County of Los Angeles Department of Public Social Services

Transcription

1 County of Los Angeles Department of Public Social Services SHERYL L. SPILLER Acting Director PHIL ANSELL Acting Chief Deputy MEDI-CAL PROGRAM FACT SHEET July 2011 September 2011 Overview The Medi-Cal (MC) Program provides comprehensive medical benefits to certain public assistance recipients and other eligible persons who are unable to afford the cost of their medical care. Individuals receiving public assistance from Supplemental Security Income/State Supplementary Payment (SSI/SSP), Foster Care, and CalWORKs (CW) are automatically eligible for MC benefits. Other aged, disabled, family-linked individuals, children up to age 21, pregnant women and adults in a skilled nursing facility may be eligible for benefits under the Medi-Cal Assistance Only (MAO) programs. Other adults between the ages of 21 and 65 who are not blind or disabled, pregnant, in a skilled nursing facility, or are not members of families with minor children who meet federal deprivation requirements, are identified as Medically Indigent Adults (MIA) and are not eligible for MC. MIAs may receive medical care from County public health facilities. MC is under the jurisdiction of the Department of Health Care Services (DHCS). Requirements for Medi-Cal Eligibility The following basic requirements must be met for MC eligibility: Residency The person must be a California resident; however, there is no durational residency requirement. Citizenship/Immigration Status To receive full-scope coverage, an individual must be a U.S. citizen or a noncitizen with satisfactory immigration status. The Deficit Reduction Act (DRA) of 2005 requires that persons declaring U.S. citizenship or U.S. national status must provide original or certified copies of documents that verify their U.S. citizenship and identity. As of January 2010, this requirement may also be met by matching a person's information with Social Security Administration (SSA) records. Noncitizens without satisfactory immigration status and citizens with no proof of citizenship and identity may receive coverage limited to emergency, skilled nursing and pregnancy related care. Medi-Cal Program Section Page 1 of 9 10/11/11

2 Requirements for Medi-Cal Eligibility (Continued) Resources An applicant s non-excluded resources must not exceed the limits, based on family size, as shown below: 1 person $2,000* 2 persons 3,000 3 persons 3,150 4 persons 3,300 5 persons $ 3,450 6 persons 3,600 7 persons 3,750 8 persons 3,900 9 persons $ 4, or more persons $ 4,200 *The property limit for one person for the 1931(b) Program is $3,000. Other property limits may vary based on specific program requirements. The person s principal residence is not considered in determining resources and eligibility. The individual may also exempt real property, other than his/her own home if it is utilized and the net market value (assessed value less encumbrances) does not exceed $6,000. The value of other real property that exceeds $6,000 is applied to the family s total resources. Other personal property, such as cash, bank accounts, and non-exempt vehicles are also included in the total resource valuation. For 1931(b), a vehicle may be exempt if it is used for self-employment, transportation of a disabled person living in the home, transportation of the primary supply of fuel or water for the home, or used as a home. For MAO, the family may choose one vehicle for exemption, regardless of its use. A vehicle used as a home is also exempt for this program. Individuals with resources valued in excess of the limit for their household size are not eligible. For some qualifying children and pregnant women, resources are not counted (see details in Special Programs). For married persons who need MC because one spouse receives long-term inpatient care, the law allows the spouse at home to retain a portion of the combined community and separate property. The 2011 Community Spouse Resource Allowance (CSRA) is $109,560. The CSRA is adjusted annually based on the Consumer Price Index, however, the limit was not increased in 2011 and remains at the 2009 level. What is the Cost of Medical Care? The amount that a family or an individual has to pay for MC benefits is determined by the amount of available income that remains after appropriate exclusions and deductions are allowed. While there are no income limits for MC eligibility, income that remains after all state-allowed deductions are applied must be paid or obligated toward the individual or family monthly medical expense before MC coverage is utilized. This amount that must be paid or obligated is called a Share of Cost (SOC). Unlike a monthly medical premium, the SOC must only be met if MC coverage is needed during the month. Each time a beneficiary receives medical services, the service provider will use the Benefits Identification Card (BIC) to determine how much, if any, is obligated to be paid. Medi-Cal Program Section Page 2 of 9 10/11/11

3 What is the Cost of Medical Care? (Continued) In certain cases where a third party may be responsible for an individual s injury or illness, the DHCS will try to recover the cost of MC treatment from the responsible party. Which Services are Covered? Individuals who are eligible to receive full-scope MC benefits are entitled to a comprehensive range of health care services, dental care (for ages 0 up to 21 years) and prescription drugs (both in and out of a hospital or nursing home) from health care providers who participate in the program. This includes hospice care to alleviate pain and suffering of individuals with a diagnosis of illness with a life expectancy of six months or less. Pregnant women may be entitled to benefits that include pregnancy-related services and 60 days of postpartum services at zero SOC. MC benefits for pregnancy-related services and for emergency medical services only, which include labor and delivery of an infant, are available to noncitizens who do not have satisfactory immigration status and citizens with unverified proof of citizenship and identity, if otherwise eligible. DHCS establishes which services are authorized. Before providing and billing for certain benefits, providers of MC services may need to obtain authorization from the Medi-Cal Consultant at DHCS. Prior authorization is required for such things as dental services, prescription drugs not on the state-approved list, hearing aids, some sickroom equipment, prosthetic and orthodontic appliances, non-emergency hospitalization, nursing home services, and intermediate facility care. An applicant may be eligible for MC coverage for services received in any of the three months immediately preceding the month of application or re-application if all requirements are met for those past months. A beneficiary who is eligible for benefits on the first day of the month is entitled to services for the entire month. How are Services Received? A plastic Benefits Identification Card (BIC) is provided to each beneficiary. The BIC must be shown to the provider each time medical services are received. The provider will use the BIC to determine the individual s MC eligibility status and SOC obligation. The BIC should be retained even if benefits are subsequently discontinued. In the event that benefits are restored at a later date or upon reapplication, the BIC is reactivated for the beneficiary s use. Certain persons entitled to zero SOC MC are now required to enroll in a managed care plan. These are private health organizations under contract with the state to provide comprehensive health services to MC enrollees. Once enrolled in a managed care plan, a recipient must obtain his/her medical care through the plan except for any medical services that are not covered (e.g., dental care). Certain other groups or persons who have a monthly SOC obligation may receive fee-for-service care from a qualified MC provider. Medi-Cal Program Section Page 3 of 9 10/11/11

4 SPECIAL PROGRAMS FOR FAMILIES, WOMEN AND CHILDREN The following programs provide MC at zero SOC to certain eligible women, families, and children. 1931(b) Program - Provides no cost MC benefits to families receiving CW payments and families who do not receive CW, but meet the eligibility requirements which were in force for the Aid to Families with Dependent Children (AFDC) Program based on the passage of welfare reform legislation on July 16, Eligibility staff must first determine if eligibility can be granted under the 1931(b) Program, and if not, then, determine if eligibility can be established for other MC programs. Verification of resources is required. 100% Program - Provides MC benefits with zero SOC to children age 6 to 19 if the family s net nonexempt income is at or below 100% of the Federal Poverty Level (FPL). Family resources are not counted for this program. 133% Program - Provides MC benefits with zero SOC to children age 1 to 6 if the family s net nonexempt income is not more than 133% of the FPL. Family resources are not counted for this program. 200% Program - Provides MC benefits with zero SOC to pregnant women and infants under age one who do not meet the zero SOC criteria under other programs. The adjusted net income can be no more than 200% of the FPL. The benefits for women are limited to pregnancy-related and postpartum medical care. Infants receive full-scope MC services. Family resources are not counted for the pregnant woman or infant. Continuous Eligibility for Children (CEC) - Protects zero SOC eligibility for children for up to twelve consecutive months. The SOC protection starts from the initial month of zero SOC eligibility determined at application or at the annual renewal. During the CEC guarantee period, any changes in the family s income or resources which would cause the child to have a SOC or be totally ineligible are disregarded until the next annual redetermination or the child s 19 th birthday, whichever occurs first. CEC will protect the child from discontinuance, even if resource changes affect the other family members. Presumptive Eligibility (PE) for Pregnant Women - Allows certain qualified health care providers to extend zero SOC prenatal MC coverage to eligible pregnant women with income up to 200% of the FPL at the first clinic/office visit. This coverage ends either at the end of the second month of PE or upon approval or denial of the regular MC application filed by the pregnant woman. Family resources are not counted for the pregnant woman s eligibility to pregnancy-related-only services. Deemed Eligibility (DE) - Provides that infants born to women eligible for and receiving MC at the time of the child's birth are automatically deemed eligible for one year without a separate MC application. Birth verification is not required and a Social Security Number (SSN) is not required for the child until age one. This program also provides that such infants shall remain eligible, regardless of any increases in the family's income or resources until the child reaches age one. Medi-Cal Program Section Page 4 of 9 10/11/11

5 SPECIAL PROGRAMS FOR FAMILIES, WOMEN AND CHILDREN (Continued) Transitional Medi-Cal (TMC) Program - Provides up to 12 months of zero SOC benefits to families who have lost eligibility to CW or 1931(b) benefits due to increased hours of employment or increased earnings of the caretaker/relative or primary wage earner. Certain eligibility requirements must be met. Four-Month Continuing Medi-Cal - Allows families who have lost eligibility to CW or 1931(b) MC due to receipt of, or an increase in child support or alimony, to receive no-cost, full- scope benefits, under certain conditions, for four additional months. Medi-Cal to Healthy Families Referrals - Allows children who are approved for MC with a SOC to be referred to the Healthy Families Program (HFP). The HFP offers low-cost health coverage to children under age 19, who are citizens or legal permanent residents with a household income under 250% of the FPL. Unlike the MC to Healthy Families Bridging program, these children are not entitled to a month of zero SOC MC eligibility. Medi-Cal/Healthy Families Bridging - Extends one month of no-cost eligibility to children under age 19 who are moving from no-cost coverage to a SOC, or who have lost eligibility due to increased resources. The additional month allows referral to the HFP for a determination of eligibility. Children must be U. S. citizens or legal permanent residents with income under 250% of the FPL. Former Foster Care Children (FFCC) Program - Provides for automatic, continuing, no-cost, full-scope MC coverage for children who were in foster care on their 18 th birthday and who were subsequently released from the foster care system due to age. There is an annual redetermination requirement which involves no income or resource verification. MC coverage continues until the FFCC s 21 st birthday as long as he/she remains in the state. SPECIAL PROGRAMS FOR ADULTS The following programs provide MC at zero SOC to certain eligible adults: Aged & Disabled Federal Poverty Level (A&D FPL) Program - Provides zero SOC MC to income-eligible aged and disabled persons and blind persons. To be eligible for this program, the individual must be at or over 65 years of age or be considered disabled or blind by Social Security criteria, have resources below the MAO limits (see Resources, page 2), and have net countable income at or below 100% of the FPL. Pickle Amendment Benefits - Under the Pickle Amendment to the Social Security Act, MC benefits, at zero SOC, are available to persons who have lost their eligibility for Supplemental Security Income (SSI) cash benefits due to cost-of-living adjustments in their regular Social Security disability or retirement benefits. To be eligible, an individual s countable income must be less than the current SSI payment level, after all cost of living adjustments subsequent to SSI ineligibility due to increased SSA benefits have been disregarded. This program was expanded to include Disabled Adult Children and Disabled Widow(er) s. Medi-Cal Program Section Page 5 of 9 10/11/11

6 OTHER SPECIAL PROGRAMS The programs listed below provide financial or medical assistance to persons who may or may not otherwise be eligible for MC benefits. Child Health and Disability Prevention Program (CHDP) - CHDP is a federally and state mandated program which provides preventive health care to children ages 0-20 who receive MC. Children, ages 0-19, who do not receive MC but have family income equal to or less than 200% of the FPL, are also eligible for these services. Eligible children receive services that include periodic assessments and referrals for diagnosis and treatment of suspected health care problems. The primary goal of the program is to keep children and teens healthy through regular check-ups and to find health problems before they become more serious. In Los Angeles County, CHDP services are provided by CHDP certified fee-for-service providers, Medi-Cal Managed Care providers, County Public Health Centers, and certain prepaid health plans. In Long Beach and Pasadena, the City of Long Beach Health and Human Services and the City of Pasadena Public Health Department also provide these services. Minor Consent Services - This program provides confidential services to minors related to sexual assault, pregnancy and pregnancy-related services, family planning, sexually transmitted diseases, drug and alcohol abuse, outpatient mental health treatment, and counseling. 250% Working Disabled Program - This program expands MC comprehensive services to working, disabled individuals, subject to payment of a monthly premium. Applicants must meet SSI eligibility rules, although their countable net income can be as high as 250% of the FPL. The county determines eligibility and premiums are collected by the state. The monthly premium is set using a sliding scale, based on individual income. Dialysis and Related Services - Limited MC coverage is provided to property ineligible persons who need life-sustaining dialysis and related services. Eligible persons may be obligated to pay a percentage of the treatment costs for services not covered by other health insurance or government programs. Organ Transplant: Anti-rejection Medication - Allows Medi-Cal beneficiaries to receive up to two years of anti-rejection medication following an organ transplant. The medication is provided at no cost to the beneficiary Health Insurance Premium Payment (HIPP) Program - Under the HIPP Program, the DHCS will pay health insurance premiums on behalf of certain MAO beneficiaries who have high-cost medical conditions. The Department of Public Social Services (DPSS) refers potentially eligible clients to DHCS for possible participation in the program. Medicare Savings Programs (MSP) - The Medicare Catastrophic Coverage Act (MCCA) of 1988 requires that states pay the Medicare Part A and Part B cost-sharing expenses of qualified low-income Medicare beneficiaries that include premiums, deductibles and coinsurance fees. Medi-Cal Program Section Page 6 of 9 10/11/11

7 OTHER SPECIAL PROGRAMS (Continued) Under the Qualified Medicare Beneficiary Program (QMB), MC will help pay monthly Medicare Part A and Part B premiums plus deductible and coinsurance fees for certain aged and disabled persons. For Part A Medicare premium coverage under the QMB Program, eligible persons may have income up to 100% of the FPL. Under the Specified Low Income Medicare Beneficiary (SLMB) Program, individuals may have income above 100% but less than 120% of the FPL. Coverage under SLMB is limited to the payment of Medicare Part B premium, not payment of Medicare Part A premium or the Part B deductibles or coinsurance fees. The Qualifying Individual-1 (QI-1) Program is limited to the payment of the Medicare Part B premium. It does not pay the Medicare Part A premium or the Part B deductibles, or coinsurance fees. To be eligible for the QI-1 Program, a person s monthly countable income must be within the 120% - 135% of the FPL. Although the program sunset date was extended to December 2010, because the QI-1 Program has been extended many times, we are to continue accepting applications and determining eligibility for the QI-1 Program until the DHCS notifies otherwise. Medicare Buy-In is the payment of Medicare Part B premiums by DHCS (state) for certain eligible aged, blind or disabled Medi-Cal beneficiaries under the Medicare Buy-In agreement with the SSA. As a result of Senate Bill 853, for persons with a SOC, the Part B premium payment will only be paid after the SOC has been paid by the beneficiary. Tuberculosis Program - This is an optional program for persons infected with tuberculosis who do not qualify for federally funded MC programs. To be eligible, income and resource requirements are applied. Breast and Cervical Cancer Treatment Program (BCCTP) - This program is administered by DHCS for affected individuals who do not meet the requirements for full-scope, no-cost MC. Breast cancer treatment is available to both men and women, while the cervical cancer treatment is available to women only. County staff refers potentially eligible persons to BCCTP for evaluation. The state refers persons who are no longer eligible for BCCTP benefits to DPSS for determination of eligibility under other MC programs. For enrollment information, individuals should call the toll-free number Assisted Living Waiver Pilot Project (ALWPP) - ALWPP is a three-year pilot project created by State law (AB 499) in 2000 to test the efficacy of assisted living as an alternative to long-term care nursing provider site placement. The ALWPP is intended to provide options for older adults and individuals with disabilities who want to remain in a community-based setting. The waiver was renewed in March 2009 to extend the project for an additional five years. OTHER PATHS TO MEDI-CAL Several programs have been developed by DHCS to facilitate children s access to MC benefits and expedite the application process. These programs offer either no-cost MC benefits for certain apparently eligible children for a period of 60 days or until a determination of eligibility has been completed OR use alternate application methods to expedite the eligibility determination. The programs that offer expedited access to MC benefits are: Medi-Cal Program Section Page 7 of 9 10/11/11

8 OTHER PATHS TO MEDI-CAL (Continued) Accelerated Enrollment - Allows apparently eligible children under age 19 to receive temporary (up to 60 days) no-cost, fee-for-service MC benefits. During this time, the HFP makes a determination of eligibility after receiving a Joint Medi-Cal/Healthy Families application (MC 321 HFP) via Single Point of Entry. If the family appears eligible to MC, the application is forwarded to the county of residence for processing. CHDP Gateway - Allows apparently eligible children, age 0 to 19 years, to enroll into temporary, no-cost MC benefits through providers at the time of the CHDP examination. Applications must be submitted during the 60-day temporary enrollment period if benefits are to continue. If an application is not returned, the temporary benefit stops at the end of the 60-day period. The exception to this CHDP Gateway process rule is: No application is required for a CHDP Gateway enrolled infant born to a mother who was eligible to and receiving MC in the infant s birth month. The infant remains eligible to receive the temporary benefits until age one or until eligibility under regular MC programs has been completed. Healthy Families to Medi-Cal Presumptive Eligibility Program - This program replaced the Healthy Families to Medi-Cal Bridging Program effective July 1, The program gives full-scope zero SOC MC benefits to children who were receiving Healthy Families benefits but who appear to be eligible for MC. The PE period continues until a MC eligibility determination has been completed. Other Paths to Medi-Cal for Adults The "Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Eliminating Barriers to Medicare Savings Programs Enrollment requires the State to treat the Low Income Subsidy (LIS) application (Medicare Part D) as an application for the Medicare Savings Programs (MSP). California has elected to also treat the LIS application as an application for MC for which an eligibility determination is required. Based on an agreement between DHCS and the Department of Corrections and Rehabilitation (CDCR), applications for adult inmates who are granted parole will be processed prior to their release. If the inmate is determined to be eligible, the CDCR is notified and a temporary BIC is issued in order to access health care upon release. Suspension of Medi-Cal Benefits for Incarcerated Juveniles Senate Bill 1147 (SB 1147) was implemented March This bill mandates that persons under age 21, who were MC beneficiaries at the time of incarceration, are to have their MC benefits suspended rather than terminated. The suspension is not to exceed twelve months and affects minors whose incarceration began on or after January 1, It also requires that MC benefits for the incarcerated minor be restored, without a new application, on the day the eligible juvenile is no longer considered an inmate of a public institution. Medi-Cal Program Section Page 8 of 9 10/11/11

9 OTHER PATHS TO MEDI-CAL (Continued) Health Care Reform The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Acts were signed into law in March The California Health Care Initiative California Bridge to Reform was approved by the Centers for Medicare and Medicaid Services (CMS) in November This will allow the state to implement coverage and improvements for a seamless transition to reform mandates effective Low Income Health Program (LIHP) The LIHP is a major component of California s 1115 Medi-Cal Waiver, which allows counties to draw down federal matching dollars to provide health coverage to childless adults if they meet certain criteria. Medicaid Coverage Expansion (MCE) - In Los Angeles County this program, also known as Healthy Way L.A. (HWLA), provides health coverage for childless adults between 19 and 64 years of age with family incomes at or below 133% of the FPL. This program is considered early expansion of Medi-Cal for childless adults. The program began in July 2011 and is administered by the Department of Health Services (DHS). To Enrich Lives Through Effective And Caring Service Bureau of Program and Policy Medi-Cal Program Section Crossroads Parkway South City of Industry, California Medi-Cal Program Section Page 9 of 9 10/11/11