Full Scope Medi-Cal Coverage and Affordability and Benefit Program for Low-Income Pregnant Women and Newly Qualified Immigrants
Beginning in 2014, the Department of Health Care Services (DHCS) worked closely with stakeholders to implement the Affordability and Benefit Program for Low-Income Pregnant Women, in accordance with Senate Bill 857, (Chapter 31, Statutes of 2014) Welfare and Institutions (W & I) Code Sections, 14148.65
, subject to federal approvals. These meetings also resulted in collaborations with Covered California to implement Full-Scope health coverage through the Qualified Health Plans (QHPs), subject to federal approvals. In 2015, the meetings were discontinued because DHCS sought federal guidance on pregnancy-related services meeting Minimum Essential Coverage (MEC). DHCS continues to work with stakeholders as part of the Assembly Bill 1296 and Eligibility Expansion
stakeholder workgroup, including the Pregnancy Workgroup subgroup
. Medi-Cal coverage for pregnant women is explained below.
In accordance with W&I Code Section 14102, DHCS is currently working closely with Covered California to establish a no-cost QHP for Newly Qualified Immigrants (NQIs) who are under the five-year bar and who would otherwise be eligible for Medi-Cal benefits under the new adult group under W & I Code Section 14005.60. NQIs will be able to opt into the no-cost plan and receive their medical care from QHP providers. DHCS will pay the monthly premium and any cost sharing charges, including deductibles, coinsurance, copayments or similar charges on behalf of the NQI. NQIs who do not opt into the Covered California no-cost QHP will be eligible for restricted-scope Medi-Cal only. DHCS anticipates implementation in January 2017. Information regarding NQIs and QHP coverage can be found on the Assembly Bill 1296 and Eligibility Expansion stakeholder workgroup listed on the Immigration Workgroup webpage
Medi-Cal Coverage for Pregnant Women includes:
Medi-Cal Coverage for Pregnant Women Between 0 Percent up to 138 Percent Federal Poverty Level (FPL)
Starting August 1, 2015, DHCS received federal approval to expand full-scope benefit coverage to pregnant women with incomes between 0 percent up to 138 percent of the FPL. Eligible pregnant women are required to enroll in a Medi-Cal managed care health plan unless they opt to remain with their physician in Fee-for-Service throughout their pregnancy and postpartum period. The expansion of coverage will ensure that pregnant women receive all medically necessary services.
Medi-Cal Coverage for Pregnant Women Above 138 Percent FPL
In addition, pregnant women with incomes above 138 percent up to 213 percent of the FPL are eligible for pregnancy-related Medi-Cal coverage. Pregnancy-related services are services required to assure the health of the pregnant woman and the fetus. These include, but are not limited to, prenatal care, services for other conditions that might complicate the pregnancy, labor, delivery, postpartum care, and family planning services. Services for other conditions that might complicate the pregnancy, including those for diagnoses, illnesses, or medical conditions which might threaten the carrying of the fetus to full term or the safe delivery of the fetus. Pregnancy-related services may be provided prenatally from the day that pregnancy is medically established and postnatally to the end of the month in which the 60th day following delivery occurs. Drug coverage, prescribed for pregnancy-related services and dispensed within this eligibility time period, includes the full scope of Medi-Cal pharmaceutical benefits. There is no Medi-Cal service that is excluded from pregnancy-related coverage as long as the service is medically necessary. Medi-Cal providers must document a pregnancy diagnosis code on the billing claim form in order to be reimbursed for pregnancy-related services. In California both full-scope and pregnancy-related coverages qualify for minimum essential coverage (MEC).
Medi-Cal Coverage or Qualified Health Plans
Also, pregnant women whose incomes are above 138 percent up to 213 percent of the FPL can choose either pregnancy-related Medi-Cal, explained above, or enroll in a Qualified Health Plan (QHP) through Covered California and receive advanced premium tax credit (APTC) to reduce their monthly premiums. Pregnant women who are enrolled in a QHP prior to becoming pregnant and are eligible for Medicaid may enroll in Medi-Cal or stay enrolled in their QHP and continue to receive APTC and cost share reductions. Pregnant women in this income range may not, however, be enrolled in Medi-Cal and a QHP at the same time.
Medi-Cal Access Program
Pregnant women who have income over 213 percent up to 322 percent of the FPL may be eligible for the Medi-Cal Access Program (MCAP). Pregnant women who are not eligible for full-scope or pregnancy-related Medi-Cal may qualify for the MCAP, regardless of citizenship and immigration status. MCAP offers low-cost comprehensive coverage, with no copayments, deductibles and coinsurance. However, there is a fee equal to 1.5 percent of the yearly family income. The fee can be paid in monthly installments over 12 months. Pregnant women may qualify for both Covered California and the MCAP, but cannot enroll in both programs and must choose one program.
Resources and Documents
DHCS 1115 Demonstration Waiver Amendment submission (pdf)
SPA 14-021: Eligibility Groups - Mandatory Coverage Pregnant Women submission (pdf)