Pregnancy is an event that completely changes the life of the mother and affects her family, her job, and her health. Whether your clients are small businesses or individuals, woman’s health insurance options during and immediately after pregnancy will affect your business and your clients.
The state of California knows how important prenatal care is to women and their developing babies. Research shows that adequate and quality prenatal care typically leads to healthier women and babies and smoother, less expensive births.
Getting quality prenatal care can be very challenging for women who are uninsured or underinsured. Luckily, the state of California has a few insurance options for pregnant women to get the care they need. Eligibility for the different healthcare options depends on the woman’s income level, family size, and citizenship or immigration status.
Covered California is the state of California’s health insurance marketplace. As provisioned by the Affordable Care Act (ACA), individuals can purchase federally subsidized health insurance that includes the required “essential health benefits.”
As part of Covered California, Medi-Cal provides health coverage to low-income individuals and families in California — similar in detail and function to the federal Medicaid program. Medi-Cal has a few options that are specific to pregnant women:
- Presumptive Eligibility for Pregnant Women
- Full-Scope Medi-Cal
- Medi-Cal for Pregnant Women
- Medi-Cal Access Program
Presumptive Eligibility for Pregnant Women
Presumptive Eligibility for Pregnant Women is available to pregnant, low income women who are likely eligible for a Medi-Cal plan but are currently not enrolled in a Medi-Cal plan. This immediate coverage is only available for 60 days while a full Medi-Cal application is submitted and processed. Prenatal, pregnancy loss, and dental care are included services, whereas services associated with labor, delivery, and hospitalization are not.
Medi-Cal allows new members to enroll at any time because it is based on income. Covered California plans are only available during the Open Enrollment period. Full-Scope Medi-Cal plans are free or have significantly lower premiums to enrollees who qualify. In order to enroll in a Full-Scope Medi-Cal plan, women must first apply online at www.benefitscal.com.
If a woman is enrolled in a Covered California plan, it is important to note that pregnancy is not considered a qualifying event to enroll in a better or different plan with a special enrollment period. Once the baby is born — a qualifying life event — the woman can sign up for a new or different healthcare plan for herself and her baby during a special enrollment period.
Medi-Cal for Pregnant Women
Some women may not be able to qualify for Full-Scope Medi-Cal; however, she may qualify for something called Medi-Cal for Pregnant Women. This program is exclusively for women who are already pregnant and includes coverage for all medically necessary services related to their pregnancy. These services include:
- Prenatal care
- Pregnancy loss
- Pregnancy related conditions that can cause complications, like gestational diabetes, preeclampsia, etc.
- Labor and delivery
- Immediate postpartum
- Family planning
- Dental care
- Mental healthcare
Eligibility for this program depends on income.
Medi-Cal Access Program
If a woman becomes pregnant and is currently enrolled in a Covered California healthcare plan and does not qualify for Medi-Cal, she can leave her Covered California plan and enroll in the Medi-Cal Access Program (MCAP) during her pregnancy. This is only possible if her income falls within a certain range. The wide-ranging coverage of MCAP is through a health plan and is not part of regular Medi-Cal.
When switching from a Covered California plan to MCAP, there is no gap in coverage. MCAP premiums are lower than Covered California plans and come without copays, coinsurance, or deductibles. This is available regardless of citizenship or immigration status. Women can go back to their Covered California plans after the delivery if they still meet the eligibility requirements for that plan.
It is important to note that not all healthcare providers accept MCAP. If a pregnant woman wants to keep her provider during pregnancy, she will have to make sure her physician accepts MCAP.