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Improving Birth Outcomes: Better Coordinating Care and Coverage for Pregnant Women

Download the full report here:  Improving Birth Outcomes Improving Birth Outcomes.pdf

After expanding coverage for prenatal care and expanding perinatal services in California, we have achieved remarkable reductions in premature births, low birth-weight, reduced smoking rates of pregnant women and important increases in access to timely prenatal care.[1] California covers care for pregnant women through Medi-Cal (up to 200% of FPL), AIM (up to 300% of FPL) and now Covered California covers maternity care (with premium subsidies up to 400% of FPL). In the Medi-Cal program, California offers Comprehensive Perinatal Services Program (CPSP), which provides health education, psychosocial counseling and nutrition counseling that help achieve better birth outcomes. Covered California and nearly all individual and employer-based health insurance plans must now offer maternity care.[2]

In implementing the ACA, we should be able to achieve 100% coverage of maternity coverage for California’s families and further improve birth outcomes. This is a great opportunity to simplify and coordinate programs and improve their performance. Let’s summarize some of the program differences.


Medi-Cal MAGI (Modified Adjusted Gross Income)

Medi-Cal pregnancy only

AIM[3] (Access for Infants and Mothers)

Covered California[4]

(enrollment begins October 1, 2013)

Income thresholds 0-133% of FPL 0-200% of FPL 200-300% of FPL 133% of FPL and up
Residency and immigration status rules Full scope for all, but limited scope for undocumented Upgraded to full scope for California residents Full scope for California residents Full scope for citizens and Legal Permanent Residents with premium assistance for new LPRs 100-133% of FPL; undocumented are ineligible
Subscriber premiums None None 1.5% of household income Sliding fee scale premiums increasing from 2 to 9.5% of household income between 100 and 400% of FPL.
MAGI income rules Yes Yes No Yes
Asset tests None None None None
Services Medi-Cal benefits (upgraded for behavioral health and adult dental) Upgraded to full scope Medi-Cal benefits AIM benefits 10 essential health benefits (Kaiser Small Group 30 Plan)
Prenatal, delivery and post partum Yes Yes Yes Yes
Comprehensive Perinatal Services Yes Yes No No
Copays for maternity care No No No Not for prenatal care
Copays for other care Nominal Nominal Nominal Sliding fee scale, increasing from $3 to $45 for individuals and families up to 250% of FPL
Reimbursement Capitation Fee for service Mix of fee for service and capitation Mix of capitation and fee for service
Health plan Choice of Medi-Cal managed care plans[5] None AIM plan(s)[6] Choice of Covered California plans[7] (including Bridge Plans,[8] where developed for some with incomes lower than 250% of FPL)
Provider networks Medi-Cal managed care[9] Medi-Cal fee for service Commercial networks Commercial networks[10]; Medi-Cal managed care for Bridge Plans
FQHC and DSH for safety net [11]  Yes Yes No No
Applications and enrollment Any time, with up to three months retroactive Any time, with up to three months retroactive During the first 30 weeks of pregnancy, prospective primarily During annual open enrollment and special life circumstances causing a loss of coverage, such as job loss or change, death, marriage, etc. Prospective only. Coverage begins the first of the next month after eligibility is determined, if coverage is determined by the 15th; otherwise the first of the following month.[12]
Simplified enrollment CalHEERS County Social Services MRMIB CalHEERS

While there are many commonalities, there are the following key differences among the programs: coverage for different provider networks and plans, different reimbursements, different rules governing the timeliness of applications, different rules for the undocumented, different rules for subscriber contributions, different covered services and different program administrators. There is as yet no common effort to coordinate these programs to improve birth outcomes. The concept of premium assistance[13] may allow us to simplify these programs in the best interests of the expectant mothers, their children and their families.

What do we suggest? We would suggest that DHCS administer the program for women with family incomes under 133% of FPL and that Covered California administer the program for women over 133% of FPL. This would merge AIM and a portion of Medi-Cal pregnancy only coverage into Covered California.[14] Covered California should use premium assistance and the available Medi-Cal funding to upgrade care and coverage for pregnant women with incomes up to 250% of FPL: [15] 1) upgraded services during pregnancy, [16] 2) reduced copays during pregnancy,[17] 3) reduced premium contributions during pregnancy,[18] 4) adding pregnancy to the list of special life circumstances where enrollment is authorized outside the annual open enrollment period,[19] and 5) continuity of care. Undocumented women would enroll through Medi-Cal using existing program rules for premium contributions.[20]

We should re-emphasize and strengthen smoking and substance abuse cessation policies and programs, particularly for pregnant women, in both Medi-Cal and Covered California. Pay for performance incentives and accountability should be in place for plans and their perinatal provider networks to continuously improve birth outcomes. We should use both programs to reduce rates of unwarranted C-Sections, to address post-partum depression, to support other health services such as lactation, nutrition and home visitors, which are proven effective in promoting healthy mothers, healthy newborns and strong infant development.

[1] In the latest March of Dimes rating, California is just short of an “A” rating for premature births. See March of Dimes Premature Birth Report Card at http://www.marchofdimes.com/mission/prematurity-reportcard.aspx California’s rate of low birth weight babies has fluctuated between 6.1 and 6.8% over the past 15 years. See Kids Count Data Center, Low Weight and Pre-term Births at http://www.kidsdata.org/data/topic/dashboard.aspx?cat=56  California has achieved a late or no prenatal care rate of 3% of live births by 2010, less than half the national average. Kids Count Data Center, Births to Women Receiving Late or No Pre-natal Care at http://datacenter.kidscount.org/data/tables/11-births-to-women-receiving-late-or-no-prenatal-care?loc=1&loct=2#detailed/2/6/true/133,38,35,18,17/any/265,266

[2] The ACA requires coverage of maternity coverage among the ten essential health benefits. California was an early adopter of this policy. See SB 222 of 2011 (Evans and Alquist).

[3] AIM is only for women ineligible for Medi-Cal.

[4] The premium subsidies in Covered California are only available to persons not eligible for Medicaid, Medicare, or private employment-based insurance (there is a 9.5% unaffordability exception).

[5] There is often a choice of two Medi-Cal managed care plans, in some counties only one plan and in a few counties up to four plans for subscribers to choose among.

[6] There is typically only one AIM plan, most commonly Blue Cross/Anthem, occasionally Kaiser or the local Medi-Cal managed care plan. In a few counties, there is a choice among two plans.

[7] There is a choice among three to six plans depending on the county.

[8] SB X 1 3 (Hernandez) authorizes Medi-Cal managed care plans (Bridge Plans) for family members where the children are in Medi-Cal with family incomes of less than 250% of FPL. It also allows individuals the option to retain their Medi-Cal managed care plan and network when their incomes increase causing loss of Medi-Cal eligibility.

[9] This is usually a mix of public and private, non-profit and for profit with a strong role for safety net providers. It is likely to be a subset of the larger Medi-Cal fee for service network that meets Medi-Cal managed care plan standards for efficiency and quality.

[10] Commercial managed care networks consist of a broader range of private providers, some of which do not participate at all in the Medi-Cal managed care program.  While safety net providers may participate, commercial insurance participation by the safety net is a weak point that needs work on both sides.

[11] These are special Medi-Cal program reimbursements that are of singular importance to community clinics and county facilities.

[12] This feature is not conducive to promoting timely access to prenatal care and pregnant women need presumptive eligibility, expedited, real time eligibility determinations and enrollment – features of Medi-Cal and AIM.

[13] Premium assistance is a long-standing but little used option for state Medicaid programs. See Wulsin, Summary of the Center for Medicaid Services FAQ’s on the Exchange and Medicaid Expansion (ITUP, Dec. 13, 2013) at http://itup.org/legislation-policy/2012/12/13/summary-of-cms-faqs-on-exchange-medicaid/ . In this instance, it could be used to purchase CPSP benefits for low and moderate income expectant families through Covered California, to buy retroactive coverage, to buy a pregnancy exception to open enrollment, and to buy down the premiums and out of pocket for families expecting a new born. California is already using this option to cover low income new Legal Permanent Resident Adults in the Exchange.

[14] We are suggesting that citizens and legal permanent residents who are otherwise eligible for both Covered California and Medi-Cal pregnancy only coverage be covered through Covered California. If we merge these programs, we would avoid the unfortunate circumstance where women have strong incentives to shift between the programs during their pregnancy.

[15] 250% of FPL is the same standard for reduced cost sharing in Covered California, for children in Medi-Cal and for Bridge Plans. 75% of AIM enrollees had incomes between 200 and 250% of FPL and 25% have incomes between 250 and 300% of FPL.

[16] We are suggesting that the CPSP services be available for pregnant women at their option to reduce the risk of low birth weight infants.

[17] $45 copays for services during pregnancy is a real hardship for families facing the additional costs associated with the birth of a new baby. This could be reduced to a more affordable level of $10-15.

[18] The cost of premiums for the expectant mother might be reduced to the AIM levels of 1.5% of household income.

[19] While there could be some limited adverse selection from this policy, it is no one’s interest over long term to have low birth-weight and very low birth-weight babies, the incidence of which can be reduced by assuring timely access to maternity coverage.

[20] While the undocumented California pregnant women cannot qualify for Covered California, their newborns will be eligible for Medi-Cal, AIM and Covered California respectively depending on their income. We think that AIM for newborns 250-300% of FPL (which is funded through CHIP and protected by the federal Maintenance of Effort for children) should be merged into Covered California with the same protections for cost sharing and premiums through premium assistance as we suggest for their pregnant mothers. AIM for pregnant undocumented women should be folded into the Medi-Cal program.

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