Ask Emily is a biweekly column by Emily Bazar of the CHCF Center for Health Reporting, answering consumers’ questions about California’s new medical world. Read her columns at sacbee.com/ask-emily.
Did you recently have or adopt a baby, get married, or move to California from another state? Perhaps you lost your job – and your health insurance with it.
These are some of life’s common events that trigger special health insurance enrollment opportunities, which allow you to buy or switch plans outside of limited open enrollment periods.
But one common life event is missing from that list: Pregnancy.
Attempts to add it this year have failed. At the same time, recent changes have expanded coverage options for some uninsured, pregnant Californians.
Q: Do you know any solution to get health insurance now that my friend’s wife is pregnant and there are no health plans accepting applications? For some reason, they say it’s not a qualifying event.
A: Jay of Rancho Cucamonga isn’t alone in wondering why pregnancy doesn’t trigger a special enrollment period for most commercial health insurance plans, whether purchased from the individual market or obtained from your employer.
In March, 37 Democratic U.S. senators urged the secretary of the U.S. Department of Health and Human Services (HHS) to include pregnancy as a qualifying life event. Within days, California’s two Democratic U.S. senators, Barbara Boxer and Dianne Feinstein, asked California’s health insurance exchange, Covered California, to do the same. In the letter, they said that doing so could save lives and reduce health costs.
“Especially since having a child is a qualifying life event, it makes sense to ensure that access to care is granted prior to birth,” they wrote.
HHS Secretary Sylvia Burwell responded in April that the department can’t make pregnancy a qualifying life event because “we do not have the legal authority to” do so.
(Which, of course, raises the question of who does have the authority. I asked HHS, but the agency declined to comment further.)
As a result of Burwell’s response, Covered California, too, said it couldn’t make pregnancy a qualifying event.
So what options are available for women who get pregnant while uninsured?
In California, you may qualify for a publicly funded health program depending on your income. The thresholds can be relatively generous and include middle-income families.
And as long as you’re eligible, you can sign up anytime of year.
The first is Medi-Cal, which is the state’s version of the federal Medicaid program for low-income residents. On Aug. 1, it increased the income limit for pregnant women to qualify for full-scope benefits to 138 percent of the Federal Poverty Level (FPL).
This year, that’s up to roughly $22,000 for a family of two. (There’s a twist here. I’ll explain more below.)
The higher income threshold means that more pregnant women will qualify for comprehensive coverage, says Lucy Quacinella, a San Francisco attorney who advocates for health coverage options for working families.
“They won’t have to worry about whether something outside of a routine prenatal visit, like a referral to a specialist, will be covered,” she says.
Pregnant women who make between 138 percent and 213 percent of FPL may qualify for Pregnancy-Related Medi-Cal.
This coverage includes “all medically necessary Medi-Cal services related to pregnancy and/or any complications that may pose a risk to the woman or her unborn child,” says Tony Cava of the state Department of Health Care Services.
(No matter how much their income is, pregnant women who are not in the country legally are not eligible for full Medi-Cal benefits. However, they are eligible for Pregnancy-Related Medi-Cal up to 213 percent of FPL, Quacinella says.)
Coverage in full-scope Medi-Cal and Pregnancy-Related Medi-Cal is free for those who qualify.
Plus, while you’re waiting for your Medi-Cal application to be processed, there’s a program called Presumptive Eligibility for Pregnant Women, which allows you to access temporary prenatal care. For details, call 800-824-0088.
Pregnant women who make between 213 percent and 322 percent of FPL (up to roughly $51,300 for a family of two), may qualify for different coverage called the Medi-Cal Access Program, formerly known as AIM.
Earlier this year, the state removed the requirement that women sign up by their 30th week of gestation, allowing them to apply anytime during pregnancy, says Lynn Kersey, executive director of Maternal and Child Health Access.
This program costs 1.5 percent of annual household income (after some adjustments) but does not have deductibles or copayments.
Now, here’s the twist: For Medi-Cal and the Medi-Cal Access Program, a pregnant woman counts not just as one person when calculating income, but one person plus the number of fetuses she’s carrying.
“That means you can make more money and still qualify for these programs,” Kersey says.
For instance, a single mom who has one child and is expecting another would have a family size of three instead of two, which means she would be eligible for the Medi-Cal Access Program up to an annual income of nearly $65,000 instead of $51,300.
If you make too much money to qualify for these programs, you still have options.
▪ Community health clinics won’t turn you away and offer care on a sliding-scale based on your income, Salganicoff says.
▪ Talk to your doctor and hospital (ask to speak with a medical social worker) to see if you can receive reduced-cost care or work out a payment plan, she adds.
▪ Check with your county health agency to see what programs, if any, might be available to you, Kersey says. For instance, she says Los Angeles County offers some services.
▪ Open-enrollment season nearly is upon us. For Covered California and the open market, it starts Nov. 1 and ends Jan. 31, 2016. If you’re pregnant and uninsured – or you’re planning to get pregnant – this is the time to sign up.
Questions for Emily: AskEmily@usc.edu
The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.