|
MCHA is working to try to make sure that low-income pregnant women benefit as much as possible from the implementation of federal health care reform in California. Our new informational sheet SB 703 and low-income pregnant women, explains that Medi-Cal's 200% Program for pregnancy-related care will need to be integrated with the new federal programs. This is necessary so that women do not have to pay premiums or co-payments during pregnancy and postpartum or miss out on pregnancy-related benefits that commercial insurance usually doesn't cover, like dental benefits and the psycho-social components of Medi-Cal's Comprehensive Perinatal Services Program. See our letter to Senator Ed Hernandez about SB 703 and the Basic Health Care Program Proposal.
SB 703 was held up in Assembly Appropriations (put on “Suspense”) and did not go to the Governor. It will likely become a two-year bill and be active this coming legislative session, 2011-12.
Presumptive Eligibility (PE) for Pregnant Women – Important Updates from MCHA
See our brochure on Presumptive Eligibility (PE) in English or Spanish |
More benefits added to PE for pregnant women! |
Background: Over half of bankruptcies in the U.S. involve medical debt. MCHA, Neighborhood Legal Services and other advocates have recently been investigating debt collection cases against women who had Medi-Cal through the Presumptive Eligibility (PE) program at the time they received their pregnancy-related care.
Through our investigation of these cases we have learned that when the State Department of Health Care Services (DHCS) initially set up the PE program, it left out many important “procedure codes” from the list of “ambulatory prenatal care” reimbursable under PE.
Most of these “missing” procedure codes involve high risk pregnancies and miscarriages. Examples of the missing services included:
- ambulatory emergency room care and physician services;
- ultrasound for miscarriages (technically known as “spontaneous” or “unspecified” abortions; see Provider Bulletins below);
- pathology reports for miscarriages; and
Over 40 procedure codes recently added to PE. As a result of our team’s advocacy, DHCS has agreed to:
- Add over 40 procedure codes to the PE list. The specific codes are set out in the two attached Provider Bulletins, from May (pages 3- 4) and August 2008 (pages 8), respectively.
Providers to be reimbursed. DHCS has also agreed to:
- Automatically reprocess rejected claims involving the recently added PE procedure codes.
- Claims will be reimbursed to providers for dates of service on or after September 1, 2005 (August 2008 Provider Bulletin, page 8), except for claims involving the new
- ultrasound procedure codes, which will be reimbursed retroactively to March 1, 2005 (May 2008 Provider Bulletin, pages 3-4).
IMPORTANT: Help make sure women get their PE bills resolved and/or reimbursed.
- Bills: Women who were billed for any of the procedure codes added in May or August, 2008 to PE’s reimbursement list should contact their providers to get the bill dropped.
- Already paid: Women who have already paid part or all of these bills should also ask the provider to reimburse them after the state pays the provider.
- If the provider won’t reimburse the woman, she should make a “Conlan” claim by calling or writing the Medi-Cal program at:
State Department of Health Care Services
Beneficiary Services
P.O. Box 138008
Sacramento, CA 95813-8008
(916) 403-2007 TDD: (916) 635-6491
- For assistance with the process, the woman should contact her local Legal Aid office or Health Consumer Alliance program (see
www.healthconsumer.org).
ALL “missing” procedure codes should be added to PE. MCHA and others continue to advocate that all medically necessary ambulatory prenatal care be covered by PE.
Do you know of any woman who was billed for a medically necessary ambulatory service related to her pregnancy while she was on PE?
- If the service is included among new procedure codes added in May and August, 2008 for services provided since March 2005 (ultrasound only) or September 2005 (see above), she can bring this to the provider’s attention for reimbursement.
provider has trouble getting reimbursed under the rules for the new 40+ PE procedure codes; OR
pambulatory prenatal care service the woman had is not on the list for PE
“Retroactive” Medi-Cal and PE |
A Medi-Cal beneficiary can get coverage for each of the three months before the date of her application if she was eligible in the earlier month; this is sometimes referred to as;
“retroactive Medi-Cal”. Because there are still some procedure codes for medically necessary ambulatory prenatal care missing from PE (see above), retroactive Medi-Cal is now more important than ever for women with PE.
All women with PE should apply for Medi-Cal and indicate they’d like retroactive coverage. All women with PE should answer “yes” to the question on the Medi-Cal application asking if they have had medical expenses in the last three months. This will get the woman retroactive benefits for each of the earlier three months in which she met Medi-Cal’s eligibility requirements
Even women who miscarry while on PE should complete and submit a Medi-Cal application, answering “yes” to the question about medical expenses in the last three months. That way, if it turns out any of the ambulatory prenatal care a woman received while on PE is not included on the DHCS list, she can get the service covered under retroactive Medi-Cal
It’s easier now for providers to extend PE |
DHCS has recently made it much easier for providers to extend PE for pregnant women-- also as a result of MCHA’s recent advocacy.
Now, once a woman shows her provider proof that she applied for Medi-Cal (for example, a copy of her signed Medi-Cal application) before her initial PE ended (the end of the month following the month in which PE started), the provider can issue the woman a new PE card for as many times as necessary until the Automated Eligibility Verification System (AEVS) shows that the county has made a final eligibility determination on the woman’s case
It is no longer necessary for the provider to telephone DHCS in Sacramento before issuing a second or third, etc., PE extension for a woman whose Medi-Cal application is pending.
NOTE: A provider may extend PE if a woman has not applied for Medi-Cal by the end of the month following the month in which PE began if there are extenuating circumstances. In these situations, however, the provider must call State DHCS to get authorization for the initial PE extension. This has been the longstanding rule, and it has not changed.
These rules are in the May 2008 Provider Bulletin (attached) at page 4.
New PE flyers expected from the State |
A new flyer, drafted by MCHA and other advocates, explaining what PE covers is expected from DHCS shortly. The new flyer will be posted on the MCHA website, along with the link to the DHCS website where the new flyer can be found.
Need more information about any of the above? |
Contact LynnK@mchaccess.org, CeliaV@mchaccess.org, or Lucy@Quacinella.com
Medi-Cal covers well over 50% of the pregnant women in Los Angeles and nearly 50% statewide.
At the request of the LA’s Best Babies Network in preparation for its "Building Capacity to Address Maternal Depression" workshop, Maternal and Child Health Access has put together a fact sheet that explains the mental health coverage that is available for low to moderate-income pregnant women. Please check back for updates and improvements to the materials here.
Contact:
Lynn Kersey lynnk@mchaccess.org
Elena Bazini elenab@mchaccess.org
Debra Winski debraw@mchaccess.org
Liz Ramirez lizr@mchaccess.org
|
