Continued Eligibility for Pregnant Individuals

All MC eligible pregnant individuals are potentially eligible for CE. Under this program:

  • When a pregnant individual has been approved for pregnancy-related MC with a SOC, increases in income must not result in an increased SOC for pregnancy-related services, throughout the pregnancy, until the end of the 365-day postpartum period. Other changes in MFBU or Maintenance Need Levels may affect MC eligibility.
  • When a pregnant individual has been approved for a zero SOC Non-MAGI aid code and reports an increase in income which would result in a SOC, the individual must maintain their zero SOC eligibility for pregnancy-related services, throughout the pregnancy, until the end of the 365-day postpartum period.
  • When a pregnant individual on a MAGI pregnancy aid code (M7, M8, M9, M0) reports an increase in income which would result in ineligibility for that aid code, the client must maintain their eligibility for the MAGI pregnancy aid code.
  • Pregnant individuals must continue to meet other eligibility criteria, such as residency requirements.
  • Increases in family income must be applied to all other individuals in the MFBU with the exception of deemed infants.

Eligibility for CE

Only a pregnant individual who is eligible for and receiving MC in the month of disposition of the pregnancy is eligible for CE.

• For individuals with a SOC, it must have been met at least once during the pregnancy, prior to, or in the same month as, the income increase, in order to qualify for CE. There are no additional requirements for individuals with no SOC (including MAGI).

• Increases in income or property of the spouse or unmarried father do not affect the individual in a postpartum period, regardless of whether the spouse or unmarried father wants MC for himself or other children.

Applying CE Rules

MAGI

When a pregnant individual reports an increase in income which results in a loss of eligibility for MAGI, Soft Pause should be applied to that individual. Due to system limitations, EWs must leave MAGI individuals who are eligible for CE on soft pause until the end of the CE period or the client reports a decrease in income which results in eligibility to a regular MC aid code.

Non-MAGI

When a pregnant individual reports an increase in income which would result in an increased SOC, CalSAWS is programmed to keep the SOC unchanged. Individuals must maintain the same SOC until the end of the CE 365 day postpartum period or the client reports a decrease in income which results in a lowered SOC.

Reminder: CE only disregards increases in income, not decreases in the MFBU composition or maintenance need level that result in a SOC.

 

Three Month Retroactive

Use actual income to determine the SOC for each retroactive month requested. Once an increase in income is reported subsequent to the month of application, the increase is to be disregarded. Increases in income after the month of application trigger CE, not the family's income in the retroactive months or the date of the initial interview.

ExampleExample

A woman applies for MC (and requests a Non-MAGI evaluation) on 10/30/17. She had a baby 10/5/17. She requests Retro Medi-Cal for August and September. She completes the application process on 11/15/17. Her net nonexempt income is as follows:

(Retro) (Retro) (App. Mo.) (Current Mo.)
8/17 9/17 10/17 11/17
None $1,000 $1,200 $1,800

Actual income is budgeted for August and September. In November, her income is much higher. Since she applied during the month of October, the income increase in November is disregarded under Continued Eligibility rules. Even though she applied after the baby was born, October is not a “Retro” month; therefore, CE rules apply. Once her SOC for 10/17 is certified, she receives zero SOC postpartum services. The newborn's SOC is based on October's income until the child turns age one, unless income decreases.

An infant can receive DE retroactively when one of the three months prior to the application month is the infant’s birth month and the mother, parent, legal guardian or responsible relative of the infant requests MC coverage for that month. If the infant’s mother had MC eligibility in the birth month, then apply DE to the infant beginning in that retroactive month.

ExampleExample

A mother applies for MC on July 6, 2017 for herself and her infant. The infant’s date of birth was June 16, 2017. The mother indicates on her application that she has unpaid medical bills for May and June and requests MC for May and June. The EW approves MC for July 2017 and ongoing. In determining her retroactive MC eligibility, the EW determined that she was not eligible in May but eligible for June. Because the infant’s month of birth is in the retro month of June and the mother was MC eligible in June, the infant has DE beginning in June.

Break In Aid

Once a pregnant individual is no longer eligible for MC, the CE period ends.

Any break in aid causes CE to end. For example, a family moves from County A and fails to notify their EW, so the case is discontinued 10/31. The family reapplies in County B after the 30 day timeframe allowed by SB 87. This is considered a break in aid for purposes of determining CE. County B determines eligibility and SOC based on November's income.

Inter County Transfers (ICTs)

If an ICT is received and the client was in the middle of a CE period, the client is still entitled to CE until the end of the original period, as no break in aid occurred.
When initiating an ICT for a recipient who is entitled to CE, EWs must include adequate documentation/explanation for the Receiving county.

Whereabouts Unknown

If the pregnant individual’s whereabouts become unknown, the case may be discontinued with a timely notice of action after following SB 87 procedures for loss of contact.

Annual Redeterminations

The following requirements apply when an MFBU includes a pregnant individual or individuals in their postpartum period:

  • Redeterminations must be completed annually as a condition of eligibility for an MFBU containing a pregnant individual.
  •  Failure to comply with RD must not result in a discontinuance for the pregnant individual or individuals in their postpartum period.
  •  If it is determined at RD (or any other time) that the pregnant individual has excess property for a Non-MAGI program, the pregnant individual must not be discontinued.

NOTE: If an individual is in their 365 day postpartum period, they must not be discontinued for failure to comply with an RD. See Allowable Discontinuances During the 365 Day Postpartum Period.

Increased Income, Pregnant Individual (MN/MI Programs)

Effective April 1, 2022, all Medi-Cal eligible individuals protected under ARPA PCE shall maintain continuous eligibility in their pregnancy and postpartum coverage through the 365-day (12-month) postpartum period.

 

For Non-MAGI individuals, use this chart to determine under which program a pregnant individual's eligibility continues when there is an increase in family income or SOC:

Increased Income, Pregnant Individual

If the Prior Month Aid is... And Income Increases... Then Continue Eligibility for the Pregnant Woman under...
No SOC, MN/MI or PA But does not exceed Maintenance Need MN/MI, no SOC. (Unaffected by Continued Eligibility)
  Between Maintenance Need and 200% of FPL Income Disregard Program for pregnancy related services. Increase her SOC for non-pregnancy care.
  Over 200% Income Disregard Program for pregnancy related services. Increase her SOC for non-pregnancy care.
Income Disregard Program (between Maintenance Need and 200% of FPL) At or Below 200% Income Disregard Program for pregnancy related services. Increase her SOC for non-pregnancy care.
  Over 200% Income Disregard Program for pregnancy related services. Increase her SOC for non-pregnancy care.
Property Waiver Provision At or Below 200% Property Waiver Provision for pregnancy related services.
  Over 200% Property Waiver Provision for pregnancy related services. (Use Income Disregard Program Aid Code.)
SOC, MN/MI (Income over 200%) Still Over 200% Continue pregnant woman at prior month's SOC for both her pregnancy and non-pregnancy services.


For MAGI individuals, an increase in income over the limit for MAGI pregnancy aid codes should trigger Soft Pause. Due to system limitations, the pregnant individual must remain on Soft Pause until the end of the CE period or when other changes (i.e. tax household information) make the client ineligible. Pregnant individuals who report income below the pregnancy aid code income limit will remain on that aid code

Increased Income, PA

Pregnant individuals who are discontinued from CalWORKs, Transitional Medi-Cal (TMC), or Edwards are potentially eligible for CE.

Determine eligibility for no SOC MC in the following sequence:

  1. Determine eligibility for MAGI.
  2. If ineligible for MAGI, determine eligibility for no SOC under Transitional Medi-Cal (TMC).

  3. If ineligible for TMC, determine ongoing MC eligibility under the MN/MI programs. Disregard increases in family income for the pregnancy related services.

    1. If income is at or below Maintenance Need Level, then establish Medi-Cal under MN/MI Program, No SOC, unaffected by CE.
    2. If income is above Maintenance Need Level (regardless of how high the income is), then establish Medi-Cal under Income Income Disregard Program for:
      1. Pregnancy related services, and
      2. A child under age one.
      3. Apply full SOC to:
        1. Other family members, and
        2. The pregnant woman's non-pregnancy care.

      4. NOTE: Other children in the MFBU may be eligible for No SOC under Federal Poverty Level programs.

Postpartum Care Periods

Prior to April 1, 2022, a pregnant individual eligible for Medi-Cal during the last month of pregnancy continued eligibility for all pregnancy-related and postpartum services for a 60-day period beginning on the last day of pregnancy. Access to these services ended on the last day of the month in which the 60-day period ends. Under the provisions of the American Rescue Plan Act (ARPA), beginning April 1, 2022, California opted to extend the Medi-Cal postpartum period to a 365-day period (12 months). The 12 month period will begin on the on the last day of pregnancy and end on the last day of the month in which the 365th day occurs. No mental health diagnosis is required for the Postpartum Care Extension (PCE). The new provisions also expand full-scope coverage to pregnant and postpartum individuals in restricted or limited scope Medi-Cal programs.

NOTE: The extension does not apply to Minor Consent or Hospital Presumptive For Pregnant Woman (HP4PEW) individuals.

Aid Codes

Beginning April 1, 2022, a pregnant individual will be granted a 365 day postpartum period and will remain in a full-scope aid code for the duration of the pregnancy and 365 postpartum period. If an individual is not in a pregnancy aid code, does not have full-scope, or is losing their coverage in a full-scope aid code, or the aid code does not provide the full breadth of medically necessary services the individual should also be aided under aid code 76 as a means to protect the pregnancy and postpartum eligibility.  Aid code 76 is not required when the beneficiary has full scope coverage or is active on M0 or M8.

Share of Cost

Individuals in Medi-Cal with a Share of Cost (SOC) may be eligible for the 365-day postpartum extension. Individuals must meet their SOC in at least one month during pregnancy, and be eligible for MC on the last day of pregnancy in order to be eligible for the postpartum period. Aid code 76 should be applied to any SOC aid code either full scope or restricted/limited as long as the SOC was met at any month during the pregnancy. Aid code 76 should be applied to the beginning of the month when it was verified that the SOC was met. If the SOC was not met at least once during the pregnancy, the beneficiary is not eligible for the postpartum period extension coverage.

 

Retroactive Eligibility

Individuals applying for Medi-Cal in April 2022 can request retroactive coverage for any of the three previous months in 2022 (January, February, March). If found eligible for retroactive Medi-Cal and their pregnancy ended in any of the three previous months, the individual must have their 365 day postpartum period established from last day of their pregnancy.

 

Late Report of Pregnancy Ending at Redeterminations

After April 2022 If the individual later informs their pregnancy has ended through the annual Medi-Cal Redetermination process and the individual did not have their 365 day postpartum period previously established, the individual must have their 365 day postpartum period established from the last day of their pregnancy

 

Allowable Reasons to Discontinue During the 365 Day Postpartum Period

There are only five allowable reasons to discontinue during the 365 day continuous eligibility period for the postpartum individual. SAWS will discontinue aid code 76 if any of the following negative actions are applied to the individual:

• Deceased

• Loss of California Residency

• Client Request

• Receipt of Social Security Supplemental income (SSI)

• Eligible for CalWORKS.

 

ARPA PCE informing

The ARPA PCE Beneficiary Flyer must be provided to all individuals when a pregnancy is reported, the flyer is available in threshold languages in the DEBS form library.

 

 

Related Topics

General Pregnancy Rules

Hospital Presumptive Eligibility Program