive Eligibility Determination Form for Pregnancy-Related Care. July 2014. http://info.dhhs.state.nc.us/olm/forms/dma/dma-5032-ia.pdf (accessed on August 21, 2014).
North Dakota Department of Human Services. North Dakota Medicaid. 2010. http://www.nd.gov/dhs/services/medicalserv/medicaid/ (accessed 26 August 2014).
Ohio Department of Job and Family Services. 5160:1-2-50 Medicaid: Presumptive Eligibility for Pregnant Women. March 2014. http://emanuals.odjfs.state.oh.us/emanuals/GetDocument.do?docId=Document(storage%3DREPOSITORY%2CdocID%3D%24REP_ROOT%24%23node-id(1631364))&locSource=input&docLoc=%24REP_ROOT%24%23node-id(1631364)&version=8.0.0 (accessed on August 21, 2014).
Oklahoma Health Care Authority. What is SoonerCare?. http://www.okhca.org/individuals.aspx?id=52&menu=40&parts=11601_7453 (accessed 26 August 2014).
Oregon Health Authority. Oregon’s Medicaid State Plan. http://www.oregon.gov/oha/healthplan/Pages/stateplan.aspx (accessed 26 August 2014).
Pennsylvania Department of Public Welfare. Provider Instructions Presumptive Eligibility Application. May 2006. http://www.dpw.state.pa.us/cs/groups/webcontent/documents/form/s_002592.pdf (accessed on August 21, 2014).
Rhode Island KIDS COUNT. RIte Care Coverage for Immigrant Children and Families. October 2010. http://www.rikidscount.org/matriarch/documents/Q%20and%20A%20For%20Helpers.pdf (accessed on August 21, 2014).
South Carolina Department of Health and Human Services. Health Connections Medicaid. https://www.scdhhs.gov/ (accessed 26 August 2014).
South Dakota Department of Social Services. Medical Services. 2011. http://dss.sd.gov/medicalservices/ (accessed 26 August 2014).
Tennessee Department of Finance and Administration Division of Insurance Administration. Chapter 0620-05-01 Cover Kids Rules. June 2014. http://www.tn.gov/sos/rules/0620/0620-05/0620-05-01.20140615.pdf (accessed on August 21, 2014).
Texas Health and Human Services Commission. CHIP State Plan. March 2012. http://www.hhsc.state.tx.us/medicaid/about/state-plan/docs/CHIPStatePlan.pdf (accessed on August 27, 2014).
Texas Department of State Health Services. Title V MCH Fee For Service Policy Manual. September 2013. http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589980232 (accessed on August 21, 2014).
Utah Department of Health. Baby Your Baby Eligibility Chart. 2014. http://www.babyyourbaby.org/financial-help/eligibility.php (accessed on August 21, 2014).
Green Mountain Care. Medicaid. 2014, http://www.greenmountaincare.org/vermont-health-insurance-plans/medicaid (accessed 26 August 2014).
Virginia’s Medicaid Program. Department of Medical Assistance Services. 2009. http://www.dmas.virginia.gov/ (accessed 26 August 2014).
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Rachel Fabi is a PhD student in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and in the Johns Hopkins Berman Institute of Bioethics. She is a 2014 intern on the Undocumented Patients Project.