Postpartum women never lost Medicaid coverage during the pandemic. But the state told them they did.

Thanks to misleading letters sent by the Mississippi Division of Medicaid in recent years, tens of thousands of new moms may have chosen to forgo health care after giving birth – even as the federal government was sending Mississippi extra money to help pay for their care during the pandemic.

Mississippians whose pregnancies were covered by Medicaid retained full benefits during the COVID-19 pandemic under federal law, instead of getting kicked off 60 days after giving birth as they ordinarily would under state policy. That should have allowed them to keep seeing their doctors and get treatment for conditions like postpartum depression, high blood pressure and anything else they needed to stay healthy after their baby's birth.

But many women thought they didn't have coverage because of letters sent to every recipient of pregnancy Medicaid telling them they were no longer eligible. While healthy adults under 65 generally don't qualify for Medicaid, pregnant women are covered as long as they meet income requirements, and about 60% of births in Mississippi are covered by Medicaid. An untold number of pregnancy Medicaid recipients may have stopped going to the doctor after receiving the letters, believing they would be charged as if they had no health insurance.

Several recipients of the letters told Mississippi Today they only found out they had coverage after going to the doctor, in some cases so desperate for care that they were willing to pay whatever they had to out of pocket.

"Your Medicaid eligibility has ended," the sparse letter from the Division of Medicaid said. The heading read "TERMINATION NOTICE – Loss of Medicaid Eligibility."

A second letter delivered later, titled "NOTICE OF MEDICAID REINSTATEMENT DURING COVID-19 PUBLIC HEALTH EMERGENCY," explained that those covered as of March 18, 2020 would have their coverage reinstated. But it did not make reference to the first letter or explain what kind of coverage recipients now had.

Some women told Mississippi Today they never got the second letter.

Dr. Anita Henderson, a Hattiesburg pediatrician and president of the Mississippi Chapter of the American Academy of Pediatrics, said she screens moms for postpartum depression during their newborns' early checkups. During the public health emergency, she and colleagues expected new moms to retain Medicaid coverage indefinitely.

"We found that some of those moms were coming back and saying, 'We don't have Medicaid, or we don't know that we have Medicaid.' Or they were saying, 'No, I have gotten this termination letter,'" Henderson said. "Once we offered clarification and discovered they still qualified, they would go to that appointment, or we would help set up the appointment and they would go. But if they did not know they had coverage, they may not have utilized it."

The new moms' confusion and reluctance to seek care almost certainly saved the Division of Medicaid money – and one expert believes the confusing communication may have been intentional.

The first letter notified the recipients that they had been kicked off of the managed care plan, a program through which the state pays a set amount of money to a "coordinated care organization" each month, which then pays for recipients' care.

The reinstatement described in the second letter shifted them to another type of Medicaid in which the state pays directly for each visit and treatment. The fewer services new moms sought, the less money the Division of Medicaid had to spend.

Joan Alker, executive director and co-founder of the Center for Children and Families (CCF) at Georgetown University and an expert on Medicaid, said she had not heard of other states moving people from managed care to fee-for-service coverage during the pandemic.

"I fear this is an intentional strategy to cut costs on the backs of these postpartum women," Alker said.

Matt Westerfield, communications director for Medicaid, said the department could not provide a "validated analysis" of postpartum spending during the public health emergency by publication time.

"Generally, it appears that monthly medical costs have exceeded $200 per beneficiary per month in months 3 to 12 of the postpartum period," he wrote.

The state pays managed care companies between $1,076 and $1,186 monthly per pregnant woman, depending on the beneficiary's location.

In a statement to Mississippi Today last week, the Division of Medicaid acknowledged the letters were a mistake.

"An automated form letter related to disenrollment from a managed care plan should have been updated to mention the continuing availability of full Medicaid benefits," said Westerfield. "We have directed that the form letter be updated, and staff is currently reviewing other beneficiary communications to make improvements where needed."

Trista Carlton gave birth to her daughter in June 2021. The 28-year-old Laurel resident had Medicaid as her secondary insurance, and about 60 days postpartum, she got the letter informing her that her coverage had been terminated.

Carlton started rationing her visits to the doctor because she was worried about the cost.

"Not only do you have your copay, you have what your insurance doesn't cover afterwards, so it definitely makes you second-guess making a visit to go to the doctor and see what's going on," she said. "Having a new baby, that comes with added costs that you're thinking about. You kind of put yourself on the back burner, not knowing what's going on."

She never got the second letter telling her the coverage had been reinstated, but she eventually decided she needed to see her doctor for anxiety and depression. Only then did she learn she still had coverage.

Trista Carlton, a 28-year-old new mom in Laurel, thought she no longer had Medicaid coverage after she got a letter telling her she had been terminated. When she finally went to the doctor, she learned she was still covered, as federal law requires during the COVID-19 Public Health Emergency. Credit: Trista Carlton

Carlton then called local Medicaid offices in Laurel and Brandon to ask what was going on. She said staff there told her she only had family planning Medicaid coverage, which pays for up to four annual visits related to birth control. Before the Public Health Emergency, women who gave birth on Medicaid were rolled onto family planning coverage for one year after they lost full coverage.

"I've never really been able to get a direct answer," she said. "But all of my primary care visits have gone through. And as far as I know, I'm still covered under Medicaid."

Several other women told Mississippi Today they had similar experiences after receiving the letters.

Chelsea Brooks, a new mom in Florence, canceled a doctor's appointment because she got the letter telling her she had lost coverage. More than two months later, she got the reinstatement letter and contacted her doctor. The experience was "very confusing," she said.

Kristen Elliott, a mom in Brandon, got the first letter a few months ago and thought she had lost coverage. But when she went to the doctor a few weeks ago, she found out she was still covered.

"I'm not even sure what was going on with it," she said.

In March 2020, Congress passed a law requiring "continuous coverage" for Medicaid recipients to ensure no one lost access to health care during the COVID-19 pandemic. That forced states to do something they had never done before: change their systems to stop kicking people off of Medicaid even if they lost eligibility, said Jennifer H. Wagner, director of Medicaid Eligibility and Enrollment at the Center on Budget and Policy Priorities.

Nearly 150,000 more Mississippians are on Medicaid than before the pandemic, said Westerfield, the state Medicaid communications officer.

In Mississippi, the termination notice at 60 days postpartum was already programmed to be sent to recipients. Creating a totally new notice to explain instead that recipients still had coverage is "more complicated than it sounds," Wagner said. Instead, the state just added a second letter telling recipients their coverage was reinstated.

Wagner said that though she understood why the state sent the letters, they were confusing.

"Coverage is only good if you know you have it," she said.

The continuous coverage requirement also came with extra federal funding for states. That funding exceeded the extra costs of covering more people in every state. But no state got a better deal from the feds than Mississippi, where the extra federal funding was six times higher than the expanded coverage costs, according to an analysis by KFF, a nonprofit research organization. (The state already had the highest federal matching rate in the country before the pandemic.)

By moving women from managed care to fee for service, and then paying for fewer services, the state saved money.

Mississippi has the second-highest share of births covered by Medicaid in the country, at 60%.

More than 21,000 Mississippi women gave birth while covered by Medicaid in 2020. Nearly all of them should have been able to continue seeing their doctors until the public health emergency ended. The Biden Administration has not yet said when that will happen, but is expected to extend it until at least January 2023.

Mississippi has a high maternal mortality rate relative to the national average. Black women in Mississippi are three times likelier than white women to die of pregnancy-related complications.

Doctors and public health advocates argue that extending postpartum Medicaid would save lives and improve infant and maternal health by ensuring women have access to health care for the first year of their baby's life. After passing the Senate with broad bipartisan support this year, a proposal to extend coverage to a year postpartum died in the House thanks to opposition from Speaker Philip Gunn, R-Clinton.

Sen. Kevin Blackwell, R-Southaven and chair of the Medicaid Committee, has vowed to reintroduce the legislation. With abortion now banned in Mississippi, lawmakers are under pressure to help families and babies who suffer the nation's highest rate of infant mortality.

Drew Snyder, the director of the Division of Medicaid, has so far declined to take a stance on whether postpartum Medicaid coverage should be extended. But he recently told the talk radio host Paul Gallo that data from the pandemic, when pregnant women didn't lose coverage after giving birth, could be used to inform the conversation.

"Maybe one of the benefits of deferring a decision on this is that Mississippi and every other state is going to have 2021 data to show … Did anything happen with maternal health outcomes?" Snyder said. "Particularly late maternal death … That may be a good argument for advocates of the 12-month [extension] to say, 'Hey, we need to do this.'"

Mississippi doctors and national experts say that idea ignores the effects of COVID-19 on pregnant women. The virus has been linked to higher rates of stillbirth and maternal death.

And now, it appears that many women may not have known they still had health insurance throughout the pandemic.

Henderson saw the coverage help moms – if they knew they had it.

"I have moms who are at two months, four months, six months, 12 months and are on antidepressants and now have those medications covered," she said. "They are getting therapy. They are getting their asthma and hypertension treated. So, I do know from a parent (and) patient standpoint, that my patients have been positively impacted if their mothers have been able to continue with access and continue with coverage in those instances."

-- Article credit to Isabelle Taft of Mississippi Today