Report Title:

QUEST; Pregnant Women; Presumptive Medicaid Eligibility

Description:

Requires the department of human services to provide presumptive medicaid or QUEST coverage to medicaid eligible pregnant women and their infants through June 30, 2005. Requires department of health to report to the legislature. (HB122 SD2)

HOUSE OF REPRESENTATIVES

H.B. NO.

122

TWENTY-SECOND LEGISLATURE, 2003

S.D. 2

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

RELATING TO PRESUMPTIVE MEDICAID ELIGIBILITY FOR PREGNANT WOMEN.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. The legislature finds that the State's best interests are to ensure that pregnant women and their infants receive appropriate perinatal care to prevent developmental disabilities and reduce medical costs and to prevent poor perinatal outcomes. By providing health care to pregnant women, babies will be born in better health, and both mother and infant will require less medical care post-delivery.

Early and continuous prenatal care for pregnant women is recommended nationally as a standard of care by virtually all maternal and child health organizations. Data collected by the National Governors Association Center for Best Practices, Health Policy Studies Division, found that as of October 2000, thirty states included presumptive eligibility for pregnant women in their Medicaid programs.

Prior to 1995, presumptive eligibility for prenatal care for pregnant women existed under the department of health's Medicaid options for mothers and infants (MOMI) program. During this time, the State reported experiencing significant improvements in birth outcomes and cost-savings through reductions of poor birth outcomes for low-income women and their families.

With the advent of the State's QUEST program in 1994 under the department of human services, the MOMI program was terminated along with the presumptive eligibility for prenatal care for Hawaii's pregnant women, who are currently processed through normal QUEST application procedures. While the department of human services has made efforts since that time to address systemic application processing delays for all QUEST enrollees, including pregnant women, the QUEST application processing time continues to average from three to five weeks, and can be longer in some circumstances. During this application processing period, pregnant women do not know if they will be found eligible for QUEST. This may be a barrier to seeking timely prenatal care, especially for women who lack the income to pay prenatal care bills should they be found ineligible and be held personally responsible for the costs of care.

Over one thousand four hundred pregnant women applied for QUEST coverage in the first three quarters of 2002, of which approximately 1,132 (seventy-six per cent) were approved for QUEST, while approximately three hundred fifty-three (twenty-four per cent) pregnant women were denied or discontinued from QUEST. The pending applications from pregnant women averaged ninety-four to ninety-five per month during the first three quarters of 2002. From 1998-2001, there were four hundred fifty to five hundred uninsured, self-paying women yearly who delivered babies in Hawaii, out of an average of seventeen thousand annual live births.

The legislature further finds that early and continuous prenatal care for pregnant women is a basic, cost-effective method for preventing low birth weight and poor birth outcomes, and for increasing the likelihood that infants will receive consistent preventive care during the crucial early years of development. Several maternal conditions that may result in costly pregnancy complications, including low birth weight or preterm labor, may be diagnosed and treated without complication if a woman receives early, continuous prenatal care. Among these conditions are sexually transmitted diseases and maternal substance abuse, which can result in substantial increases in the risk for delivering a low birth weight infant, and gestational diabetes, which increases the risk of preterm labor and early birth. Approximately one in every thirteen (seven and one-half per cent) of pregnant women overall deliver a low birth weight infant. However, this statistic increases to approximately one in three (thirty-three per cent) for those with an untreated sexually transmitted disease and one in five (twenty per cent) for women who abuse drugs or alcohol during their pregnancies. Women with gestational diabetes are up to twice as likely to deliver a preterm infant as women without this condition. In addition to the immediate benefits to the pregnancy, national research into infant health issues has found that poor women who receive prenatal care are more likely to get preventive care for their infants, including routine well baby check-ups and timely infants immunizations, than those who did not receive prenatal care.

Low birth weight has been determined nationally as one of the top three most expensive reasons for hospital stays in the United States, with higher infant birth weights correlated with lower post-delivery health care costs for infants. On average, approximately eight per cent of all Hawaii babies are born with low birth weight (less than 2,500 grams or 5.5 pounds). During 2001, approximately 1,372 Hawaii infants were born with low birth weight. About $69,600,000 was spent in Hawaii in 2001 alone in newborn infant care post-delivery with an additional $78,600,000 spent on the mother's care. One in four babies born in Hawaii between 1998-2001 were QUEST-insured babies; however, QUEST currently pays for the care of approximately thirty-eight per cent of all babies with hospital charges of over $50,000, and seventy-five per cent of those with birth and post-delivery hospital charges of over $1,000,000.

The current cost for outpatient prenatal care in Hawaii now average approximately $1,800 for the three trimesters of visits and tests, which is very cost effective compared to the costs of either extended mother or infant care in an acute care facility.

The purpose of this Act is to require the department of human services to provide presumptive Medicaid or QUEST eligibility to Medicaid eligible pregnant women and their infants.

SECTION 2. Chapter 346, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"§346-   Presumptive medicaid or QUEST eligibility for pregnant women. (a) The department shall presume that a pregnant woman applying for medicaid or QUEST coverage for prenatal care or other medically indicated services relating to the pregnancy is eligible for coverage; provided that the applicant is able to show proof of:

(1) An annual income at or below the maximum level allowed under federal law and the medicaid section 1115 waiver approved for Hawaii; and

(2) Confirmation of pregnancy through a pregnancy test or a physical examination, as certified by a licensed health care provider.

The presumption shall apply immediately upon application. The woman shall be notified, within forty-five days of the application, of eligibility for continuing coverage under either medicaid or QUEST.

Infants of women presumptively covered by medicaid or QUEST shall be deemed eligible for services and shall be processed for coverage under the state children's health insurance program.

(b) If the pregnant woman is later determined to be ineligible for medicaid or QUEST after receiving services during the presumptive eligibility period, the department shall disenroll the pregnant woman and notify the plan of disenrollment by facsimile transmission or e-mail. The department shall provide reimbursement to the plan for the months in which the pregnant woman was enrolled.

(c) Reimbursement payments to providers of prenatal care coverage under subsection (a) shall be calculated on the basis of reimbursement standards for prenatal care established by the department. The standards shall be based on the recommended guidelines of the American College of Obstetrics and Gynecology for prenatal and postnatal care."

SECTION 3. The presumptive medicaid or QUEST eligibility for pregnant women shall be in effect through June 30, 2005. Upon the termination of the presumptive medicaid or QUEST eligibility, the department shall submit a report including recommendations, to the legislature on the costs and other issues related to the two-year period in which the presumed eligibility was in effect, no later than twenty days prior to the convening of the 2006 regular session of the legislature.

SECTION 4. New statutory material is underscored.

SECTION 5. This Act shall take effect on July 1, 2003.