Zero-Cost Coverage for Pregnant Women

In California’s work to implement and Improve the ACA, our legislative advocate Beth Capell reports on one victory in the budget to win zero-cost coverage for low- and moderate-income pregnant women:

In state budget health trailer bills passed this evening, effective January 1, 2015, California will provide zero-cost, full-scope Medi-Cal to pregnant women up to 138% FPL and providing zero cost coverage for pregnant women 139%-208% FPL by coordinating Medi-Cal coverage with coverage through Covered California. This is a real victory for low and moderate income pregnant women and their families.

Low and moderate income pregnant women will get help paying for coverage and more comprehensive benefits just at a time when a family needs every dollar for maternity clothes and baby gear. Women will no longer face the nonsensical situation of being eligible for two sets of uncoordinated benefits, one through Medi-Cal which is zero cost but limited benefits and another through Covered California which has significant premiums and copays/deductibles but comprehensive coverage. Starting in January, pregnant women below 208%FPL (about $23,000 for a single woman or $32,000 for a couple) will be eligible for zero cost, comprehensive coverage, including dental during the pregnancy.

Pregnant women with incomes 109% FPL-208% FPL are eligible for both pregnancy-only Medi-Cal and Covered California but today the benefits are not coordinated. What does this mean?

  • A woman making as little at $13,000 a year is required to pay 2% of her income on premiums for Covered California and up to $2,250 in copays, deductibles and other out of pocket costs to get comprehensive coverage.
  • Pregnancy-only Medi-Cal was implemented more than 20 years ago: it is not comprehensive coverage because it only covers the pregnancy, not a broken leg, not breast cancer, not diabetes that predates the pregnancy.
  • Pregnancy-only Medi-Cal benefits are not coordinated with Covered California: in many counties, the insurers contracted with Medi-Cal are different than the insurers contracted with Covered California.
  • The benefits are different: women on Medi-Cal get dental, enhanced psycho-social support and more nutrition counseling while women in Covered California get commercial benefits.
  • And importantly, starting next year, a woman who has pregnancy-only Medi-Cal faces the individual mandate penalty while a woman covered through Covered California does not.

Under the agreement reached between the Administration and the Legislature, pregnant women will get the best of both worlds—and the General Fund will save $60-$65 million as pregnant women 139%-208%FPL get their basic coverage through 100% federal funded Covered California rather than Medi-Cal which is 50/50 state/federal.

Pregnancy-Only Medi-Cal Covered California Coordinated Benefits: Effective Jan 1, 2015
Cost of Coverage
  • Zero premium
  • Zero co-pays
  • Premium: 2% to 6.3% of income, scaled to income
  • Out of pocket max: up to $5200
  • Zero premium
  • Zero co-pays
  • Pregnancy-only
  • Dental during pregnancy
  • No coverage for breast cancer, broken leg, etc., if not related to pregnancy
  • Comprehensive medical
  • No Dental
  • Comprehensive medical coverage
  • Adds Dental during pregnancy
  • Women 109%-208%FPL
  • Women over 109% FPL
  • Full-scope Medi-Cal: Women below 138%FPL
  • Coordinated benefits: Women 139%-208%FPL
Open Enrollment? Anytime
  • Limited to open enrollment periods or life events (special enrollment)
  • Pregnancy does NOT qualify for a special enrollment
  • Limited to open enrollment periods or life events (special enrollment)
  • Pregnancy does NOT qualify for a special enrollment
  • Women can enroll in pregnancy-only Medi-Cal anytime and get coordinated benefits at next open enrollment
Individual Mandate? Penalty applies because limited benefits No penalty: comprehensive benefits No penalty: comprehensive benefits

Much thanks to Elizabeth Landsberg from the Western Center on Law and Poverty and other advocates for the leadership work on this issue. California has done much to implement, and improve on, the Affordable Care Act: this is one more piece of that work.