When some of us were out on summer vacation, two rulings came down regarding Obamacare subsidies provided through Exchanges. One appeals court rejected challenges to the law; but another three-judge appeal court panel split 2-1 in accepting the idea that the federal Exchange is not able to provide subsidies.

Apparently, there was some ambiguous language in the Affordable Care Act, which indicated that those in state-run exchanges would get affordability subsidies, but it wasn’t totally explicit that patients in states using the federal fallback exchange should also have access to these subsidies. Nevermind that is is clearly implied, that the bills was scored and budgeted for subsidies going to all 50 states, that never in the reporting or hearings of the law was there any suggestion that there would be a difference in subsidies between those in state-based exchanges and federally-run exchanges. Two Republican judges took it upon themselves to use a super-literal reading of the text to take money to afford health care from millions of Americans in 36 states.

This would be a “blow to Obamacare,” if it were real. But this challenge isn’t advancing. It’s not just the other appeals panel that rejected the argument; even the conservative members of the Supreme Court, in their deliberations two years ago, assumed that all states would be getting subsidies.

As we stated on Twitter, this has zero, zilch, nada, no impact on California whatsoever, even in the worst case scenario, which ain’t going to happen. Even in that worst-case scenario where this crazy ruling is upheld, California has protected itself by setting up its own exchange, Covered California–its most likely that several more states would set up Exchanges if that were the point. There is no challenge to the subsidies provided for getting Covered California plans–the over 1.2 million Californians getting subsidies in Covered California can rest easy that this will have no impact on their ability to get coverage or subsidies.

We would have hoped that Jon Stewart in covering this would have brought this key point up, but the rest of his coverage on this subject is spot on:

The Not So Narrow Impacts of the Hobby Lobby Decision

Consumer, community, women’s and health organizations expressed disappointment in the Supreme Court decision in the Hobby Lobby case.

It’s very disappointing that the Supreme Court is allowing corporations to determine the health options of their workers, however narrowly tailored the decision. If a corporation provides coverage, it shouldn’t impose the beliefs of its owners onto the health care of its workers. This decision puts an asterisk on how we define health coverage, and thus how we regulate it.

Most Californians will continue to get all the benefits of the Affordable Care Act; the contraception benefit is not struck down, nor any other part of Obamacare: most will continue to get the newly-won right to get birth control without a co-payment. Specific California law also limits the impact of this law, and there’s a bill pending SB1053(Mitchell) in the California legislature that would further reduce its reach.

That said, what is concerning is the health options for those specific workers directly impacted, and the precedent that corporations can assert religious beliefs to avoid implementing key worker and consumer protections, or other health benefits.

Justice Ginsburg was right to ask how a future court might allow a corporation might use an religious reason to not provide coverage for blood transfusions, vaccinations, anti-depressants, or other medical treatments. That’s a precedent that should concern everybody.

Senate Health Committee on deadline day

Senate Health Committee, Chaired by Doctor Ed Hernandez met today and heard the following bills of interest to health advocates. Here’s a report by our Sawait Hezchias-Seyoum:

* Health Access sponsored legislation, AB 2088 (Hernandez) would close a loophole in federal law which allows insurers to sell large employers skinny benefit plans that do not meet ACA requirements. The bill passed out with a vote of 6-2.

* AB 1792 (Gomez), which would require the Employment Development Department to report on receipt of public assistance by employees of California employers, passed out with a vote of 6-1.

* AB 1558 (Hernandez) which would allow create a health care cost and quality database at the University of California, and publish studies on health care cost and quality passed out with a vote of 6-1.

* AB 1759 (Pan) which as amended would require an annual independent assessment of Medi-Cal provider reimbursement rates and their impact on access to care and quality of care in the Medi-Cal program passed out with a vote of 8-0.

Assembly Health Committee takes on Medi-Cal renewals, network adequacy, etc.

The Assembly Health Committee, chaired by Doctor Richard Pan met today and heard several bills of interest to health advocates. Here’s a report by our Sawait Hezchias-Seyoum:

* SB 18 (Hernadez) as amended would accept $6 million in free foundation funds, and then draw down another $6 million in federal funding to help California consumers who are enrolled in Medi-Cal renew their coverage next year. This bill sponsored by Health Access and Western Center on Law and Poverty passed out with 13 votes.

* SB 964 (Hernandez) which as amended would require additional scrutiny of managed care plans that cover Medi-Cal beneficiaries or Covered California enrollees passed out with 14 votes. This Health Access-sponsored bill would increase enforcement for timely access to care and network adequacy standards.

* There was significant back-and-forth debate around SB 1094 (Lara) which as amended would extend the timeframes for the Attorney General review of nonprofit hospital transactions and give the Attorney General authority to enforce the conditions imposed on such transactions without litigation. Proponents and opponents alike were on pins and needles until the very end of the hearing.  Senator Lara argued that SB 1094 (Lara) is an important bill to assure a nonprofit hospital will continue to serve its community after a transaction in which ownership changes. The opposition argued that the bill adds uncertainty in transactions involving the sale or transfer of nonprofit hospitals by allowing the Attorney General to unilaterally impose post-transaction conditions–which Senator Lara clarified was only allowed if a hospital had lied. The bill finally passed out of committee.

* SB 1100 (Hernandez) was scheduled to be heard today, but was pulled by the author at the hearing after the chair requested amendments to narrow the bill considerably.  These amendments were not acceptable to Dr. Hernandez and Health Access, the sponsor. This bill would have applied longstanding California law on continuity of care to individual market coverage, so patients can continue with their provider to finish a course of treatment even if they need to change health plans in open enrollment, and would have provided notice to all Californians with coverage of their right to continuity of care.

* SB 974 (Anderson) which deals with privacy concerns around personal information and the Health Benefits Exchange passed out with 19 votes.

* SB 1052 (Torres) as amended would require the California Health Benefits Exchange to require qualified health plans to post the drug formulary for the qualified health plan on the carrier’s website and would also require insurers (in and outside Covered California) to themselves post their formularies. The bill passed out with 14 votes.

* SB 1182 (Leno) which as amended would implement large group rate review and would require provision of detailed data to large purchasers passed out with 13 votes.

* SB 1276 (Hernandez) which, as amended, would update the existing Fair Hospital Pricing Act  sponsored by Health Access to assure uninsured and underinsured Californians are not overcharged for hospital care, by ensuring patients have the option of a payment plan, passed out with 11 votes.

* SB 1322 (Hernandez) which as amended would create an all-payer database passed out of committee with 13 votes.

* SB 1341 (Mitchell) which as amended would require that the Statewide Automated Welfare System (SAWS) has the ability to make use of the Medi-Cal rules housed in the IT system, CalHEERS, jointly operated by the California Health Benefits Exchange and the Medi-Cal program passed on consent.

Covered California Getting Ready for 2015

Here’s our report on the five-hour Covered California Exchange meeting on Thursday, June 19, as written by our director of administrative advocacy, Elizabeth Abbott:

The board of Covered California continued its evaluation of the 2014 enrollment, outreach, and customer service metrics.  They also revealed their preparations for the 2015 open enrollment period which begins November 15, 2014.  They provided a clear focus on what they would change and what would remain the same in their policy and operations.

Comings and Goings.  The Executive Director and the Covered CA board expressed genuine regret that the Contra Costa Health Plan would not be participating in 2015 as a plan offering.  The Exchange said they truly valued their partnership, but that Contra Costa reluctantly made their decision based on certain provisions and limitations in the federal law.  The CEO of Contra Costa expressed the plan’s hope that their absence from the exchange would only be temporary.   Peter Lee also wished the best to Gabriel Ravel on their legal staff who has been selected by the Department of Managed Health to be their chief counsel.  Peter acknowledged his tremendous work from the beginning in making Covered CA a reality.

Customer Service.  Covered CA was pleased to announce that their Service Center was now meeting and exceeding their customer service goals of 80% of their calls answered within 30 seconds.  They are now performing at the level where they are able to answer 94% of the calls within the first 30 seconds and less than 2% of calls were abandoned as measured in June.  This improved customer service is due principally to the reduction in the volume of calls, but they still recorded more than 205,000 calls in May, and 47,727 calls through June 9.  Covered CA staff also attributed these better customer service metrics to a combination of factors including:  better trained and proficient customer service staff, the fully functioning dedicated call numbers provided for brokers, agents, certified enrollment counselors, and SHOP questions, the shift of some calls to the selected health plans, and greater efficiencies and applying what they had learned during the first open enrollment period.  However, public comments urged increased recruitment of bi-lingual staff, and re-examination of the technological language transfer capacity because when some callers asked to be transferred to a Spanish-speaking customer service representative, they were cut off.

In addition, Covered CA has done extensive research and technical evaluation regarding allowing web-based entities to enroll consumers in plans offered on the exchange.  Although there was significant interest in exploring this alternative, there were concerns about the additional costs, the specific web design and integration, and, in light of the experience during the first open enrollment period, whether the online broker entities would actually be able to reach high numbers of unique, new applicants.  Consumer advocates raised issues regarding web based entities being able to reach those with limited English proficiency, the ability to offer expertise about Medicaid eligibility, and privacy and security concerns.  The staff recommended that Covered CA use the balance of time to investigate these technical problems, choices, and costs and defer this until after the end of the 2015 open enrollment season.

Covered CA noted their accomplishment of completing the training and certifying enrollment support for consumers and applicants.  These numbers totaled 5,919 Certified Enrollment Counselors and 12,376 Certified Insurance Agents.  Both groups had significant representation of assisters who spoke Spanish and several Asian languages.

Analysis of Initial Findings of the 2014 Open Enrollment and Plan Offerings

Covered CA released early analysis of the popularity of enrollment channels and plan selections.  They included:

  • African-Americans were most likely to enroll (60.4%) through a self-service enrollment channel.
  • Asians were most likely to enroll (54%) through a certified insurance agent.
  • Latinos were most likely to enroll using Certified Enrollment Counselors (48.2%) or Plan-based Enrollers (40.6%)
  • However, some public commenters questioned these racial and ethnic differentiations based on their field experience and were anxious for further analysis.
  • The most common plans selected by new enrollees were Anthem Blue Cross (30%), Blue Shield (27%), Health Net (19%), and Kaiser (17%).  Smaller plans were also well represented in several regions.
  • Covered CA board and staff affirmed their plan to incorporate very few changes to the benefit design for the 2015 Open Enrollment Period.
  • The staff were pleased to announce that they have successfully worked out embedding pediatric dental benefits in the medial plan offerings in 2015.
  • They also announced they will offer a family dental package for purchase which goes beyond the federal essential health benefits standards for CA consumers.

Policy Issues for Discussion. . .and A Little Controversy

Covered CA is refining their approaches to consumer assistance and correlating it with “successful enrollment” tallies, efforts to reach hard-to-reach groups, and the costs associated with each.  They are facing the imperative of being able to support their operations based on premium assessments (and not federal grants) which at least have the potential to drive up premiums.  In order to assure the most efficiencies and the largest numbers of successful enrollments, they are planning to adjust and realign the outreach and marketing operations and reimbursement to assisters paid by the Exchange.  Initially, they planned to move toward combining educational and enrollment efforts and reimburse only the most successful entities who exceed a relatively high threshold of signing up consumers.  They are rethinking this reimbursement model to account for the fact that they may want to keep smaller CBOs focused on hard-to-reach applicants.  They have undertaken to revise the timetable for that reimbursement to provide up-front costs for small organizations, and further streamlining administrative requirements.  Comments from consumer advocacy organizations urged further dialogue with their groups to incorporate their field experience and consider further refinements and options.  They also pressed for fewer administrative reporting requirements.  Covered CA will continue the dialogue before adopting entirely new models.

There was a heated discussion regarding the issue of the verification needed to confirm eligibility for a special enrollment period.  Plans are leery of consumers “conveniently” undergoing a life-changing event to enable them to elect coverage to coincide with a sudden onset of a serious illness or accident.  Consumer advocates pushed for as expedited as possible ability to do a systems verification of a life-changing event (e.g. marriage, birth of a baby, loss of a job etc.) and not require the applicant consumer to furnish paper evidence.  They also questioned whether Covered CA had the staffing to examine and analyze all of these paper submissions.  This attestation procedure models what is being done by the federal exchanges run by HHS.  Consumer advocates also pointed out that consumers are attesting to these events under penalty of perjury which should be sufficient deterrent to misrepresenting their change in circumstance.  Legal advocates also argued for this conditional eligibility to remain in place for 90 days according to state law, while health plans felt 30 days would be more than enough time.  The board voted to explore these possibilities with further research, with only board member Paul Frears showing flexibility to a broader standard or proof, based on his experience with the Pacific Business Group on Health.

The final controversial topic touched on is the ballot initiative proposed for the November ballot that will give additional authority over rate review to the Insurance Commissioner.  There remained many unanswered questions regarding what that rate review authority, if approved by the voters, would do to the timing for negotiations between Covered CA and the qualified health plans.  There are further discussions planned to work out specific plans and timelines if the measure passes.

There is no Covered CA board meeting planned for July, but they will resume their monthly schedule in August.

Assembly Health Committee considers soda labels, cost-sharing tracking, etc.

The Assembly Health Committee, chaired by Assemblymember Richard Pan met today and heard several pieces of legislation of interest to health care advocates. Here’s a quick report from Sawait Hezchias-Seyoum:

Perhaps the most contested bill heard today was SB 1000 (Monning), a bill that would require safety warning on sugar sweetened beverages. Most Members of the committee agreed sugar sweetened beverages contribute to the obesity and diabetes epidemic, however the majority of the With signficant industry opposition, Members held off on voting for the bill, stating were not convinced that safety warning labels are the solution.

Other bills were passed by the Assembly Health Committee:

* SB 204 (Corbett) on Prescription Drug Labeling passed out with 13 votes.

* SB 959 (Hernandez) a clean-up bill for half dozen major pieces of legislation on the implementation of the Affordable Care Act passed out with 19 votes.

* SB 1124 (Hernandez) which would limit Medi-Cal estate claims recovery to inpatient nursing home care for those over age 55 passed out with 17 votes.

* SB 1340 (Hernandez) which would eliminate gag clauses in contracts between all types of health care providers and health plans or insurers passed out with 15 votes.

* SB 1176 (Steinberg) which puts the burden on the health plan or insurer to track out of pocket costs and reimburse the consumer if their cost sharing exceeds the annual out of pocket limit was presented by Senator Ed Hernandez and passed out with 14 votes.

Getting ready for open enrollment 2.0

It’s official: Gov Brown signed SB20(Hernandez), setting the next Covered California open enrollment period from Nov 15, 2014 to Feb 15, 2015.

So we have less than five months to get everything ready for what will be an open enrollment period that will be half-as-long, to renew all those enrolled and bring in many more Californians into the peace of mind of coverage.

Update: California Legislature Passes Budget–Continues ACA Implementation, But Also Recession-Era Cuts


Monday, June 16, 2014


*        Budget continues implementation of the Affordable Care Act and Medi-Cal expansion and enrollment, extends full-scope Medi-Cal coverage to pregnant women, and restores Black Infant Health Program and HIV Prevention Programs, but also neglects key investments, leaves in place cuts made in past years, to Medi-Cal rates and benefits, public health programs and the safety-net.

*        Budget deal leaves in place health cuts made in the depths of the recession, including a 10% reduction to some of the lowest Medicaid provider reimbursement rates in the nation, making it harder for patients to access doctors and specialists they need. Other cuts remain to Medi-Cal benefits, and to public health programs that invest in prevention, children’s health, school health centers, and other areas. The budget also reallocates $725 million from county safety-net and public hospitals, limiting services to the remaining uninsured.

        Most inexplicably, the budget also rejects foundation money offered to help enroll/renew people in Medi-Cal, denying California federal matching funds for this purpose that would have been provided without any state cost. 

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Yesterday evening, the California Legislature passed a California state budget for 2014-15. It includes a health budget and trailer bill that continues the state’s implementation of the Affordable Care Act, including budgeting for high Medi-Cal enrollment, and extends full-scope Medi-Cal coverage to pregnant women. At the same time, the budget continues many of the recent cuts made to Medi-Cal rates and benefits, public health programs, and the safety-net for the remaining uninsured.

While most of the legislative discussion on the health care items was about the lack of restoration of recession-era cuts that were made to Medi-Cal rates and other public health programs, benefits, and services, the California Budget did have some notable changes in health policy. The Budget:


* provides a high level of enrollment in the Medi-Cal expansion as part of the implementation of the Affordable Care Act;

* expands full-scope Medi-Cal for pregnant women, by increasing Medi-Cal eligibility to 138 percent of the federal poverty level (FPL) for pregnant women, and establishes a “wrap program” for women between 139 and 213 percent FPL so they can have Medi-Cal pay their premiums & co-pays, and cover services not covered by their Covered California plan–a more detailed description of this victory is on the Health Access blog;

* requires Medi-Cal coverage of behavioral health treatment for children with autism if required by the federal government, with a stakeholder process for implementation;


* restores $4 million for the Black Infant Health Program and $3 million for new HIV prevention projects;

* establishes a 3-year mobile vision services pilot program for children in schools in Los Angeles with $1 million;

* adds the new Hepatitis C drugs to the ADAP formulary ($26 million for the Office of AIDS) and covers out-of-pocket costs of other AIDS patients with coverage.

* establishes a State Dental Director and a statewide dental health program;


* reforms the Office of Patient Advocate, including to improve systems to collect data on health complaints and how they are resolved;

* approves trailer bill language that establishes a new payment structure for the Martin Luther King, Jr. Community Hospital to allow it to reopen in 2015.

* ensures an agricultural workers health plan covers catatrophic care, wtih $3.2 million;

* includes a rate increase for PACE programs, starting in April 1, 2015, with $1..8 millions

* includes approximately $20 million and 86 positions for a variety of programs and purposes, including the following: healthcare reform, new county budgeting methodology, Coordinated Care Initiative, mental health wellness, MEDS modernization, ground emergency medical transportation, Breast & Cervical Cancer Program, and Drug Medi-Cal provider re-certifications.

* eliminates the Managed Risk Medical Insurance Board, and transfer to the Department of Health Services any remaining MRMIB programs, including the Major Risk Medical Insurance Program, which will hold stakeholder processes on getting its enrollees covered elsewhere.


The most discussion yesterday was on what was not included in the budget, most notably any restoration of Medi-Cal rates. In both Senate Budget Committee in the afternoon and the floor debates in the evening (which were livetweeted on the @HealthAccess Twitter account), legislators from both the Assembly and Senate, both Democrat and Republican, decried that California has one of the lowest Medi-Cal provider rates in the nation.

Senate Budget Chair Mark Leno made the point that the difference was with the Administration, and in order to make headway legislators need to bring specific issues and problems to the Department of Health Care Services for them to see and rectify. When the Administration argued that most Medi-Cal recipients were in Medi-Cal managed care, and thus not impacted by the fee-for-service rates, Senator Holly Mitchell responded stating that “those in fee-for-service include some of our most vulnerable,” and that we also needed to examine the Medi-Cal provider capacity in managed care: “When we talk about Medi-Cal, we are talking about lives.”

Other items not included in the final budget–even though some were proposed in Assembly or Senate versions of the budget–included:

* restoration of key Medi-Cal benefits cut in 2009, including acupuncture, audiology, chiropractic, incontinence creams and washes, optician and optical labs, podiatry, and speech therapy ($13 million total);

* restoration and funding for various public health programs including the Early Mental Health Initiative, Drug Overdose Grant Program, School-Based Health Centers, Public Health Laboratory Training Program, Dental Disease Prevention Program, Asthma Public Health Initiative, Syringe Access Programs, and other initiatives on Adolescent Family Life, STD Prevention, Teen Pregnancy, Injury Control, and the Office of AIDS (each $1-$15 million);

* consideration of coverage or care for the remaining uninsured including the undocumented, given that the budget, under a formula adopted in last year’s budget, reallocates $725 million from the county safety-net that serves this population, limiting their ability to serve the remaining uninsured.

The most inexplicable health budget item was the rejection of money offered by the California Endowment to assist Medi-Cal enrollment and renewals. Both houses of the legislature agreed to accept the money earlier this year, as they did with a similar offer last year. But in the final budget this year, the Administration is refusing these free foundation dollars, offered at no cost to the state, denying California the federal matching funds that are available for this purpose.

The Legislature passed the Budget Sunday evening, meeting the constitutional deadline to pass a final Budget by June 15th; the Governor has until the end of June to sign the measure (with whatever “blue pencil” line-item vetoes he decide that are within his discretion), so the spending plan is in place when the new budget year begins on July 1.

Assembly Health Summary of the #CABudget

Here’s the health portions of the California Assembly’s Report of the 2014-15 Budget Plan, which is up for a vote later today, Sunday, June 15th. It’s a good summary of what the budget includes, complementary to our recent update which discusses what the bill *doesn’t* include:

Department of Health Care Services
* Approves of $437 million General Fund in Medi-Cal to support implementation of the Affordable Care Act.
* Increases Medi-Cal eligibility to 138 percent of the federal poverty level (FPL) for pregnant women, and establishes a “wrap program” for women between 139 and 213 percent FPL in which they can choose to have both Covered California coverage and Medi-Cal as a wrap to pay their premiums and co-pays and to cover services not covered by their Covered California plan, for $16.5 million General Fund savings.
* Includes $1.8 million for a rate increase for PACE programs, effective April 1, 2015.
* Includes trailer bill to allow DHCS to collect supplemental rebates on, and make supplemental payments for, specialty high-cost drugs through managed care, for $6 million General Fund savings. Denies the administration’s January proposal to create a statewide contract drug list, for $32.5 million General Fund savings.
* Approves trailer bill language that clarifies the role of Medicare Advantage plans related to the Coordinated Care Initiative.
* Approves trailer bill language that establishes a new payment structure for the Martin Luther King, Jr. Community Hospital to allow it to reopen in 2015. These provisions conform to federal Affordable Care Act and other federal funding structure changes and there are no additional state cost from this action.
* Approves of establishment of a 3-year mobile vision services pilot program for children in schools, for $1 million General Fund in 2014-15 and $2 million General Fund in 2015-16.
* Includes $3.2 million in one-time Major Risk Medical Insurance Fund for any health plan that is funded by contributions made by agricultural employers, and 85 percent or more of the plan’s eligible participants are agricultural employees for work performed and covered under a collective bargaining agreement.
* Requires the coverage of behavioral health treatment by Medi-Cal if required by the federal government, and requires DHCS to consult with stakeholders on the design of the benefit.
* Includes approximately $20 million and 86 positions for a variety of programs and purposes, including the following: healthcare reform, new county budgeting methodology, Coordinated Care Initiative, mental health wellness, MEDS modernization, ground emergency medical transportation, Breast & Cervical Cancer Program, and Drug Medi-Cal provider re-certifications.
* Includes $3.75 million one-time Major Risk Medical Insurance Fund as the state match in order to receive a total of $37 million to support electronic health records.

Department of Public Health
* Includes $4 million (General Fund) for the Black Infant Health Program and $3 million (General Fund) for new HIV demonstration projects.
* Approves $474,000 ($250,000 General Fund, $224,000 federal funds) and 1 position to establish a State Dental Director and a statewide dental health program.
* Approves $1.9 million and 18 limited-term positions to investigate complaints against long-term care professionals through the Licensing & Certification program.
* Includes $26 million for the Office of AIDS (OA) to add new Hepatitis C drugs to the ADAP formulary and $9.9 million savings to cover out-of-pocket costs for OA beneficiaries who have obtained comprehensive health coverage.
* Approves of trailer bill language to transfer the Drinking Water Program from the Department of Public Health to the State Water Resources Control Board.
* Adopts trailer bill language to require the Department to establish a stakeholder group and report to the Legislature on the Licensing & Certification Program which licenses nursing homes and other facilities. This proposal will enable the Department of Public Health to improve internal business practices and meet federal benchmarks, and support continuation of federal grants through complete and timely fulfillment of state licensing and federal certification workload.
* Adopts trailer bill language to require the Department to convene stakeholders to solicit input on nutrition education and obesity prevention programs, as well as on the transition from contracted to state civil service staff for the operation of the Supplemental Nutrition Assistance Program Education (SNAP-Ed) program.

Managed Risk Medical Insurance Board (MRMIB)
* Approves of the elimination of the MRMIB, the transfer of MRMIB programs to the Department of Health Care Services, and trailer bill for this purpose.
* Denies the proposed elimination of the Major Risk Medical Insurance Program, and instead adopts trailer bill language requiring DHCS to: 1) provide information to enrollees of state-only programs on opportunities for comprehensive coverage; and 2) establish a stakeholder workgroup to explore the use of Proposition 99 funds for on-going coverage for remaining uninsured populations.

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.