COVERAGE FOR
PREGNANT WOMEN UNDER
HEALTH CARE REFORM
December 18, 2013
County Welfare Directors Association of California
•
Cathy Senderling-McDonald
Los Angeles County
•
Isabelle Maggio
Maternal and Child Health Access
•
Lucy Quacinella of Multiforum Advocacy Solutions
Revised 12/19/13
OVERVIEW OF TRAINING
• Importance of Care During Pregnancy
• Existing Programs for Pregnant Women
• New Programs for Pregnant Women
• Minimum Essential Coverage (MEC) and Medi-Cal
• Programs for Pregnant Immigrants
• Modified Adjusted Gross Income (MAGI) Aid Codes and
Federal Poverty Levels
2
QUICK NOTE
For the purpose of this presentation:
•
We will use the term MAGI, when referring to new programs implemented
under Health Care Reform (HCR).
•
We will use the term Non-MAGI, when referring to current Medi-Cal
programs.
• A childless pregnant woman is considered a childless adult until she
reaches her 3rd trimester and would not be aided under the Medi-Cal
expansion.
• A pregnant woman in her 3rd trimester, is evaluated under the MAGI
“Parent/Caretaker Relative category for full-scope benefits if her income
is at or below 109% of the Federal Poverty Level (FPL). Applicable aid
codes are M3 and M4.
• Wherever reference is made to benefits for pregnant women being
limited, that is true unless the woman has linkage to other available
programs.
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IMPORTANCE OF CARE DURING PREGNANCY
• Prenatal care is important for both maternal and child health.
Babies of mothers who do not get prenatal care are three times
more likely to have low birth weight and five times more likely to
die than those born to mothers who do get care.
(Womenshealth.gov accessed 11-25-13)
• Pregnancy is an “immediate need” situation for processing
applications!
• California improved birth outcomes with major Medi-Cal
expansions in 1989-90.
• Medi-Cal covers half of all women giving birth - about 250,000 of
the state’s 502,023 births.
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PROGRAMS CURRENTLY AVAILABLE FOR PREGNANT WOMEN
• Presumptive Eligibility (PE) for Pregnant Women
• Limited-Scope Medi-Cal Programs
Asset Waiver Program
Income Disregard Programs for Pregnant Women and Infants
200% Parental Disregard for Pregnant Teens
Minor Consent Services
• Full-Scope Medi-Cal when all Eligibility Requirements are Met
No Share-of-Cost (SOC):
 Medically Indigent (MI) and Medically Needy (MN)
SOC:
 MI and MN
• Other
60-Day Post-Partum Period for Medi-Cal
Continued Eligibility (CE) for Medi-Cal
Access for Infants & Mothers (AIM)
Notes:
• In Medi-Cal, for purposes of household size, a pregnant woman counts as two
persons. She counts as more, if multiple births are expected.
• Self-attestation for pregnancy is accepted.
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NEW PROGRAMS FOR PREGNANT WOMEN
• Hospital Presumptive Eligibility (HPE) Gateway
• MAGI Medi-Cal for Pregnant Women
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EXISTING PROGRAMS
FOR PREGNANT
WOMEN
Presumptive Eligibility
Medi-Cal Programs
Access for Infants & Mothers
7
PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN
Current benefits:
•
Presumptive Eligibility (PE) for pregnant women allows Qualified Providers to grant immediate,
temporary Medi-Cal coverage to low income, pregnant patients, pending a final eligibility
determination on their formal Medi-Cal application. Benefits include:




Ambulatory prenatal care.
Prescription drugs for conditions related to pregnancy.
Outpatient hospital services.
Preventive dental care.
•
Applicant must apply at a Qualified Provider’s office.
•
Family income must be at or below 200% of the FPL. Applicant must attest to income and state
residency. Satisfactory Immigration Status (SIS) is not required.
•
Eligibility begins with the day of application and ends the last day of the following month, unless
the applicant applies for Medi-Cal. If an application has been submitted, PE is then extended
until a determination has been made.
What changes with HCR?
•
•
There will be no changes to current regulations with the implementation of HCR.
The FPL will increase from 200% to 213%, reflecting the new MAGI income methodology.
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ASSET WAIVER PROGRAM (PREGNANT WOMEN)
Current benefits:
•
This program provides limited-scope Medi-Cal coverage to pregnant women who have
income at or below 200% of the FPL.
•
Property under the asset waiver program is disregarded when determining eligibility.
•
Coverage is restricted to pregnancy-related services.
•
Eligibility begins with the first day of the month for which pregnancy is verified.
Self-attestation of the pregnancy is accepted.
•
Eligibility ends on the last day of the month in which the 60-day post-partum period ends.
•
Current program aid codes are 44 and 48.
What changes with HCR?
•
•
•
This program will be part of the new federal MAGI group for pregnant women.
The FPL will range from 61% up to 213%, reflecting the new MAGI income methodology.
Program aid codes will change to M9 and M0.
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ASSET WAIVER PROGRAM (INFANTS)
Current benefits:
•
This program provides Medi-Cal coverage to infants under age 1 who have income
at or below 200% of the FPL.
•
Property under the asset waiver program is disregarded when determining
eligibility.
•
Infants receive full-scope Medi-Cal coverage if they are U.S. citizens or have
Satisfactory Immigration Status (SIS).
•
Infants without SIS receive restricted-scope benefits for emergency services only.
•
Coverage ends when the infant turns 1 year old, unless the infant is in an inpatient
status, which began before the infant’s first birthday.
What changes with HCR?
•
•
•
This program will be part of the new federal MAGI group.
There will be no changes to eligibility or benefits provided under this program.
The FPL will increase from 200% up to 208%, reflecting the new MAGI income
methodology.
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INCOME DISREGARD PROGRAM (PREGNANT WOMEN AND CHILDREN)
Current benefits:
• To initially qualify under this program, net non-exempt family income must be
over the Maintenance Need Level, but not to exceed 200% of the FPL.
• The amount of the income disregard is the difference between 200% and
185% of the FPL for the family size.
• Only cases with a Share-of-Cost (SOC) are potentially eligible for the Income
Disregard Program.
• Assets are also waived under this program.
• Coverage for women is restricted to pregnancy-related services.
What changes with HCR?
• There will be no changes to current regulations with the implementation of
HCR.
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200% PARENTAL DISREGARD FOR PREGNANT MINORS
Current benefits:
• All income from a parent or parents of a pregnant minor who live
together in the home is disregarded when determining eligibility for the
Income Disregard (200%) program if the minor is not eligible using regular
rules.
• This includes a pregnant minor who is between the age of 18 and 21 and
claimed as a tax dependent by her parents even though she does not
live in the home of her parents.
• Only the non-exempt income of the pregnant minor, her unborn child’s
father, or her spouse, if applicable, will be counted in the determination.
What changes with HCR?
• There will be no changes to current regulations with the implementation
of HCR.
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60-DAY POST-PARTUM PERIOD FOR MEDI-CAL
Current benefits:
• A pregnant woman who was eligible for and received Medi-Cal during
the last month of pregnancy continues to be eligible for Medi-Cal for a
60-day period, whether or not the other conditions of Medi-Cal eligibility
are met.
• 60-day post-partum period begins after pregnancy ends (birth of child or
termination of pregnancy).
• Eligibility ends on the last day of the month in which the 60-day
post-partum period ends.
What changes with HCR?
• Coverage during the post-partum period is available for all pregnant
women who qualify for Medi-Cal, whether they receive MAGI or
non-MAGI Medi-Cal benefits.
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CONTINUED ELIGIBILITY AND DEEMED ELIGIBILITY
Continued Eligibility (CE) current benefits:
•
Once a pregnant woman has been approved for Medi-Cal benefits, increases in
income are not counted in her SOC determination for pregnancy-related services,
throughout the pregnancy, until the end of her 60-day post-partum period.
Deemed Eligibility (DE) current benefits:
•
An infant whose mother is eligible for, and receiving Medi-Cal in the month of
delivery is automatically “Deemed Eligible” for full-scope Medi-Cal for one year
without a separate application or submission of a social security number and
regardless of the mother’s immigration status.
•
Increases in the family’s income or other changes in the MFBU, which could cause
ineligibility, do not affect the newborn’s eligibility for Medi-Cal until the child
reaches age 1.
What changes with HCR?
•
There will be no changes to current regulations with the implementation of HCR.
14
MINOR CONSENT SERVICES
Current benefits:
•
Minor Consent is a state-only program which excludes parental income and
resources from consideration as a condition of Medi-Cal eligibility for certain,
limited services to youth under the age of 21 who live with their parent(s) or
guardian(s). The application and all services provided are confidential.
•
Provides services related to sexual assault, pregnancy, family planning, sexually
transmitted diseases, drug or alcohol abuse, and outpatient mental health care.
•
To consent to receive services related to sexually transmitted diseases, drug or
alcohol abuse, or outpatient mental health care, the minor must be 12 years of age
or older.
•
There are no age restrictions for services related to sexual assault, pregnancy, or
family planning.
What changes with HCR?
•
There are no changes to the Minor Consent Program with the implementation of
HCR.
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ACCESS FOR INFANTS & MOTHERS
Current benefits:
•
Access for Infants & Mothers (AIM) is administered by the Managed Risk Medical Insurance
Board.
•
To qualify for AIM, the woman must not be more than 30 weeks pregnant when applying, a
California resident, ineligible for no-cost Medi-Cal (income above 200% of the FPL), not
receiving Medicare Part A and Part B, and uninsured or covered by private insurance with a
separate maternity deductible or copayment of more than $500.
•
SIS is not required.
•
A pregnant woman enrolled in AIM receives care from an AIM health plan.
•
AIM provides comprehensive coverage and is not limited to pregnancy-related care.
•
The pregnant woman pays 1.5% of her annual gross income to participate in AIM, with no
co-pays.
•
AIM infants are “deemed eligible” for coverage for the first year. If family income is at or below
250% of the FPL, they are enrolled in Medi-Cal. If income is over 250%, they are currently
enrolled in Healthy Families with no income limit during the first year and with income up to
300% in the second year.
What changes with HCR?
•
FPLs for the AIM program will increase to between 214% - 322%.
16
NEW PROGRAMS FOR
PREGNANT WOMEN
Hospital Presumptive Eligibility Gateway
MAGI Medi-Cal for Pregnant Women
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HOSPITAL PRESUMPTIVE ELIGIBILITY GATEWAY
•
The Hospital Presumptive Eligibility (HPE) Program provides temporary no SOC Medi-Cal benefits
during a presumptive period to individuals determined eligible by a qualified hospital, on the
basis of preliminary information.
•
The HPE program begins on January 01, 2014. The eligibility determination is based on the
applicant’s self-attestation of income, household size, and state residency provided on the HPE
application.
•
Individuals potentially eligible for Hospital PE benefits are uninsured California residents, who
are:




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Pregnant women.
Children (0-18 years of age).
Adults (19-64 years of age) not pregnant, and not on Medicare.
Parents/Caretaker relatives.
Individuals between the ages of 18-26, who received Foster Care on their
18th birthday.
•
The 60-day HPE period begins the first day of the month the HPE application is approved and
may end the last day of the following month.
•
The patient must submit a completed Medi-Cal application before her HPE period terminates in
order to be eligible for continued coverage beyond the 60-day HPE period and/or retroactive
coverage back to 3 months from the date of the Medi-Cal application.
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MAGI MEDI-CAL FOR PREGNANT WOMEN
Rule for Applicants:
•
Pregnant applicants are not eligible under the new adult expansion category, with the
exception noted in the third bullet (below).
•
Pregnant applicants who have income between 0%-60% of the FPL will be eligible for
full-scope Medi-Cal benefits under the new MAGI category for pregnant women.
Coverage will be full scope for citizens and those with SIS, and limited scope for those
without SIS (aid codes M7 and M8).
•
A pregnant women in her 3rd trimester with income of 61% - 109% FPL will be covered
under the MAGI parent/caretaker relative category, with no assets test. Coverage is full
scope for citizens and those with SIS, and limited scope for those without SIS (aid codes
M3 and M4).
•
Pregnant applicants with income of 61% -109% in the 1st and 2nd trimesters with no
linkage, and pregnant applicants with income of 110% - 213% in any trimester, will be
eligible to limited scope – pregnancy services only (aid codes M9 and M0).
 When evaluation for the pregnant applicant results in limited-scope services,
the pregnant applicant should also be evaluated for:
 MN/MI (all trimesters) without a SOC.
 MN/MI with a SOC.
 AIM .
 Advanced Premium Tax Credits (APTC).
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MAGI MEDI-CAL FOR PREGNANT WOMEN
Rule for Applicants:
Income Level
Trimester
ACA Coverage
Group
Scope of Coverage
0 – 60% FPL
1st, 2nd or 3rd
Pregnant Woman
Citizen/SIS: Full
No SIS: Pregnancy Only
61% - 213%
1st or 2nd
Pregnant Woman
Pregnancy Only
61% - 109% FPL
3rd
Parent/Caretaker
Citizen/SIS: Full
No SIS: Pregnancy Only
110% - 213% FPL
3rd
Pregnant Woman
Pregnancy Only
20
MAGI MEDI-CAL FOR PREGNANT WOMEN
Rule for Beneficiaries:
•
Women who are already enrolled in MAGI Medi-Cal under the new childless adult
expansion program at the time of becoming pregnant, will continue to be eligible
to benefits under MAGI Medi-Cal.
 Scenario:
 30-year-old, childless adult with income at 135% of the FPL
applies for Medi-Cal benefits in February 2014 and is eligible to
full-scope MAGI Medi-Cal.
 In June 2014, she becomes pregnant. She will continue with
full-scope benefits, including pregnancy-related services under
MAGI Medi-Cal.
•
Federal guidance indicates that states are not required to monitor or report
pregnancy status for adults who have enrolled in the new 138% adult expansion
program.
21
MINIMUM ESSENTIAL
COVERAGE & MEDI-CAL
Minimum Essential Coverage Benefits
Full-Scope vs. Limited-Scope Medi-Cal Coverage
Dual Enrollment
22
MINIMUM ESSENTIAL COVERAGE BENEFITS
•
Beginning in 2014, most individuals will be required to have Minimum Essential Coverage
(MEC) or pay a penalty with their tax return.
•
A person has MEC if he or she has:



•
An eligible employer-sponsored plan;
An individual policy (obtained through or outside Covered California); or
A government plan (Medicare, Medi-Cal without a SOC, TRICARE, VA, etc.)
MEC benefits include:










Ambulatory patient services.
Emergency services.
Hospitalization.
Maternity and newborn care.
Mental health and substance use disorder services, including behavioral
health treatment.
Prescription drugs.
Rehabilitative and habilitative services and devices.
Laboratory services.
Preventative and wellness services and chronic disease management.
Pediatric services, including dental and vision.
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MINIMUM ESSENTIAL COVERAGE: FULL-SCOPE VS. LIMITED-SCOPE MEDI-CAL
• Full-scope Medi-Cal coverage during pregnancy (or any other
time) is considered to meet MEC rules.
• Pregnancy-only coverage under Medi-Cal is not considered to
meet the MEC requirement as mandated by federal regulations.
• However, pregnant women will not be penalized in 2014 for the
months in which they are enrolled in limited-scope Medi-Cal.
Note: The rules on MEC are different for AIM.
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DUAL ENROLLMENT
•
Under HCR, pregnant women will be eligible to full-scope benefits if their income is at or
below 60% of the FPL, 109% in the third trimester, or 138% if they have other children in the
home. Otherwise, limited-scope pregnancy-related benefits are available to pregnant
women with income at or below 213% of the FPL.
•
Pregnant women who enroll in both the 200% Program for their pregnancy-related
services and Non-MAGI Medi-Cal, are considered to have met the MEC requirement
when the woman has no SOC or her SOC has been met.
Note: Final federal guidance on SOC is still pending and subject to change.
•
Pregnant women might prefer dual enrollment in both the 200% Program and MI/MN
Programs, even with a SOC, instead of enrollment in a Covered California health plan.
 Unlike Medi-Cal, Covered California requires monthly premiums and
co-payments for labor and delivery and other services (though not for prenatal
or other preventive care).
 Medi-Cal includes pregnancy-related benefits that are not available through
Covered California, such as the Comprehensive Perinatal Services Program
(CPSP) and preventive dental care.
 Such considerations are especially important for women with high-risk
pregnancies and very limited income.
25
DUAL ENROLLMENT
• Since the 200% Program is not considered to meet the MEC
requirement by itself, pregnant women can qualify under
the federal rules for APTC and Cost Sharing Reduction (CSR)
subsidies through Covered California to reduce
out-of-pocket costs.
• If a pregnant woman, who is eligible for Medi-Cal’s 200%
Program, also enrolls through Covered California, she will be
responsible for paying an insurance premium, and will have
to use Covered California’s coverage for maternity services
as primary coverage, due to Medi-Cal’s “Other Health
Coverage” (OHC) rules.
26
PROGRAMS FOR
PREGNANT IMMIGRANTS
Immigrants With Satisfactory Immigration
Status
Immigrants Without Satisfactory
Immigration Status
27
PROGRAMS FOR PREGNANT IMMIGRANTS
Immigrants with SIS, Regardless of the Federal 5-Year Bar Requirement:
• Medi-Cal eligibility and scope of benefits are the same as for citizens.
• Depending on income, pregnant women may be eligible to full-scope Medi-Cal benefits
with or without a SOC, AIM, and/or an Advanced Premium Tax Credit (APTC) through
Covered California, in addition to pregnancy related services.
Immigrants without SIS:
• If all other eligibility requirements are met, undocumented immigrants or others without SIS
are eligible for:
 Emergency-related services.
 Pregnancy-related services:
 Prenatal care.
 Labor and delivery.
 Post-partum care to the end of the month in which the 60th day of post-partum
occurs.
 Post-partum family planning services.
 Preventive and emergency dental services.
•
May seek health services at community health centers or safety-net hospitals.
28
MAGI AID CODES AND
FEDERAL POVERTY
LEVELS
Pregnant Women
Infants
29
MAGI AID CODES AND FEDERAL POVERTY LEVELS
30
ADDITIONAL
INFORMATION
Pending Future Guidance
31
PENDING FUTURE GUIDANCE
• Amount of increase in FPL for Income Disregard Program.
• Applicable Affordable Care Act (ACA) category for Income
Disregard Program.
• Labor and delivery coverage under the HPE Program.
• Decision on whether Medi-Cal with an unmet SOC meets MEC.
• Policy to be determined on Medi-Cal Premium Assistance for
pregnant women with income at or below 200% of the FPL who
enroll through Covered California.
• Administration of AIM program and integration with
Medi-Cal.
32
QUESTIONS?
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