Medi-Cal-enrolled women who are pregnant are entitled to coverage for enriched pregnancy-related care under Medi-Cal’s Comprehensive Perinatal Services Program (CPSP), a national landmark in the care and management of pregnant women with elevated health risks due to their low economic status. This entitlement applies to all pregnant women enrolled in Medi-Cal, including women who also are enrolled in subsidized health plans purchased through Covered California. The task that jointly faces Medi-Cal and Covered California is how best to align these two sources of pregnancy care financing in order to achieve a central goal of SB 857 – ensuring that dually enrolled pregnant women continue to have full access to CPSP-level treatment.
With roots in California’s acclaimed Obstetrical Access demonstration program, the CPSP program does not simply provide additional coverage. CPSP effectively alters the standard of care available to pregnant women facing elevated health and social risks by establishing a provider network certified and overseen by the California Department of Public Health and qualified to provide CPSP-level care. This care is furnished in a fully integrated manner, through treatment teams comprised of clinicians, social workers, health educators, nutrition counselors, and other health professionals. By contrast, California’s essential health benefit regulations, which define the scope of coverage to which Covered California enrollees are entitled, do not specify either a range of maternity benefits comparable to those available through CPSP, or access to a provider network possessing the comprehensive treatment capabilities of CPSP providers. A review of health plans sold through Covered California reveals that these plans offer the standard level of maternity care expected from traditional commercial insurance. The care they offer, as described in their benefit summary materials, contains none of the special social, nutritional, enabling, or behavioral services available through CPSP, nor is there mention of special treatment standards that fully integrate a broader range of services into highly integrated care programs.
The absence of this higher standard of care is not surprising, since Covered California is designed to reflect the commercial insurance market. This fact also explains the legislative intent behind SB 857 – to ensure that women enrolled in both Covered California plans and Medi-Cal and receiving pregnancyrelated care continue to have full access to the services and benefits of the CPSP program.
Two options exist for aligning and integrating the CPSP program and Medi-Cal coverage with Covered California for dually eligible women. The first is to specify CPSP providers as “essential community providers” and direct health plans to extend network membership to all CPSP providers in their service areas. This approach might be combined with special payment incentives to plans that provide additional risk adjustments related to the treatment of pregnant women at higher health risk. Plans would pay CPSP providers for the standard maternity care they furnish and that are part of women’s Covered California coverage, and Medi-Cal would pay an enhancement to CPSP providers for the additional care they furnish. The California Department of Public Health would continue to maintain certification and oversight responsibilities for CPSP providers. The benefit of this model is that it would fully integrate CPSP providers into plan networks, thereby easing referral arrangements, especially for the treatment of underlying and diagnosed medical conditions. The limitation is the regulatory direction over plan network composition.
A second option would be to treat CPSP providers as covered out-of-network care. Medi-Cal would pay providers as it currently does and seek repayment from Covered California plans up to the level of payment for standard maternity care. The strength of this model is the absence of greater regulation of 3 plan networks, while the limitation is the lesser level of integration of CPSP into broader health plan coverage and care through Covered California.
Rosenbaum, S. J., Hurt, C., Dorley, M., Rothenberg, S., & Lopez, N. (2014). Access to comprehensive perinatal services among pregnant women enrolled in both Medi-Cal and Covered California: aligning and integrating care. , (). Retrieved from http://hsrc.himmelfarb.gwu.edu/sphhs_policy_facpubs/839