365-Day Postpartum Program

(Former 60- Day Postpartum Program)

In accordance with the American Rescue Plan Act (ARPA), California opted to extend the Medi-Cal postpartum period from 60-days to 365-days (12 months). The new provisions also expand full scope coverage to pregnant and postpartum individuals in restricted or limited scope Medi-Cal programs.

Prior to April 1, 2022, The 60-Day Postpartum Program provided no share of cost (SOC) restricted pregnancy related and postpartum services for certain eligible pregnant individuals. 60-Day Postpartum benefits would be approved only when the individual is not otherwise eligible for MC under another program with No-SOC and services during the postpartum period for conditions which are not related to the pregnancy are not covered by the 60-day program. The decision of whether or not a service is pregnancy related will be made by the physician on a case-by-case basis

Service Aid Code 76 was used for the restricted 60-Day Postpartum Program and will continue to be used under 365-day Postpartum Care extension. If a beneficiary does not have full-scope or willlose their coverage in a full-scope aid code, they should be transitioned to aid code 76 or have aid code 76 run concurrently with other aid codes as a means to protect the pregnancy and postpartum eligibility.

Note: Because MAGI aid codes are No-SOC, the Postpartum Care extension does not apply. Individuals on a pregnancy MAGI aid code (i.e. M7, M8, M9, M0) are eligible for 365 days of postpartum care and will be placed on soft pause. The 365-Day Postpartum policy described in this chapter refers to Non-MAGI individuals only.

Eligibility Requirements

A pregnant individual who was eligible for and received MC during the last month of pregnancy continues to be eligible for all pregnancy-related and postpartum services for the 365-day period, regardless of whether the other conditions of MC eligibility are met.

In order to receive postpartum benefits, eligible individuals must:

Have applied and been eligible for Medi-Cal, and
Have received Medi-Cal benefits on their last day of pregnancy
Have met their SOC for the month the pregnancy ends before postpartum benefits are approved.

Before April 1, 2022, the 60-Day Postpartum Program is not available to any individual who received retroactive MC coverage in the month in which the pregnancy ends. Exception: Eligibility for 60-day postpartum benefits under the 200% Income Disregard or Property Waiver Program can be established retroactively.

Note: Pregnancy verification is not required; self-attestation is sufficient.

Period of Eligibility

Before March 31, 2022, via the 60- Day Postpartum Program eligibility began on the first day of the month following the month the pregnancy ends, and ends on the last day of the month in which the 60th day occurs.

Beginning April 1, 2022, under the 365-day Postpartum Care extension, 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

Dual Eligibility and Postpartum

An individual may have dual MC eligibility, that is:

Postpartum coverage which provides 365 days (12 months) of no-SOC benefits for her pregnancy related and postpartum services only, and
Full or Restricted scope Medi-Cal benefits with a SOC.

The SOC must be met for the month the pregnancy ends before postpartum benefits are approved.

Minor Consent

An Medically Indigent (MI) child with a SOC is eligible for the 365-Day Postpartum Program, as long as the SOC is met during the month pregnancy ends.

A child receiving Minor Consent Services with No SOC continues to be eligible for pregnancy related and postpartum care under the Minor Consent program; therefore, 60-Day Postpartum benefits must not be issued.

If the Minor Consent eligible child has a SOC and the SOC is met for the month pregnancy ends,
60-Day Postpartum benefits must be issued. The paper BIC must be issued as an immediate need, as nothing is to be mailed to the home.

As Minor Consent eligibility is on a month to month basis and cannot be applied automatically by the system it is not included under the American Rescue Act Postpartum Care Extension (ARPA PCE).

Discontinuance of Postpartum Benefits

Eligibility for Postpartum ends on the last day of the month in which the 365th day occurs. EWs must evaluate eligibility for continuing Medi-Cal coverage when the 365th-day postpartum period ends. Reevaluate any new information reported by the client. Make the appropriate changes if new information is reported which entitles the client to other Medi-Cal benefits. If the client is no longer eligible for MC, discontinue with a timely and adequate 10-day NOA