Medi-Cal Eligibility: History, ACA Changes and Challenges

Transcription

1 Medi-Cal Eligibility: History, ACA Changes and Challenges PRESENTATION TO CAHP SEMINAR CATHY SENDERLING-MCDONALD, CWDA FEBRUARY 26,

2 Presentation Overview What is CWDA? Medi-Cal Eligibility Overview Affordable Care Act (ACA) Changes to Medi-Cal County Roles ACA Successes Challenges in ACA Implementation 2

3 What is CWDA? The County Welfare Directors Association of California represents all 58 county human and social services departments before various state and federal departments and other stakeholders. Medi-Cal Eligibility Child Protective Services CalWORKs Welfare to Work Program Areas Adult Protective Services In-Home Supportive Services CalFresh Child Care 3

4 Medi-Cal Eligibility Overview Pursuant to state law, eligibility for Medi-Cal is administered at the county level The human services/social services agency is the county entity responsible for eligibility operations Counties employ an estimated 15,000 eligibility workers to determine initial and ongoing eligibility About 5,000 workers added to implement ACA Counties use one of three statewide automated welfare systems (SAWS): CalWIN, C-IV, and LEADER; plus a new state-run computer system, CalHEERS. 4

5 Medi-Cal Eligibility Overview Medi-Cal consists of multiple programs serving various populations: children, parents, pregnant women, elderly, disabled, individuals in Long Term Care (LTC) Historically Medi-Cal was similar to the state s cash assistance (welfare) program, where factors such as deprivation and linkage had to exist for eligibility Childless adults were generally not eligible (i.e., had no linkage to coverage) unless they had a disability As a result of these requirements, the eligibility determination process was generally quite complex A lot of verification (income, residency) was required 5

6 ACA Changes to Medi-Cal Use of tax filing information to determine eligibility Modified Adjusted Gross Income (MAGI) rules Eliminated asset tests for MAGI-based programs Expanded Federal Poverty Levels Expansion to childless adults Self attestation of most data elements Maintained system of non-magi programs Still follow old rules (asset test, etc) For individuals not eligible under MAGI rules 6

7 ACA Changes to Medi-Cal ACA added a new step in evaluating applications for Medi-Cal eligibility Although ACA changed Medi-Cal, many of the old programs were not eliminated Individuals are first screened electronically for ACA (MAGI) Medi-Cal before the county screens for other traditional Medi-Cal programs Expansion to childless adult population reduced the need for disability evaluations for most applicants 7

8 ACA Changes to Medi-Cal New application process to determine MAGI eligibility: Collect application and all family/household information Collect income, tax filing, social security number, address and residency information Screen the applicant for eligibility electronically Use paper verification and additional forms if eligibility cannot be determined under ACA Additional information, including assets or additional forms may be required 8

9 County Roles Accept applications submitted in-person, online, by mail and over the phone directly to the county human services office Determine eligibility for Medi-Cal and Covered California programs Accept transfers of likely Medi-Cal eligible applicants who call the Covered California number for help (a.k.a. "Quick sort") Conduct all ongoing case management for Medi-Cal recipients Coordinate case management with Covered California for individuals receiving Advance Premium Tax Credits or unsubsidized coverage 9

10 Statewide Automated Welfare System (SAWS) System LEADER CalWIN C-IV Counties Using Los Angeles Alameda, Contra Costa, Fresno, Orange, Placer, Sacramento, San Diego, San Francisco, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Tulare, Ventura, Yolo Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Plumas, Riverside, San Benito, San Bernardino, San Joaquin, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, and Yuba 10

11 SAWS System of record for Medi-Cal Houses non-magi eligibility rules and ongoing case management logic Also includes eligibility rules for CalWORKs, CalFresh, Refugee programs Connects to MEDS (state Medi-Cal system) and CalHEERS via interfaces Operates online functionality applications and case management Online portal ( to submit applications 11

12 CalHEERS The California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) is co-owned by DHCS and Covered California CalHEERS is a computer system, not a business entity CalHEERS contains the business rules engine used to determine MAGI Medi-Cal eligibility and eligibility for Covered CA programs (subsidized/unsubsidized) 12

13 ACA Successes Huge influx of new Medi-Cal eligibles Counties had head start with Low-Income Health Program (LIHP) Express lane eligibility brought significant number in via CalFresh Counties staffed up to meet the challenge of new volume Partnered with DHCS to address initial backlog Partnered with Covered California to move eligibles into their programs Excellent response times for quick sort calls transferred to counties Counties have been the go-to for key subpopulations not served by new computer system 13

14 Post-ACA Pre-ACA Medi-Cal Enrollment Medi-Cal had been growing, but at a slower pace, for the year prior to ACA implementation Through the ACA period, the program has grown substantially and at a much faster pace January 2013: 7.8 million eligibles December 2013: 8.6 million eligibles January 2014: 9.9 million eligibles January 2015: 12.2 million eligibles 14

15 ACA Challenges CalHEERS functionality issues Transitions between Medi-Cal and Covered California Completely new redetermination process 2014 transition year Manual workarounds require more staff time per case Rapidly changing policies and practices Much greater demand than anticipated Early policy choices (since fixed) led to backlogs 15

16 Overcoming the Challenges 24 Month Roadmap for CalHEERS changes SB 1341 Moving Notices of Action into SAWS Budget augmentations for county staff Continued and growing partnerships with: DHCS / Covered California Consumer Advocates Providers/Plans 16

17 Questions? Cathy Senderling-McDonald Deputy Executive Director Phone: