When Katie Silvia learned she was pregnant in November 2016, her first call wasn’t to her obstetrician – it was to the Alabama Medicaid office.
Her husband had received a letter from Blue Cross Blue Shield of Alabama that his insurance, a Blue Cross plan purchased through the health exchange, was not going to cover her pregnancy because their income level qualified her for pregnancy Medicaid.
But according to doctors and patients, Alabama’s complex maternity Medicaid process can mean some moms don’t get their first OBGYN appointment until they’re well into their second trimester, 13 or more weeks into their pregnancies.
After she applied online for Medicaid, Silvia heard nothing for several weeks. She tried calling the Medicaid office in Montgomery but got no answer. She called the Best Start program – which administers the Medicaid maternity care program for part of North Alabama – and they told her to try reapplying.
But the Medicaid website wouldn’t let her reapply.
In the meantime, she was able to schedule her first OBGYN appointment because she was still on her husband’s insurance through the end of December.
“When I went for my eight-week appointment, I was actually 12 weeks along and hadn’t known it,” she said. That was just before Christmas.
Medicaid covers more than half of all births in Alabama – 52.6 percent. And while most obstetricians prefer to see their patients for their initial exam when they are eight weeks pregnant – or about four weeks after a woman would get a positive result on an at-home pregnancy test – Alabama Medicaid has more than six weeks to approve an application once it’s filed.
At the same time, the percentage of Alabama women receiving adequate prenatal care has dropped in recent decades, from 79 percent in 2003 to 75 percent in 2015, according to the Alabama Department of Public Health. More than a quarter of rural Alabama mothers receive less than adequate prenatal care.
“There isn’t any individual doing something purposely malevolent to individual pregnant women,” said Dr. John Waits, an obstetrician and the director of Cahaba Family Medicine in rural Bibb County. Cahaba is a Federally Qualified Health Center, meaning it’s a primary source of medical care for the uninsured and those who have Medicaid.
“Family doctors, OBGYNs, social workers, Medicaid, maternity waiver folks – everybody is working hard and everybody is doing good things, but we’ve created these convoluted steps patients can’t navigate,” he said. “It’s nobody’s fault, but it’s everybody’s fault for not fixing it.”
How it works
Most OBGYN offices require a patient to have Medicaid or other insurance before making the first prenatal appointment.
Women can apply for pregnancy Medicaid in person at the county health department, apply online, or make an appointment with a Medicaid outreach worker – if there is one in their county – and get assistance filling out the paperwork.
Online enrollment requires computer and internet access, and the ability to scan or create digital copies of the paperwork required to apply – including proof of pregnancy, proof of citizenship status and proof of income. You can have someone from Medicaid contact you later about getting those documents, though that will add wait time to your application.
Alternately, you can go to the Medicaid office in your county to apply in person, as long as you have all the necessary paperwork – and are able to find transportation.
Office hours for the Medicaid office vary by county, but a lack of funding means that the Medicaid officer isn’t there all the time. In rural areas, they’re often available one day a month or a half-day each week.
So if, for example, you don’t show up on a Tuesday afternoon or the first Friday of the month, you will have missed the Medicaid window until next week or month. If you did make your appointment but you’re missing one piece of paperwork, you’ll have to come back the next time a Medicaid officer is in your county.
After you apply, Medicaid has 45 days to approve or deny the application. Medicaid was unable to provide AL.com with information on the average length of time it takes to approve an application.
“The sad news is it takes 4-6 weeks, regardless of how you do it,” said Laura Thompson, director of Best Start, which administers social services for Medicaid moms in North Alabama. The extended wait time between application and actually seeing a doctor is “something we have identified for years that is an issue,” she said.
Once you are approved, you must make an appointment with your local Medicaid Maternity Care program, a network of contractors that provide social services and assist in making OBGYN appointments.
“They really care about maternity and do great work,” said Waits of the state’s maternity care case workers. “They assign case managers and have social workers available, they do home visits and hospital visits. But it’s another step in the process.”
Thompson said once a woman has been approved for Medicaid and calls the Best Start Office, which administers the Medicaid Maternity Care program in North Alabama, Best Start gets the woman an appointment within two weeks of that call.
For 16 counties in Alabama, however, there is no Medicaid Maternity Care Program. Women in those counties, located in the Black Belt and in south Alabama, must locate their own doctor that accepts Medicaid.
Silvia kept calling Medicaid in January. Eventually the Alabama Medicaid website let her reapply.
Weeks passed and still she heard nothing. She kept calling.
“I had to go to my 18-week appointment and get (an ultrasound)” without Medicaid, she said. “I just went and didn’t say anything until after the appointment.
“I told them, ‘I’m having an insurance issue with Medicaid’ and they were like, ‘Everybody’s having an insurance issue with Medicaid.'”
A couple weeks later, she finally got a letter saying she’d been approved. By that point, she was halfway through her pregnancy.
See them anyway
Dr. Jesanna Cooper, an OBGYN at the Simon-Williamson Clinic in Birmingham, chooses to accept patients before their Medicaid has been approved.
“We will go ahead and see them because they need the care,” said Cooper. “They’ll get their tests and sonogram, but if we pick something up like an STD, we can give them a prescription but they can’t get it filled until they get Medicaid approval.
“The doctor is taking a risk they’re not going to get paid for the service,” she said. “It’s very practice-dependent, and that’s going to affect how soon you get seen (by a doctor).”
At Waits’ practice in Bibb County, doctors tell patients to come in as soon as they get a positive pregnancy test.
“We have always thought the Medicaid enrollment process made it difficult for women to get into prenatal care early enough,” said Dr. Lacy Smith, who works with Waits and is chief medical officer at Cahaba Medical Care.
“This is definitely a big component for women who normally would present on time but are now having to navigate a complicated, multi-step insurance enrollment process with not always a lot of assistance or adequate transportation.”
Cahaba has gone further than most clinics are able to go, employing a social worker to help its patients with Medicaid enrollment and doing in-house enrolling of patients into the Medicaid Maternity Care Program. Cahaba also pushed to get a Medicaid worker to hold office hours at the clinic.
Even with those extra supports in place, it can be hard to get women to show up for prenatal care on time, said Smith.
Some delay applying or seeking care for personal reasons, ranging from not wanting parents or a spouse to know about the pregnancy to lack of education to drug abuse.
“We have them all across the spectrum of compliance,” said Thompson, the Best Start director. “Some women, no matter how quickly you got them on Medicaid, probably wouldn’t get in to care more quickly.
“But you do have a population who want to do the right things and want to get into care quicker.”
On average, about 64 percent of Medicaid mothers receive a prenatal visit in the first trimester or within 42 days of enrollment, according to a Medicaid representative.
“There are only a handful of issues we can intervene on, and a lot of them depend on (a pregnant woman) being seen in the first trimester,” said Waits.
“But we’ve created a system where everybody is doing their job and yet we can’t find the political wherewithal to fix the system.”
A new system
Change to maternity Medicaid may be coming. In October, Medicaid plans to place all of its maternity care management under contracted Regional Care Organizations. One goal of the new RCO system is to get 80 percent of women to have their first prenatal visit in their first trimester.
There are still unknowns about how the new RCO system will affect women on maternity Medicaid.
“There are good people working on RCOs,” said Waits. “I’m always planning for the worst but hoping for the best, and I think there’s an opportunity for them to fix several of these steps in case management.”
In the meantime, he said he thinks Alabama doctors could help fill the gap between when women apply for Medicaid and when they’re approved.
“A Band-Aid while we do the hard work of healthcare policy reform is to allow that a positive pregnancy test equals an appointment,” he said. “To me, the easiest fix is – I’m sorry – but it’s Medicaid expansion. If we had expanded Medicaid, everybody would have had coverage.”
For women like Silvia, waiting for approval can add an extra layer of stress and uncertainty during an already overwhelming time.
“If I hadn’t just gone, I would have been there at 21 weeks (pregnant), making my first appointment,” she said.
“All you can do is hope it all pans out.”