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 Code of Federal Regulations (Last Updated: November 8, 2024)
 Title 42 - Public Health
 Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services
 SubChapter C - Medical Assistance Programs
 Part 435 - Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa
 Subpart B - Mandatory Coverage
 Mandatory Coverage of Pregnant Women, Children Under 19, and Newborn Children

§ 435.116 - Pregnant women.  

Latest version.

  • § 435.116 Pregnant women.

    (a) Basis. 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 Act.

    (b) Scope. The agency must provide Medicaid to pregnant women whose household income is at or below the income standard established by the agency in its State plan, in accordance with paragraph (c) of this section.

    (c) Income standard. The agency must establish in its State plan the income standard as follows:

    (1) The minimum income standard is the higher of:

    (i) 133 percent FPL for the applicable family size; or

    (ii) Such higher income standard up to 185 percent FPL, if any, as the State had established as of December 19, 1989 for determining eligibility for pregnant women, or, as of July 1, 1989, had authorizing legislation to do so.

    (2) The maximum income standard is the higher of -

    (i) The highest effective income level in effect under the Medicaid State plan for coverage under the sections specified at paragraph (a) of this section, or waiver of the State plan covering pregnant women, as of March 23, 2010 or December 31, 2013, if higher, converted to a MAGI-equivalent standard in accordance with guidance issued by the Secretary under section 1902(e)(14)(A) and (E) of the Act; or

    (ii) 185 percent FPL.

    (d) Covered services.

    (1) Pregnant women are covered under this section for the full Medicaid coverage described in paragraph (d)(2) of this section, except that the agency may provide only pregnancy-related services described in paragraph (d)(3) of this section for pregnant women whose income exceeds the applicable income limit established by the agency in its State plan, in accordance with paragraph (d)(4) of this section.

    (2) Full Medicaid coverage consists of all services which the State is required to cover under § 440.210(a)(1) of this subchapter and all services which it has opted to cover under § 440.225 and § 440.250(p) of this subchapter.

    (3) Pregnancy-related services consists of services covered under the State plan consistent with § 440.210(a)(2) and § 440.250(p) of this subchapter.

    (4) Applicable income limit for full Medicaid coverage of pregnant women. For purposes of paragraph (d)(1) of this section -

    (i) The minimum applicable income limit is the State's AFDC income standard in effect as of May 1, 1988 for the applicable family size converted to a MAGI-equivalent standard in accordance with guidance issued by the Secretary under section 1902(e)(14)(A) and (E) of the Act.

    (ii) The maximum applicable income limit is the highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) of the Act or under section 1931(b) and (d) of the Act in effect under the Medicaid State plan or waiver of the State plan as of March 23, 2010 or December 31, 2013, if higher, converted to a MAGI-equivalent standard.

    [77 FR 17204, Mar. 23, 2012, as amended at 78 FR 42302, July 15, 2013]