Summary of Pregnancy Coverage Trailer Bill

June 4, 2014

The Governor’s budget proposes offering premium assistance, cost-sharing assistance, and wraparound coverage to pregnant women who enroll in Covered California in lieu of pregnancy-only Medi-Cal. The following is a summary of the trailer bill (Health & Human Services, 602) implementing the provision.

The State will establish a program within Covered California that will provide “no cost coverage” to pregnant women with household incomes between 109-208% FPL who are enrolled in Covered California qualified health plans (QHPs) or opt to enroll in a QHP that is equivalent to full-scope comprehensive benefits for pregnant women in Medi-Cal. This voluntary option for pregnant women will resolve the issues presented by women in this income range being dually eligible for premium assistance through Covered California and pregnancy-only Medi-Cal. The proposal will maximize federal dollars and provide continuity of care.

Pregnant women who chose this option will have their full premium and cost sharing obligations covered first by federal subsidies, then the remainder covered by State payments, equivalent to the second lowest cost Silver plan. Women who choose a more expensive plan will have to pay the difference in premium cost. The State will also provide wraparound benefits for services not available through the QHPs, including Comprehensive Perinatal Services Program (CPSP) benefits. Women enrolled in the program will have access to providers who are contracted with Medi-Cal but not with QHPs.

DHCS will directly compensate the health plans and providers for premiums and cost-sharing. Covered California will set up the infrastructure to accommodate the program through CalHEERS no earlier than January 1, 2015. A process to inform beneficiaries of how to take advantage of various options will be developed and providers will be notified of how to deliver and bill for services within the program.

The bill also considers the reconciliation of federal tax credits. If the beneficiary received excess federal premium subsidies, she can pay the cost due to the federal government upon reconciliation and apply to the department for reimbursement. Likewise, beneficiaries are required to reimburse the State for any extra subsidies obtained through tax refunds. The state has the right to seek to recover the overpayment.

Finally, the bill authorizes full-scope Medi-Cal for pregnant women up to 109% FPL. While pregnant women with citizenship or legal residency qualify for full-scope through MAGI Medi-Cal, undocumented women have been restricted to limited scope. Some advocates are calling for full-scope coverage for pregnant women to go to 138% FPL, aligned with MAGI standards.