If a woman indicates on her Covered California individual and family plan account that she is pregnant, the application will be automatically screened for eligibility of certain Medi-Cal pregnancy programs. Some women have found that they are kicked off their private health plan with the premium assistance and relegated to the health care services only from Medi-Cal. This means they may not be able to see their regular OBGYN for pre-natal visits. However, you do not have to report your pregnancy to Covered California and risk being forced onto Medi-Cal.
Reporting a pregnancy may result in Medi-Cal coverage
It was with good intentions that Covered California changed their CalHEERS online health insurance application to screen for additional Medi-Cal services for women who indicate they are pregnant. Unfortunately, the Covered California enrollment system can now strip a pregnant woman of her private health insurance and force her into a county Medi-Cal program depending her household income. Many mothers-to-be have found this exasperating as they just want to see their current OBGYN, who may not be a Medi-Cal provider, and may not want or need the reduced cost sharing that the Medi-Cal pregnancy programs provide.
Covered California triggers Medi-Cal enrollment for pregnant women
Initially when Covered California was launched a woman could indicate she was pregnant and she would receive additional information about the various Medi-Cal pregnancy assistance programs available to her. The unborn child was not figured into the calculation for the premium tax assistance. A pregnant woman and her spouse were considered a household of two for the purposes of determining the Advance Premium Tax Credits to lower the monthly health insurance premium.
California Healthline has done a follow-up story on the numbers of women who have been forced in Medi-Cal when they reported they were pregnant.
Lynn Kersey, executive director of Maternal and Child Health Access, an advocacy group based in Los Angeles County, also suggested that women who bought health insurance policies from Covered California and want to keep them should not report their pregnancies to the agency. She has two clients whose plans were canceled without notice. – Kaiser Health News, “Lawmakers Demand Quick Action on Covered California Pregnancy snafu“
Federal Poverty Levels and income
However, if a woman indicates she is pregnant, Medi-Cal then views the household as a total of three individuals. This changes the family’s income in relation to federal poverty level (FPL) guidelines. For example, a husband and wife, household of two, report income of $39,825. Under the 2015 Covered California income chart they are 250% of the FPL. If the woman indicates she is pregnant, it is a household of three and their income drops to under 213% of the FPL and the woman will be placed into the Medi-Cal pregnancy program. Her spouse or domestic partner will continue on the private health plan with the subsidy. 2015 Covered California Income Chart
Loss of Enhanced Silver Plan benefits
In a similar situation, a single woman with a reported income of $17,655 is at 150% of the FPL. If she reports she is pregnant, she is now a household of two and her income drops below 138% of the FPL and is automatically enrolled in Medi-Cal. Ironically, the single woman with an income of between 138% and 213% of the FPL is eligible for an Enhanced Silver plan that include reduced cost sharing such as a lower deductible and office visit copayments. While Medi-Cal coverage is no cost to the pregnant woman in this scenario, she may lose the ability to visit her chosen OBGYN for pregnancy related services.
You don’t have to tell Covered California you are pregnant
Of course, pregnant women are under no obligation to report their pregnancy to Covered California. You must report the birth of your child so the newborn can be enrolled in the family health plan. The Medi-Cal pregnancy programs can be very beneficial to the family to help to reduce the costs associated with child birth.
Covered California has issued a synopsis of the byzantine rules regarding pregnancy.
2016 Pregnancy Coverage Quick Sheet Certified Enrollers
Pregnant Women Have Coverage Options
Pregnant women have multiple coverage options when applying on CoveredCA.com or when reporting changes in the application. These options include Medi-Cal for Pregnant Women, the Medi-Cal Access Program (MCAP), and Covered California Health Plans.
When applying for coverage on CoveredCA.com, pregnant women are first evaluated for their eligibility for Medi-Cal and MCAP based on the monthly Modified Adjusted Gross Income (MAGI) of their household (the number of expected babies is included in the household size for Medi-Cal).
New applicants who are pregnant with a household income up to 213% of the Federal Poverty Level (FPL) will be determined eligible for Medi-Cal. Pregnant women whose household income is over 213% and up to 322% FPL are eligible for MCAP, or may elect coverage with a Covered California Health Plan during open enrollment or if they have a qualifying life event for special enrollment.
While it is not necessary to report a pregnancy to Covered California, it is necessary to report the birth of a baby to Medi-Cal, MCAP, or Covered California so that eligibility can be re-determined for the household.
Pregnancy Coverage by Federal Poverty Level (FPL)
Medi-Cal for Pregnant Women (M9)
Previously was a restricted-scope aid code for pregnancy services only, and not considered Minimum Essential Coverage (MEC). It is now considered MEC and covers all the same services full-scope Medi-Cal offers.
- Household monthly income over 138% and up to 213% FPL.
- Eligibility ends at the end of the month of the 60 days after the birth of the baby (or end of pregnancy)
- Women must report a birth or end of pregnancy to their County Eligibility Worker within 30 days, at which time eligibility will be redetermined.
- For current Covered California health plan consumers, reporting a pregnancy will reevaluate eligibility for the pregnant consumer using the above FPL range. Unless an existing Covered California consumer wants to switch to Medi-Cal or MCAP, reporting a pregnancy is not necessary nor recommended. If a break in coverage results from reporting a pregnancy, contact the Covered California Service Center.
- Consumers who are interested in switching coverage from Covered California to Medi-Cal can call the Covered California Service Center to have their eligibility reevaluated.
Medi-Cal Access Program (MCAP)
- Household monthly income between over 213% and up to 322% FPL.
- Must be a resident of California and agree to pay 1.5% of the household MAGI as a subscriber contribution.
- Consumer’s information is automatically sent from the online application to the MCAP program (not the local county) and enrollee will be contacted to complete the enrollment.
- Pregnant consumers who are eligible for MCAP are allowed to switch to Covered California during open enrollment or if they have a qualifying life event for special enrollment. Consumers can contact the MCAP program at their website http://mcap.dhcs.ca.gov or at 800-433-2611 for any questions about the program or to check the status of an application.
Pregnancy Program Income Guidelines
The monthly income guidelines for eligibility in Medi-Cal and MCAP are listed below. These amounts are valid until the Department of Health Care Services updates them in 2016.
|2015 Monthly Federal Poverty Levels for Pregnancy Coverage|
|Family Size*||138% (up to this income qualifies for Medi-Cal)||213% (up to this income qualifies for Medi-Cal for Pregnancy M9)||322% (up to this income qualifies for MCAP)|
*Medi-Cal includes expected baby/babies in FPL and Covered California does not
Women are smart enough to make their own choices
Women should not be forced into Medi-Cal based on being pregnant and their income. They should be able to opt-in to such programs or retain their current health plan with their current providers. Automatically pushing a pregnant woman into Medi-Cal is the sort of paternalistic government approach that so many people feared with health care reform. While the forced Medi-Cal enrollment is well intentioned, no doubt at the behest of many Medi-Cal proponents and health plans, the unintended consequences is that it robs women of making their own health care choices for their pregnancy.
Quick fact sheet on Medi-Cal pregnancy programs offered through Covered California based on income.
|Date:||February 11, 2016|