Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.

Existing law requires a health care service plan and a health insurer, at the request of an enrollee or insured, to provide for the completion of services by a terminated or nonparticipating provider if the enrollee or insured is undergoing a course of treatment for one of specified conditions, including a serious chronic condition, at the time of the contract or policy termination or the time the coverage became effective.

This bill would, for purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition, as defined, from the individuals treating health care provider, require completion of covered services for that condition, not exceeding 12 months, as specified. By expanding the duties of health care service plans, the bill would expand the scope of an existing crime, thereby imposing a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 577

Author:(Eggman)

As Amended Ver:August 14, 2019

Majority vote

SUMMARY:

Extends the duration of the requirement that health plans and health insurers provide continuity of care for pregnant women to up to 12 months from the diagnosis or from the end of pregnancy, whichever occurs later, if the woman presents written documentation of being diagnosed with a maternal mental health condition from the individual's treating health care provider.

The Senate Amendments:

Delete the requirement that the Department of Health Care Services (DHCS), after the 60-day postpartum period of Medi-Cal coverage and coverage through the Medi-Cal Access Program, to provide transition assistance to the individual in applying for and purchasing a qualified health plan in Covered California if the individual is eligible for that coverage. Delete the extension of the duration of full scope Medi-Cal coverage for postpartum care for up to one year beginning on the last day of the pregnancy for all women below 138% of the federal poverty level.

COMMENTS:

According to the federal Centers for Disease Control and Prevention (CDC), postpartum depression is depression that occurs after having a baby. Feelings of postpartum depression are more intense and last longer than those of "baby blues," a term used to describe the worry, sadness, and tiredness many women experience after having a baby. CDC research found that about one in nine women experience symptoms of postpartum depression. Estimates of the number of women affected by postpartum depression differ by age and race/ethnicity. For example, CDC found that postpartum depression symptoms were highest among women 19 years old or younger and American Indian or Alaska Native women.

EXTENSION OF CONTINUITY OF CARE. Existing law requires health plans and insurers to provide coverage for the completion of covered services by a terminated provider or a nonparticipating provider for specified conditions (such as a pregnancy, a serious chronic condition, or an acute condition) when, at the time of the contract of policy termination, the insured individual was receiving services from that provider, and the non-contracting provider agrees to accept the rate of payment. Under existing law, a pregnant woman is eligible for continuity of care during the three trimesters of pregnancy and for "the immediate postpartum period." This bill would extend the duration of continuity of care for a woman who presents written documentation of being diagnosed with a maternal mental health to 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee, instead of being limited to "the immediate postpartum period."

According to the Author:

Maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending the duration of continuity of care for pregnant women with a maternal mental health condition who have had to switch health coverage plans, and extending full scope Medi-Cal benefits for undocumented pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.

Arguments in Support:

This bill is sponsored by the American Congress of Obstetricians and Gynecologists, District IX (ACOG), which writes that perinatal depression, which includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, is one of the most common medical complications during pregnancy and the postpartum period, affecting one in seven women. ACOG recognizes the importance of identifying pregnant and postpartum women with depression because untreated perinatal depression and other mood disorders can have devastating effects on women, infants, and families. Once a woman is diagnosed, ACOG argues it is crucial she is afforded with appropriate follow-up and treatment when indicated. ACOG writes that, when receiving treatment, patients develop a trustful relationship with their physicians, a relationship which is essential when treating delicate conditions such as maternal mental health. If there were a break in this relationship due to coverage issues, a patient's adherence to the treatment plan may be jeopardized. To prevent this from occurring, ACOG concludes, the health plans and insurers must allow the continuity of care between a patient and their treating physician to remain uninterrupted.

Arguments in Opposition:

There is no opposition to this bill.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Chu, Santiago, Waldron

ASM APPROPRIATIONS: 13-0-5

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Brough, Diep, Fong, Obernolte

ASSEMBLY FLOOR: 76-0-4

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager- Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Obernolte, Patterson, Petrie- Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Cooley, Dahle, Eduardo Garcia, Gray

SENATE FLOOR: 40-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

UPDATED:

VERSION: August 14, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0001840

 THIRD READING  

Bill No: AB 577

Author: Eggman (D), et al.

Amended: 8/14/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 7/10/19

AYES: Pan, Stone, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 76-0, 5/24/19 - See last page for vote

SUBJECT: Health care coverage: maternal mental health

SOURCE: American College of Obstetricians and Gynecologists District IX

March of Dimes

DIGEST:

This bill permits completion of covered services, for up to 12 months from diagnosis or from the end of the pregnancy, whichever occurs later, for an individual who presents written documentation of being diagnosed with a maternal mental health condition to her health plan or health insurer when her provider is terminated, or when she is newly covered, if the provider agrees to the rate and terms and conditions of the health plan or policy.

Senate Floor Amendments of 8/14/19 extend the completion of covered services to include the end of the pregnancy; revise the definition of maternal mental health from “a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression,” to, “a mental health condition that can impact a woman during pregnancy, peri or postpartum, or that arises during the pregnancy, in the peri or postpartum period, up to one year after delivery,” and make a technical clarification.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services, under which health care services are provided to qualified low-income persons. [WIC §14000, et seq.]
   
2. Establishes the Department of Managed Health Care to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance to regulate health insurance. [HSC §1340, et seq. and INS §106, et seq.]
   
3. Requires health plans and health insurers to cover the completion of covered services by a terminated provider, if requested by an enrollee or insured for the treatment of certain conditions, and if the provider and plan agree on terms and reimbursement, as specified. Requires health plans to cover the completion of covered services by non-participating providers for new enrollees under similar circumstances. [HSC §1373.96 and INS §10133.56]
   
4. Establishes as a condition eligible for completion of services, a serious chronic condition that is a medical condition due to a disease, illness, or other medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Requires completion of covered services to be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practices. Limits completion of covered services for a serious chronic condition to not more than 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee. [HSC §1373.96 and INS §10133.56]
   
5. Establishes as a condition eligible for completion services, the three trimesters of pregnancy and the immediate postpartum period. Requires the completion of covered services to be provided for the duration of pregnancy. [HSC §1373.96 and INS §10133.56]
   
6. Requires a health plan or insurer, at the request of a newly covered enrollee or insured under an individual health care service plan contract or health insurance policy, to arrange for the completion of covered services as set forth in existing law by a nonparticipating provider if the newly covered enrollee’s or insured’s prior coverage was terminated, as specified, including when a health benefit plan is withdrawn from any portion of a market. Requires a notice as to the process by which an enrollee or insured may request completion of covered services to be provided as part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described above.

This bill:

1. Permits completion of covered services, as specified, for an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individual’s treating health care provider for 12 months from the diagnosis or from the end of the pregnancy, whichever occurs later for a newly covered enrollee.
   
2. Defines “maternal mental health condition” as a mental health condition that can impact a woman during pregnancy, peri or postpartum, or that arises during pregnancy, in the peri or postpartum period, up to one year after delivery.

Comments

1. Author’s statement. According to the author, maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending the duration of continuity of care for pregnant women with a maternal mental health condition who have had to switch health care coverage plans, and extending full scope-Medi-Cal benefits for undocumented pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.
2. Budget Act. The American College of Obstetricians and Gynecologists District IX (ACOG), the sponsor of this bill, requested resources to expand Medi-Cal benefits for a postpartum woman from 60 days to one year if that woman is diagnosed with a maternal mental health disorder. According to ACOG, maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Low-income women and women of racial and ethnic minorities are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. While many of these women may already be enrolled in Medi-Cal, others, who do not meet Medi-Cal’s income eligibility, are not. Under current law, the income eligibility requirements for pregnancy-related Medi-Cal increases from 138% of the federal poverty level (FPL) to 213% FPL for women who are pregnant. Pregnant women whose income is above 213% FPL up to and including 322% FPL may qualify for assistance through the Medi-Cal Access Program (MCAP). While MCAP is comprehensive coverage, it does require a small fee (1.5% of annual family income) to participate. These programs enable more low-income women who may not otherwise qualify for Medi-Cal to receive medically necessary treatment to ensure the health of their pregnancy and baby. These benefits end after 60 days from the birth of the child. Any treatment the mother is receiving under Medi-Cal would no longer be covered. She would either need to obtain commercial insurance or explore community resources that offer appropriate mental health services. A disruption in coverage could break the continuity of care and potentially halt treatment altogether. This is unhealthy for the mother and the baby. This issue was heard during the Senate Budget Subcommittee on Health and Human Services on March 21, 2019. Ultimately, the Budget Act included General Fund expenditure authority of $8.6 million annually to support the extension of Medi-Cal eligibility from 60 days to one year for a post-partum woman diagnosed with a mental health disorder.
   

Related/Prior Legislation

SB 104 (Senate Budget and Fiscal Review Committee, Chapter 67, Statutes of 2019) extended Medi-Cal eligibility from 60 days to 12 months after delivery for women in pregnancy-related Medi-Cal programs who are diagnosed with a maternal mental health condition. Suspends the program on December 31, 2021, unless the Director of Finance determines that General Fund revenues exceed expenditures by a sufficient amount for the 2021-22 and 2022-23 fiscal years to fund programs subject to suspension.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 8/15/19)

American College of Obstetricians and Gynecologists District IX (co-source)

March of Dimes (co-source)

Insurance Commissioner Ricardo Lara

American Academy of Pediatrics, California

Association of California Healthcare Districts

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Council of Community Behavioral Health Agencies

California Legislative Women’s Caucus

California Medical Association

California Nurses Association/National Nurses United

California Pan-Ethnic Health Network

California Psychiatric Association

California School Employees Association, AFL-CIO

CaliforniaHealth+ Advocates

County Behavioral Health Directors Association of California

County Health Executives Association of California

Disability Rights California

First 5 California

Health Officers Association of California

Hispanas Organized for Political Equality

Los Angeles County Board of Supervisors

National Association of Social Workers, California Chapter

National Union of Healthcare Workers

Nurse-Family Partnership

Sutter Health

OPPOSITION: (Verified 8/15/19)

None received

ARGUMENTS IN SUPPORT: Proponents write that maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. In addition, symptoms may lead to poor bonding with the baby and difficulties with breastfeeding (which can itself lead to distress, anxiety and low mood). Research has shown potential impacts on cognitive development, including language development, conduct and school performance. An extension of health care coverage ensures that women will get access to mental health services for a full 12 months post-partum – befitting mothers, their infants and their families. Expanding the duration of continuity of care for pregnant women with a maternal mental health condition will ensure that they receive the care they need.

ASSEMBLY FLOOR: 76-0, 5/24/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Cooley, Dahle, Eduardo Garcia, Gray

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/16/19 13:32:13

**** END ****

 THIRD READING  

Bill No: AB 577

Author: Eggman (D), et al.

Amended: 7/11/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 7/10/19

AYES: Pan, Stone, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 76-0, 5/24/19 - See last page for vote

SUBJECT: Health care coverage: maternal mental health

SOURCE: American College of Obstetricians and Gynecologists District IX

March of Dimes

DIGEST:

This bill permits completion of covered services, for up to 12 months from diagnoses, for an individual who presents written documentation of being diagnosed with a maternal mental health condition to her health plan or health insurer when her provider is terminated, or when she is newly covered, if the provider agrees to the rate and terms and conditions of the health plan or policy.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services, under which health care services are provided to qualified low-income persons. [WIC §14000, et seq.]
   
2. Establishes the Department of Managed Health Care to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 and the California Department of Insurance to regulate health insurance. [HSC §1340, et seq. and INS §106, et seq.]
   
3. Requires health plans and health insurers to cover the completion of covered services by a terminated provider, if requested by an enrollee or insured for the treatment of certain conditions, and if the provider and plan agree on terms and reimbursement, as specified. Requires health plans to cover the completion of covered services by non-participating providers for new enrollees under similar circumstances. [HSC §1373.96 and INS §10133.56]
   
4. Establishes as a condition eligible for completion of services, a serious chronic condition that is a medical condition due to a disease, illness, or other medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Requires completion of covered services to be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practices. Limits completion of covered services for a serious chronic condition to not more than 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee. [HSC §1373.96 and INS §10133.56]
   
5. Establishes as a condition eligible for completion services, the three trimesters of pregnancy and the immediate postpartum period. Requires the completion of covered services to be provided for the duration of pregnancy. [HSC §1373.96 and INS §10133.56]
   
6. Requires a health plan or insurer, at the request of a newly covered enrollee or insured under an individual health care service plan contract or health insurance policy, to arrange for the completion of covered services as set forth in existing law by a nonparticipating provider if the newly covered enrollee’s or insured’s prior coverage was terminated, as specified, including when a health benefit plan is withdrawn from any portion of a market. Requires a notice as to the process by which an enrollee or insured may request completion of covered services to be provided as part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described above.

This bill:

1. Permits completion of covered services, as specified, for an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individual’s treating health care provider for 12 months from the diagnoses for a newly covered enrollee.
   
2. Defines “maternal mental health condition” as a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.

Comments

1. Author’s statement. According to the author, maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending the duration of continuity of care for pregnant women with a maternal mental health condition who have had to switch health care coverage plans, and extending full scope-Medi-Cal benefits for undocumented pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.
2. Budget Act. The American College of Obstetricians and Gynecologists District IX (ACOG), the sponsor of this bill, requested resources to expand Medi-Cal benefits for a postpartum woman from 60 days to one year if that woman is diagnosed with a maternal mental health disorder. According to ACOG, maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Low-income women and women of racial and ethnic minorities are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. While many of these women may already be enrolled in Medi-Cal, others, who do not meet Medi-Cal’s income eligibility, are not. Under current law, the income eligibility requirements for pregnancy-related Medi-Cal increases from 138% of the federal poverty level (FPL) to 213% FPL for women who are pregnant. Pregnant women whose income is above 213% FPL up to and including 322% FPL may qualify for assistance through the Medi-Cal Access Program (MCAP). While MCAP is comprehensive coverage, it does require a small fee (1.5% of annual family income) to participate. These programs enable more low-income women who may not otherwise qualify for Medi-Cal to receive medically necessary treatment to ensure the health of their pregnancy and baby. These benefits end after 60 days from the birth of the child. Any treatment the mother is receiving under Medi-Cal would no longer be covered. She would either need to obtain commercial insurance or explore community resources that offer appropriate mental health services. A disruption in coverage could break the continuity of care and potentially halt treatment altogether. This is unhealthy for the mother and the baby. This issue was heard during the Senate Budget Subcommittee on Health and Human Services on March 21, 2019. Ultimately, the Budget Act included General Fund expenditure authority of $8.6 million annually to support the extension of Medi-Cal eligibility from 60 days to one year for a post-partum woman diagnosed with a mental health disorder.
   

Related/Prior Legislation

SB 104 (Senate Budget and Fiscal Review Committee, Chapter 67, Statutes of 2019) extended Medi-Cal eligibility from 60 days to 12 months after delivery for women in pregnancy-related Medi-Cal programs who are diagnosed with a maternal mental health condition. Suspends the program on December 31, 2021, unless the Director of Finance determines that General Fund revenues exceed expenditures by a sufficient amount for the 2021-22 and 2022-23 fiscal years to fund programs subject to suspension.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 8/12/19)

American College of Obstetricians and Gynecologists District IX (co-source)

March of Dimes (co-source)

Insurance Commissioner Ricardo Lara

American Academy of Pediatrics, California

Association of California Healthcare Districts

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Council of Community Behavioral Health Agencies

California Legislative Women’s Caucus

California Medical Association

California Pan-Ethnic Health Network

California Psychiatric Association

California School Employees Association, AFL-CIO

CaliforniaHealth+ Advocates

County Health Executives Association of California

Disability Rights California

Health Officers Association of California

Hispanas Organized for Political Equality

Los Angeles County Board of Supervisors

National Association of Social Workers, California Chapter

National Union of Healthcare Workers

Nurse-Family Partnership

Sutter Health

OPPOSITION: (Verified 8/12/19)

None received

ARGUMENTS IN SUPPORT: Proponents write that maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. In addition, symptoms may lead to poor bonding with the baby and difficulties with breastfeeding (which can itself lead to distress, anxiety and low mood). Research has shown potential impacts on cognitive development, including language development, conduct and school performance. An extension of health care coverage ensures that women will get access to mental health services for a full 12 months post-partum – befitting mothers, their infants and their families. Expanding the duration of continuity of care for pregnant women with a maternal mental health condition will ensure that they receive the care they need.

ASSEMBLY FLOOR: 76-0, 5/24/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Choi, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Gipson, Gloria, Gonzalez, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Cooley, Dahle, Eduardo Garcia, Gray

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/14/19 15:29:35

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 577

SUBJECT: Health care coverage: maternal mental health

SUMMARY:

1. Permits completion of covered services, for up to 12 months, for an individual who presents written documentation of being diagnosed with a maternal mental health condition to her health plan or health insurer when her provider is terminated, or when she is newly covered, if the provider agrees to the rate and terms and conditions of the health plan or policy.
   

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which health care services are provided to qualified low-income persons. [WIC §14000, et seq.]
   
2. Establishes DMHC to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and CDI to regulate health insurance. [HSC §1340, et seq. and INS §106, et seq.]
   
3. Requires health plans and health insurers to cover the completion of covered services by a terminated provider, if requested by an enrollee or insured for the treatment of certain conditions, and if the provider and plan agree on terms and reimbursement, as specified. Requires health plans to cover the completion of covered services by non-participating providers for new enrollees under similar circumstances. [HSC §1373.96 and INS §10133.56]
   
4. Establishes as a condition eligible for completion of services, a serious chronic condition that is a medical condition due to a disease, illness, or other medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Requires completion of covered services to be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the health plan in consultation with the enrollee and the terminated provider or nonparticipating provider and consistent with good professional practices. Limits completion of covered services for a serious chronic condition to not more than 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee. [HSC §1373.96 and INS §10133.56]
   
5. Establishes as a condition eligible for completion services, the three trimesters of pregnancy and the immediate postpartum period. Requires the completion of covered services to be provided for the duration of pregnancy. [HSC §1373.96 and INS §10133.56]
   
6. Requires a health plan or insurer, at the request of a newly covered enrollee or insured under an individual health care service plan contract or health insurance policy, to arrange for the completion of covered services as set forth in existing law by a nonparticipating provider if the newly covered enrollee’s or insured’s prior coverage was terminated, as specified, including when a health benefit plan is withdrawn from any portion of a market. Requires a notice as to the process by which an enrollee or insured may request completion of covered services to be provided as part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described above.

This bill:

1. Permits completion of covered services, as specified, for an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individual’s treating health care provider for 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.
   
2. Defines “maternal mental health condition” as a mental health condition that occurs during pregnancy or during the postpartum period and includes, but is not limited to, postpartum depression.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. Additional General Fund costs likely to exceed $10 million dollars annually to Medi-Cal to extend coverage for additional months for populations not otherwise eligible for Medi-Cal. Staff assumes a federal match would continue to be available for restricted-scope Medi-Cal services to offset the cost to cover this population.
2. Unknown administrative costs to DHCS to develop a process to assist women disenrolling from Medi-Cal to enroll in Covered California plans.
3. Minor one-time increased county training and minor ongoing administrative workload to maintain a higher number of cases. As counties are not reimbursed on a case or time basis, this increased workload is not likely to translate directly into increased state costs.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending the duration of continuity of care for pregnant women with a maternal mental health condition who have had to switch health care coverage plans, and extending full scope-Medi-Cal benefits for undocumented pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.
2. Budget Act. The American College of Obstetricians and Gynecologists (ACOG), the sponsor of this bill, requested resources to expand Medi-Cal benefits for a postpartum woman from 60 days to one year if that woman is diagnosed with a maternal mental health disorder. According to ACOG, maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Low-income women and women of racial and ethnic minorities are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. While many of these women may already be enrolled in Medi-Cal, others, who do not meet Medi-Cal’s income eligibility, are not. Under current law, the income eligibility requirements for pregnancy-related Medi-Cal increases from 138% of the federal poverty level (FPL) to 213% FPL for women who are pregnant. Pregnant women whose income is above 213% FPL up to and including 322% FPL may qualify for assistance through the Medi-Cal Access Program (MCAP). While MCAP is comprehensive coverage, it does require a small fee (1.5% of annual family income) to participate. These programs enable more low-income women who may not otherwise qualify for Medi-Cal to receive medically necessary treatment to ensure the health of their pregnancy and baby. These benefits end after 60 days from the birth of the child. Any treatment the mother is receiving under Medi-Cal would no longer be covered. She would either need to obtain commercial insurance or explore community resources that offer appropriate mental health services. A disruption in coverage could break the continuity of care and potentially halt treatment altogether. This is unhealthy for the mother and the baby. This issue was heard during the Senate Budget Subcommittee on Health and Human Services on March 21, 2019. Ultimately, the Budget Act included General Fund expenditure authority of $8.6 million annually to support the extension of Medi-Cal eligibility from 60 days to one year for a post-partum woman diagnosed with a mental health disorder.
   
3. Related legislation. SB 104 (Senate Committee on Budget and Fiscal Review) extends Medi-Cal eligibility from 60 days to 12 months after delivery for women in pregnancy-related Medi-Cal programs who are diagnosed with a maternal mental health condition. Suspends the program on December 31, 2021, unless the Director of Finance determines that General Fund revenues exceed expenditures by a sufficient amount for the 2021-22 and 2022-23 fiscal years to fund programs subject to suspension. SB 104 is pending on the Governor’s desk.
4. Prior legislation. AB 2193 (Maienschein, Chapter 755, Statutes of 2019) requires a health plan or insurer to develop a maternal mental health program by July 1, 2019, and requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to ensure the mother is offered screening or is appropriately screened for maternal mental health conditions.

SB 133 (Hernandez, Chapter 481, Statutes of 2017) requires a health plan or insurer, at the request of a newly covered enrollee or insured under an individual health plan contract or health insurance policy, to arrange for the completion of covered services as set forth in existing law by a nonparticipating provider if the newly covered enrollee’s or insured’s prior coverage was terminated, as specified, including when a health benefit plan is withdrawn from any portion of a market. Requires a notice as to the process by which an enrollee or insured may request completion of covered services to be provided as part of, accompany, or be sent simultaneously with any termination of coverage notice sent in the circumstances described above.

1. Support. Proponents write that maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. In addition, symptoms may lead to poor bonding with the baby and difficulties with breastfeeding (which can itself lead to distress, anxiety and low mood). Research has shown potential impacts on cognitive development, including language development, conduct and school performance. An extension of health care coverage ensures that women will get access to mental health services for a full 12 months post-partum – befitting mothers, their infants and their families. Expanding the duration of continuity of care for pregnant women with a maternal mental health condition will ensure that they receive the care they need.
   

SUPPORT AND OPPOSITION:

Support: American College of Obstetricians and Gynecologists District IX (co-sponsor)

March of Dimes (co-sponsor)

American Academy of Pediatrics, California

Association of California Healthcare Districts

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Council of Community Behavioral Health Agencies

California Health Executives Association of California

California Insurance Commissioner, Ricardo Lara

California Legislative Women’s Caucus

California Medical Association

California Pan-Ethnic Health Network

California Psychiatric Association

California School Employees Association, AFL-CIO

CaliforniaHealth+ Advocates

County Health Executives Association of California

Disability Rights California

Hispanas Organized for Political Equality

Health Officers Association of California

National Association of Social Workers, CA Chapter

Nurse-Family Partnership

Sutter Health

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 577

Author:(Eggman)

As Amended Ver:May 17, 2019

Majority vote

SUMMARY:

Extends the duration of the requirement that health plans and health insurers provide continuity of care for pregnant women to up to 12 months from the contract termination date or 12 months from the effective date of coverage, if the woman presents written documentation of being diagnosed with a maternal mental health condition. Extends the duration of full scope Medi-Cal coverage for postpartum care for up to one year beginning on the last day of the pregnancy for all women below 138% of the federal poverty level. Requires the Department of Health Care Services (DHCS), after the 60-day postpartum period of Medi-Cal coverage and coverage through the Medi-Cal Access Program, to provide transition assistance to the individual in applying for and purchasing a qualified health plan in Covered California if the individual is eligible for that coverage.

Major Provisions

COMMENTS:

According to the federal Centers for Disease Control and Prevention (CDC), postpartum depression is depression that occurs after having a baby. Feelings of postpartum depression are more intense and last longer than those of "baby blues," a term used to describe the worry, sadness, and tiredness many women experience after having a baby. CDC research found that about one in nine women experience symptoms of postpartum depression. Estimates of the number of women affected by postpartum depression differ by age and race/ethnicity. For example, CDC found that postpartum depression symptoms were highest among women 19 years old or younger and American Indian or Alaska Native women.

EXTENSION OF CONTINUITY OF CARE. Existing law requires health plans and insurers to provide coverage for the completion of covered services by a terminated provider or a nonparticipating provider for specified conditions (such as a pregnancy, a serious chronic condition, or an acute condition) when, at the time of the contract of policy termination, the insured individual was receiving services from that provider, and the non-contracting provider agrees to accept the rate of payment. Under existing law, a pregnant woman is eligible for continuity of care during the three trimesters of pregnancy and for "the immediate postpartum period." This bill would extend the duration of continuity of care for a woman who presents written documentation of being diagnosed with a maternal mental health to 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee, instead of being limited to "the immediate postpartum period."

MEDI-CAL. In 2015, there were approximately 493,000 births in California, of which Medi-Cal was the principal source of payment for delivery on approximately half of all births that year. Medi-Cal coverage for all pregnant women extends to 322% of the federal poverty level (FPL), while Medi-Cal coverage for parents and non-elderly adults without minor children extends to 138% of the FPL. Undocumented adults (who are not pregnant) are not eligible for full scope coverage, and are instead eligible for limited scope coverage (primarily emergency services). For individuals with incomes between 138% and 400% of the FPL, premium subsidies are available for people purchasing individual coverage through Covered California, with cost-sharing subsidies available for people with incomes up to 250% of the FPL, but undocumented individuals are not eligible for premium or cost-sharing subsidies or to purchase coverage through exchanges (such as Covered California) under federal law.

According to the Author:

Maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending the duration of continuity of care for pregnant women with a maternal mental health condition who have had to switch health coverage plans, and extending full scope Medi-Cal benefits for undocumented pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.

Arguments in Support:

This bill is sponsored by the American Congress of Obstetricians and Gynecologists, District IX, which writes that ensuring very low income, undocumented woman maintain Medi-Cal coverage for a year, as well assisting all other women to transition smoothly from Medi-Cal to a federally subsidized Covered California health plan will ensure they continue to receive important pregnancy-related and post-partum health care.

Arguments in Opposition:

None received

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Additional General Fund costs likely to exceed $10 million dollars annually to Medi-Cal to extend coverage for additional months for populations not otherwise eligible for Medi-Cal. Staff assumes a federal match would continue to be available for restricted-scope Medi-Cal services to offset the cost to cover this population.
2. Unknown administrative costs to DHCS to develop a process to assist women disenrolling from Medi-Cal to enroll in Covered California plans.
3. Minor one-time increased county training and minor ongoing administrative workload to maintain a higher number of cases. As counties are not reimbursed on a case or time basis, this increased workload is not likely to translate directly into increased state costs.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Chu, Santiago, Waldron

ASM APPROPRIATIONS: 13-0-5

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Brough, Diep, Fong, Obernolte

UPDATED:

VERSION: May 17, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0000975

Date of Hearing: April 24, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 577

Author:(Eggman) – As Amended Ver:March 26, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill extends the duration of Medi-Cal eligibility for postpartum care for an individual who is diagnosed with a maternal mental health condition from 60 days beginning on the last day of pregnancy to, instead, up to one year beginning on the last day of pregnancy.

FISCAL EFFECT:

1. GF costs likely in low millions of dollars annually to Medi-Cal to extend coverage. No federal match is available to offset the cost for covering this population.
2. Minor one-time increased county training and minor ongoing administrative workload to maintain a higher number of cases. As counties are not reimbursed on a case or time basis, this minor increased workload is not likely to translate directly into increased state costs.

COMMENTS:

1. Purpose. This bill is sponsored by the American College of Obstetricians and Gynecologists to ensure continuity of care for mothers enrolled in Medi-Cal who are diagnosed with postpartum mental health conditions.
2. Current Coverage. Medi-Cal coverage for pregnant women extends to 322% of federal poverty level (FPL), while Medi-Cal coverage for other individuals extends to 138% of FPL.

Women with incomes in the range of 213%-322% of the FPL have a share of cost for Medi-Cal: they are eligible for Medi-Cal via participation in the “Medi-Cal Access Program,” which requires a premium payment of 1.5% of the subscriber's modified adjusted gross income (MAGI). The Medi-Cal Access Program provides comprehensive healthcare from the effective date of coverage until the last day of the month in which the 60th day following the end of the pregnancy occurs.

Though there have been bills introduced in the U.S. Congress to extend Medi-Cal coverage for postpartum women for up to one year from the last day of pregnancy, in a manner similar to this bill, there are currently no federal matching funds available to pay for extended coverage for this population.

1. Maternal Mental Health. Maternal mental health conditions, including postpartum depression, anxiety, and psychosis, affect about one in five mothers in California. Research shows these conditions are often undiagnosed and untreated.
2. Staff Comments. This bill would benefit new mothers who would qualify for extended coverage. It also raises a number of implementation, fiscal and policy issues. These include setting a precedent of eligibility for full-scope Medi-Cal coverage based on a medical diagnosis, process considerations of how women would be identified as eligible for extended coverage, and using state-only dollars for this expanded coverage when other heavily federally subsidized health plan options are available for most individuals who would qualify.

The author may wish to consider alternative, more cost-effective approaches. For instance, an enhanced case management process could be set up to assist women who currently lose Medi-Cal coverage at 60 days postpartum to enroll in other coverage. Exclusively state-funded benefits could be a last resort if other affordable coverage is not available.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: March 19, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 577

Author:(Eggman) – As Introduced Ver:February 14, 2019

SUBJECT: Medi-Cal: maternal mental health.

SUMMARY: Extends the duration of Medi-Cal eligibility for postpartum care for an individual who is diagnosed with a maternal mental health condition from 60 days beginning on the last day of pregnancy to instead be up to one year beginning on the last day of the pregnancy. Specifically, this bill:

1. Extends the duration of Medi-Cal eligibility for postpartum care for an individual who is diagnosed with a maternal mental health condition to up to one year beginning on the last day of the pregnancy.
   
2. Defines a “maternal mental health condition” as a mental health condition that occurs during pregnancy or during the postpartum period and, includes, but is not limited to, postpartum depression.
   
3. Makes other clarifying changes.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low income individuals are eligible for medical coverage.
   
2. Makes adults who are not pregnant, under age 65 and parents with minor children with incomes up to 138% of the federal poverty level (FPL) eligible for Medi-Cal, and makes children with incomes up to 266% of the FPL eligible for Medi-Cal. 
   
3. Requires DHCS to adopt the federal option provided the Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) to extend eligibility for medical assistance under Medicaid to all pregnant women and infants with family incomes not in excess of 185% of the FPL.
   
4. Makes state-funded perinatal services available under the Medi-Cal program to pregnant women and state funded medical services to infants up to one year of age in families with incomes from 185% to 208% of the FPL.
   
5. Establishes the Medi-Cal Access Program (MCAP) for pregnant women and infants with family incomes between 208% and 322% of the FPL.
   
6. Makes a woman Medi-Cal eligible, to the extent required by federal law, as though she were pregnant, for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy.
   
7. Defines “postpartum services” as those services provided after childbirth, child delivery or miscarriage.
   
8. Require counties to perform redeterminations of eligibility for Medi-Cal beneficiaries every 12 months, and to promptly redetermine eligibility whenever the county receives information about changes in a beneficiary’s circumstances that may affect eligibility for Medi-Cal benefits.
   
9. Establishes, under the Patient Protection and Affordable Care Act (ACA), an advanced and refundable premium tax credit for qualified individuals under 400% of the FPL who are ineligible for Medicaid who purchase a qualified health plan through a health benefit exchange (such as Covered California) and cost-sharing reductions for qualified individuals with incomes below 250% of the FPL who choose specified plans.

FISCAL EFFECT: This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, maternal mental health conditions have impacts far beyond the mothers that are experiencing them – they also influence the well-being of children, families, and communities. New parents already deal with incredible challenges adapting to the responsibility of an expanding family, but low-income women and women of racial/ethnic minorities, like many of the women in my community, are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. Maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Extending Medi-Cal benefits for pregnant women will ensure that they receive important pregnancy-related and post-partum health care, including mental health care.
2. BACKGROUND. According to the federal Centers for Disease Control and Prevention (CDC), postpartum depression is depression that occurs after having a baby. Feelings of postpartum depression are more intense and last longer than those of “baby blues,” a term used to describe the worry, sadness, and tiredness many women experience after having a baby. CDC research found that about one in nine women experience symptoms of postpartum depression. Estimates of the number of women affected by postpartum depression differ by age and race/ethnicity. For example, CDC found that postpartum depression symptoms were highest among women 19 years old or younger and American Indian or Alaska Native women.
   
   The symptoms of postpartum depression are similar to symptoms of depression, but may also include:
   
   1. Crying more often than usual;
   2. Feelings of anger;
   3. Withdrawing from loved ones;
   4. Feeling distant from your baby;
   5. Worrying or feeling overly anxious;
   6. Thinking about hurting yourself or your baby; and,
   7. Doubting your ability to care for your baby.

Experiences that may put some women at a higher risk for depression can include:

• 1. Stressful live events;
  2. Low social support;
  3. Previous history of depression;
  4. Family history of depression;
  5. Difficulty getting pregnant;
  6. Being a mom to multiples, like twins, or triplets;
  7. Being a teen mom;
  8. Preterm (before 37 weeks) labor and delivery;
  9. Pregnancy and birth complications; and,
  10. Having a baby who has been hospitalized.

Depression can also occur among women with a healthy pregnancy and birth. Postpartum psychosis (PP) occurs in one to two per 1,000 childbearing women within the first two to four weeks after delivery. The onset of PP is rapid. As early as two to three days after childbirth, the patient develops paranoid, grandiose, or bizarre delusions, mood swings, confused thinking, and grossly disorganized behavior that represent a dramatic change from her previous functioning. PP is far less common than postpartum depression.

A 2012 Harvard Review of Psychiatry systematic review of post-partum literature entitled “The Course of Postpartum Depression: A Review of Longitudinal Studies” reviewed studies published between 1985 and 2012 concerning the course of postpartum depression, as well as factors implicated in post-partum depression with a chronic course. The review article indicated that that about 30% of post-partum depression-affected mothers in community samples and about 50% in clinical samples remain depressed throughout and beyond the first postnatal year.

1. MEDI-CAL AND COVERED CALIFORNIA SUBSIDY INCOME ELIGIBILITY. In 2015, there were approximately 493,000 births in California, of which Medi-Cal was the principal source of payment for delivery on approximately half of all births that year. As shown in the chart below, Medi-Cal coverage for pregnant women extends to 322% of FPL, while Medi-Cal coverage for parents extends to 138% of the FPL. For individuals with incomes between 138% and 400% of the FPL, premium subsidies are available for people purchasing individual coverage through Covered California, with cost-sharing subsidies available for people with incomes up to 250% of the FPL.

1. SUPPORT. This bill is sponsored by the American College of Obstetricians and Gynecologists, District IX, which writes that maternal mental health is of increasing concern because of the high prevalence of depression and anxiety during the perinatal period and the resulting long-term implications of delayed, inconsistent, or absent treatment. Maternal mental health conditions influence the well-being of mothers, children, families, and communities. Low-income women and women of racial/ethnic minorities are disproportionately affected by maternal mental health disorders, as they face unique barriers to diagnosis and treatment. While many of these women may already be enrolled in Medi-Cal, others, who do not meet Medi-Cal’s income eligibility, are not. Fortunately, Medi-Cal raises the income eligibility for women who are pregnant so they may receive important pregnancy-related and post-partum health care, including mental health care.

Under current law, the income eligibility requirements for pregnancy-related Medi-Cal increases from 138% to 213% FPL for women who are pregnant. For pregnant women whose income is above 213% FPL up to and including 322% FPL, they may qualify for assistance through the Medi-Cal Access Program (MCAP). While MCAP is a comprehensive coverage, it does require a small fee (1.5% of annual family income) to participate. These programs enable more low-income women who may not otherwise qualify for Medi-Cal, to receive medically necessary treatment to ensure the health of their pregnancy and baby. These benefits however, end after 60 days from the birth of their child. Unless the new mom enrolls in a Covered California program, which requires her to pay a premium, any treatment she would be receiving would no longer be covered. She would either need to obtain commercial insurance or explore community resources that offer appropriate mental health services. This disruption in coverage could break the continuity of care and potentially halt treatment altogether. This is unhealthy for the mother and the baby. Extending Medi-Cal benefits for pregnant women will ensure that they continue to receive important pregnancy-related and post-partum health care, including mental health care.

1. policy questions:
   
   1. What should be the duration of coverage after pregnancy? The chart below with data from the 2012 study published in the Harvard Journal of Psychiatry study show the prevalence of post-partum depression at different follow-up time points for the community sample:
      

Medi-Cal currently provides coverage for a 60-day period beginning on the last day of pregnancy. This bill extends the duration of coverage to “up to” a year following birth. The data from the study published in the Harvard Journal does not provide a clear medical evidenced-based answer to what should be the duration of coverage following childbirth based on the prevalence of postpartum depression.

• 1. Fiscal trade-off. California receives Medicaid matching funds for people enrolled in Medi-Cal, ranging from 50% to 93%, depending upon the eligibility group of the individual. Medi-Cal eligibility for pregnant women is funded up to 322% of the FPL, and up to 138% for other adults with children under age 65. For individuals ineligible for Medi-Cal, federal premium subsidies are available to individuals with incomes up to 400% of the FPL for individual coverage purchased through Covered California, and cost-sharing subsidies for individuals with incomes up to 250% of the FPL. There are no federal subsidies in Covered California available above 400% of the FPL, although Governor Newsom has proposed extending subsidies up to 600% of the FPL.
     
     Extending the duration of Medi-Cal coverage from 60 days postpartum to up to one year means a woman who is no longer income eligible would continue to receive Medi-Cal coverage using state only dollars (meaning no federal matching funds). This would include women who are income eligible for Covered California (if the person has income below 400% FPL), and women who are not eligible for federal subsidies (under existing law, if the individual has income above 400% FPL). The benefit of Medi-Cal coverage is a broad benefit package, no or very limited premiums (premiums in MCAP only) and cost-sharing for services as compared to coverage in Covered California or the private market, and the likelihood of the woman being able to keep her existing plan and provider. From a state fiscal perspective, the downside of this approach is the state would be using state-only dollars (General Fund) to provide the coverage, instead of federal funds for women who might otherwise be income-eligible for federal premium and cost-sharing subsidies in Covered California.
     
  2. Should Medi-Cal coverage be extended based on medical condition? The income of the beneficiary population and the availability of federal matching funds (or federal subsidies in Covered California) largely determines state policy and fiscal decisions on which populations to provide low or no-cost insurance. While not downplaying the significance and impact of postpartum depression or questioning the benefit of limited premiums and no cost-sharing in Medi-Cal, coverage for pregnant women extends to higher income levels (322% of the FPL for a family of three is $68,683 annually in 2019) compared to other Medi-Cal eligibility categories (for example, parent eligibility goes to 138% of the FPL or $29,435 for a family of 3 in 2019). In addition, there are multiple serious, chronic or terminal conditions that could make a similar compelling argument for extended Medi-Cal state-only coverage.
     
  3. How to identify a woman for extended Medi-Cal coverage? This bill is silent on the process by which a woman would receive extended coverage if she has postpartum depression, and how county workers (who perform Medi-Cal eligibility determinations) would know to continue the individual’s coverage. Under existing law, DHCS is required to accept the attestation of an individual regarding whether she is pregnant unless DHCS has information that is not reasonably compatible with the attestation. Staff recommends an amendment to clarify how eligibility for extended Medi-Cal coverage under this bill would be documented for purposes of implementing the extension of Medi-Cal coverage.
     
  4. Drafting clarifications. This bill provides coverage for “Medi-Cal postpartum care” when the intent of the measure is to provide extended full scope coverage through Medi-Cal (not limited to postpartum care only). In addition this bill provides coverage for “up to” a year when it is the intent that Medi-Cal coverage be extended a year post birth, and that this requirement apply even if the woman’s annual Medi-Cal eligibility redetermination falls within this year period. Finally, the 60-day limit on postpartum care is also contained in the MCAP statute. Staff recommends clarifying amendments to the language to address these issues.

REGISTERED SUPPORT / OPPOSITION:

Support

American College of Obstetricians and Gynecologists (sponsor)

California Psychiatric Association

California School Employees Association

Disability Rights California

March of Dimes

Opposition

None on file.

Analysis Prepared by: Scott Bain / HEALTH / (916) 319-2097