Physicians advised to check enrollment status of pregnant patients insured by Covered California June 8, 2016 Managed Care, Medi-Cal Covered California, Medi-Cal, Women's Health 0 In April, news broke that nearly 2,000 pregnant women with Covered California health plans were automatically – and without their knowledge or consent – transferred from their exchange plan to Medi-Cal, even though they were supposed to have the option to stay with Covered California. The problem, attributed by Covered California partly to a computer glitch, can be traced to a recent policy change. Usually, consumers are placed in either Covered California or Medi-Cal based on their income, with no choice in the matter. But the rules are different for some pregnant women whose household income falls between 138 percent and 213 percent of the federal poverty level, or roughly $22,100 to $34,100 for a family of two. Under the October policy change, women who are pregnant at the time they apply for health coverage and fall into this income bracket will automatically be placed into Medi-Cal. Previously, they had a choice between Medi-Cal and Covered California. Women in the affected income range who already have Covered California plans before they become pregnant are now supposed to be given the choice to remain in their subsidized exchange plans—which have out-of-pocket costs such as co-pays and deductibles—or move to Medi-Cal, which is free. The Covered California computer glitch, however, is moving these women into Medi-Cal automatically, without giving them the option to stay with their current plans. Covered California has promised to fix the problem, but the fix is not expected to go live until September. The California Medical Association (CMA) called representatives of Covered California for clarification and was advised that providers should check the eligibility of their pregnant patients to determine if the patient is still enrolled in a Covered California plan or if they have been migrated to Med-Cal. If the patient has been migrated, physicians should ask the patient if she intends to keep Medi-Cal or if she wants to be reinstated with Covered California. Patients who would like to be reinstated should call the Covered California “Pregnancy Escalation Line” at (800) 675-2607. This issue reinforces the importance of verifying eligibility each time the patient is seen to ensure the physician can be paid for services rendered. If the patient opts to switch back to Covered California and pays her premiums retroactively back to the cancellation date, the claims will be paid by the patient’s Covered California plan. However, if the patient opts to keep her Medi-Cal coverage and the physician is not a Medi-Cal participating provider, the physician will not be paid and cannot bill the patient. If a provider knows a patient has Medi-Cal coverage, regardless of whether the provider participates in the Medi-Cal program or not, California law prohibits them from seeking payment from the patient. Covered California has taken several steps to help reduce the number of women who are switched without their consent. The agency sent multiple written notices to the approximately 2,000 women that it identified as having been impacted by the glitch. The agency has updated its main website to give consumers more information about reporting a change related to pregnancy. It is also important to note that the exchange does not require members to report a pregnancy. Covered California patients only need to report a pregnancy if they are interested in other coverage options for pregnant women such as Medi-Cal or the Medi-Cal Access Program. Comments are closed.
