Title: Health Coverage

Transcription

1 Title: Health Coverage OBJECTIVES: Participants will be able to: 1. Describe health coverage programs and services in Los Angeles County for pregnant women and their newborns. 2. Explain varying eligibility criteria and application procedures for the different health coverage programs. 3. Demonstrate how to advocate for families when there are problems accessing healthcare insurance. AGENDA: TIME PRESENTATION FACILITATORS/ SPEAKERS 8:00-8:30 am BREAKFAST AND REGISTRATION 8:30-8:35 am Introductions, Overview of Training Objectives Terrie Anciano, BS 8:35-8:45 am Pre-Test Liz Ramirez 8:45-9:00 am The Affordable Care Act Liz Ramirez 9:00-9:15 am Introduction to Medi-Cal Liz Ramirez 9:15-9:45 am Medi-Cal Programs Liz Ramirez Presumptive Eligibility 60% FPL Program 213% FPL Program 138% FPL Program Minor Consent 9:45-10:00 am Medi-Cal Managed Care Liz Ramirez Who Must Join Medical Exemptions Request Getting Assistance

2 10:00-10:15 am BREAK 10:15-10:25 am Deemed Eligible Newborn Liz Ramirez Newborn Referral Form 10:25-10:35 am Dental Coverage Liz Ramirez 10:35-10:55 am Access for Infants and Mothers (AIM) Liz Ramirez 10:55-11:15 am Covered California Liz Ramirez 11:15-11:30 am LA County Child Delivery Plan Liz Ramirez 11:30-11:45 am Post-test Liz Ramirez Wrap Up/Evaluations 11:45 am LUNCH/REGISTRATION FOR AFTERNOON SESSION Terrie Anciano, BS

3 Health Coverage SPEAKER BIO Liz Ramirez is the Director of Training and Education for Maternal and Child Health Access. Ms. Ramirez provides training and education for agencies and low-income people on access to health care. She also provides a Core course for agency, school, clinic and social service staff entitled, We ve Got You Covered which explains dozens of health services and programs that help to ensure at least some health care for everyone in Los Angeles County. Prior to joining Maternal and Child Health Access Ms. Ramirez worked as a Health Care Advocate for Los Angeles Unified School District. She developed an outreach and enrollment program within the second largest school district in the United States. She has been committed to issues with health care access for over 18 years.

4 Presented by, Liz Ramirez, Director of Training and Education (213) or Private Insurance Improvement Medi-Cal Expansion Covered California PRIVATE INSURANCE IMPROVEMENT Changes to Private Policies: No pre existing condition exclusion! Prohibiting Insurance Companies from Rescinding Coverage Kids stay on until 26! No prevention co pays! Rebate if plans don t pay 80% of premium costs on care Ends Lifetime Limits on Coverage 1

5 Affordable Care Act Insurance Coverage Improvements FOR INSURANCE TO BE CONSIDERED MINIMAL ESSENTIAL COVERAGE (MEC) IT MUST INCLUDE: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services What Does MAGI Mean? Modified Adjusted Gross Income MAGI MEDI CAL PROGRAMS MC For Parents & Caretaker Relatives MC for other adults (single childless) MC for Children INCOME CALCULATIONS 2

6 MAGI CRITERIA FOR ELIGIBILITY INCOME IMMIGRATION STATUS WHO S ACHILD? WHO S ANADULT? Under age 19 For eligibility evaluated at 266% Ages For eligibility evaluated at 138% Age 21 For purposes of special benefits: dental, EPSDT 3

7 Medi-Cal Immigration Basics Who gets what? FULL SCOPE (USC, LPR,PRUCOL) RESTRICTED (UNDOCUMENTED OR PREGNANT WOMEN WITH INCOME ABOVE 138%) PRUCOL Permanently Residing in the U.S. Under Color Of Law Undocumented immigrants who would otherwise only be eligible for restricted scope benefits can get full scope benefits if they are in the process of adjusting their immigration status. PRUCOL will only determine the scope of benefits. The family or individual still has to meet the income requirements. PRUCOL is not an immigration term; it is a public benefits eligibility category through which certain undocumented immigrants can apply for Full Scope Medi CAL 4

8 SENTATE BILL 75 Senator Ricardo Lara's (D 33rd district) bill to cover undocumented children through Medi Cal. California expanded Full Scope Medi Cal eligibility to all children up to 19 years of age regardless of immigration status. Qualifying income is up to 266% of the FPL. Remember: you still have to have the intent to reside in California! Presumptive Eligibility Medi-Cal (PE) ELIGIBILITY All pregnant women who declare they are income eligible (213% of poverty) and state residents are presumed to be eligible for Medi Cal for their pregnancy WHERE TO APPLY At the clinic or doctor s office where woman receiving prenatal care a Qualified Provider to Enroll.aspx 5

9 MEDI-CAL PRESUMPTIVE ELIGIBILITY (PE) CARD PE IS TEMPORARY COVERAGE Women with PE need to apply for Medi-Cal for continuation of coverage DPSS Office Community Based Organizations OR HOSPITAL OR CLINIC US Citizen and Qualified Immigrants Undocumented Where do you belong? 0 138% FPL % FPL Full Scope Medi Cal Restricted Medi Cal Restricted Medi Cal Restricted Medi Cal % FPL 214% and up MCAP (AIM) Comprehensive Coverage MCAP (AIM) Comprehensive Coverage Covered California (Also available to women over 139%) Not eligible Pregnancy Related Medi Cal considered Minimal Essential Coverage (MEC)! 6

10 Managed Care & Medi-Cal LOS ANGELES COUNTY S TWO PLAN MODEL MAXIMUS (The State s Enrollment Contractor) Health Care Options English 1 (800) Spanish 1 (800) Farsi 1 (800) Arabic 1 (800) Lao 1 (800) Korean 1 (800) Hmong 1 (800) Tagalog 1 (800) Russian 1 (800) Armenian 1 (800) Vietnamese 1 (800) Cambodian 1 (800) Cantonese 1 (800) Mandarin 1 (800) HEALTH NET Commercial Plan Admin: (800) (800) Health Net (800) Molina Medical Center (800) Anthem Blue Cross (888) LA Care (888) LA CARE Local Initiative Admin: (213) (888) Care First (800) Kaiser (800)

11 THE BABY IS BORN. NOW WHAT? Guess what? I m Deemed Eligible!!! 1. CALL THE WORKER/CALL CENTER (626) (310) (818) (866) Toll Free Number Tell the EW the name, DOB and gender of the baby. No documents are needed for Medi-Cal only! Worker should issue BIC card and add baby to MEDI-CAL FOR THE NEWBORN 2. CHDP GATEWAY At the provider office at first visit postpartum, if no Medi-Cal yet. Issues: Deemed infants do not always get full year via the CHDP Gateway. Limit on CHDP Gateway (2 in 12 month period) Hospital PE counts as 1 case. 3. NEWBORN REFERRAL (MC 330) Fill out and send/ it to the County using the Advocate Liaison List Medi Cal Access Program Formerly Access for Infants and Mothers (AIM) Income % poverty, or $500 maternity deductable (insurance cost) Has been programmed into CalHEERS Family Size MAGI Monthly Family Income Total Cost Payments of: (1.5% of your MAGI Monthly Income x12 ) 12 Monthly *2 $2,806 $4,221 $505 $760 $42 $64 3 $3,530 $5,311 $530 $796 $45 $67 4 $4,254 $6,400 $639 $960 $54 $80 8

12 Medi-Cal Access Program Is now -ALMOST- Medi-Cal MCAP provider system is now in Fee For Service Medi Cal Will move to Managed Care in June, 2017 Full coverage, including dental Eligibility goes back to first of the month of application Other changes: 1) Pregnant applicants to Covered CA with income between % are offered the option of enrolling in MCAP 1) If income drops during pregnancy can now switch to free Medi Cal with no penalty PREGNANT? CONGRATULATIONS! Pregnancy in the Exchange 9

13 Beginning August 2015 Pregnant women who are enrolled in Covered CA have options! 1. Stay in Covered CA & keep subsidies OR 2. If income is % FPL transfer to Medi Cal. 3. If income is 214% 322% FPL transfer to MCAP Pregnancy Related Medi Cal considered MEC COVERED CALIFORNIA: The Exchange

14 What is a PREMIUM? What is a DEDUCTIBLE? What is a CO-PAY? What is What is CO-Insurance? OUT OF POCKET MAXIMUM? YOUR COSTSHARING PERCENTAGE PLAN CATEGORY INSURANCE PAYS CONSUMER PAYS SAMPLE PREMIUM 45 YRS. 37,000/YR BRONZE 60% 40% $237 SILVER 70% 30% $277 GOLD 80% 20% $350 PLATINUM 90% 10% $446 LA COUNTY Health Programs OK, What about the rest of us? 11

15 MY HEALTH LA At or below 138% FPL Ages 19 and above as of May 2016 Cannot be eligible for full scope Medi Cal Primary Health Care at community clinics Patients choose a medical home Specialty care referred into LA County Health system L.A. COUNTY DEPARTMENT OF HEALTH SERVICES ABILITY TO PAY (ATP) LA County residents who do not qualify for Medi Cal or Medicare Clinic and outpatient hospital visits Includes Specialty Care Tests and medicines Inpatient hospital care Emergency Room visits Certain surgeries 12

16 County Pre-Pay Program $60 for clinic visits at Comprehensive Health Centers (CHC) and Health Centers (HC); $80 for clinic visits at county hospital clinics and Multiservice Ambulatory Care Centers (MACC); $80 for urgent care visits at all County facilities; $140 at county hospital emergency rooms; $500 at outpatient surgery clinics. $2000 Pre Natal and Child Delivery Plan CostLow CostFlyer_Span_April1,2015.pdf SENTATE BILL 75 Senator Ricardo Lara's (D 33rd district) bill to cover undocumented children through Medi Cal. California expanded Full Scope Medi Cal eligibility to all children up to 19 years of age regardless of immigration status. Qualifying income is up to 266% of the FPL. Remember: you still have to have the intent to reside in California! What will happen to. Kaiser Child Health Plan? Healthy Kids? Closed What about kids in MHLA? 13

17 Kaiser Child Health Program CHANGES: Members who are not currently enrolled in Medi cal will had until December, 2016 to enroll. Members may choose to stay with Kaiser as their MC Managed Care plan. KPCHP will remain open for kids with family income between 267% 300% FPL. CONTACT US! (213) (800) New MCHA pregnancy coverage helpline:

18 Los Angeles County s Two Plan Model MAXIMUS (The State s Enrollment Contractor) Health Care Options English 1 (800) Spanish 1 (800) Farsi 1 (800) Arabic 1 (800) Lao 1 (800) Korean 1 (800) Hmong 1 (800) Tagalog 1 (800) Russian 1 (800) Armenian 1 (800) Vietnamese 1 (800) Cambodian 1 (800) Cantonese 1 (800) Mandarin 1 (800) HEALTH NET Commercial Plan Admin: (800) (800) LA CARE Local Initiative Admin: (213) (888) Health Net (800) Anthem Blue Cross (888) Care First (800) Molina Medical Center (800) Community Health Plan (800) Kaiser (800) NOTE: A Primary Care Physician might contract with several plans. Un Doctor Primario puede tener contrato con varios de estos planes Maternal and Child Health Access/May be reprinted with permission February, 2012

19 Los Angeles County s Two Plan Model Regular Medi-Cal MAXIMUS (The State s Enrollment Contractor) Health Care Options English 1 (800) Spanish 1 (800) Vietnamese 1 (800) Armenian 1 (800) Cambodian 1 (800) Cantonese 1 (800) Arabic 1 (800) Mandarin 1 (800) Korean 1 (800) Farsi 1 (800) Hmong 1 (800) Lao 1 (800) Russian 1 (800) Tagalog 1 (800) HEALTH NET Commercial Plan Admin: (800) (800) LA CARE Local Initiative Admin: (213) (888) Health Net (800) Blue Cross (888) Care First (800) Molina Medical Center (800) Community Health Plan (800) Kaiser (800) Guidelines for Changing Health Plan Membership or Providers (Providers are able to contract with multiple plans) 1. To change Primary Care Providers (PCP) while staying with the same LA Care plan partners, call the specific plan s member services number. PCP transfers on the Health Net side are handled by Health Net s member services office, not the plan partners (Universal or Molina). 2. To change from one Health Net subcontracting plan to another Health Net plan, call Health Net s member services department (for example, moving from Molina Medical to Universal Health Care). Do the same for LA Care subcontracting plan transfers. 3. For voluntary health plan members to move from a health plan to regular fee-for-service Medi-Cal, contact Health Care Options. 4. To request an Expedited disenrollment from an LA Care plan to join a Health Net plan or to disenroll from a Health Net plan to join an LA Care plan, contact Health Care Options Maternal and Child Health Access/May be reprinted with permission March, 2011

20 Get Help Applying for Free or Low-Cost Health Coverage All agencies listed below serve clients in Los Angeles County. Bilingual staff assist families in enrolling in public and private health programs. Please contact the agencies listed below for more information. Antelope Valley, Lancaster, Palmdale Tarzana Treatment Center , Ext or 4323 Carson, Hawthorne, Inglewood, Lawndale, Lomita Community Health Councils Crystal Stairs Burbank, Glendale, San Fernando Valley, Santa Clarita, Northridge El Monte, Monrovia, San Gabriel Valley, Pomona Boyle Heights, Chinatown, Downtown LA, Echo Park, El Sereno, Elysian Park, Hollywood, Koreatown, Westlake Little Toyko, Pico Union Artesia, Bell, Bellflower, Bell Gardens, Downey, East L.A, Hunt. Park, Hawaiian Gardens, Lakewood, Lynwood, Montebello, Norwalk, Pico Rivera, South Gate, Santa Fe Springs, Whittier Northeast Valley Health Corporation Valley Community Clinic ext 333 Child and Family Guidance Center Citrus Valley Health Partners, G.E.M Asian Pacific Health Care Venture Maternal and Child Health Access Worksite Wellness LA Maternal & Child Health Access California Hospital Medical Center Asian Pacific Health Care Venture Chinatown Service Center Worksite Wellnes LA Korean Health Education Information & Research Center Human Services Association Maternal & Child Health Access St. Francis Medical Center Worksite Wellness LA City of Long Beach Pasadena, Altadena, Sierra Madre Culver City, Santa Monica, Venice, West Los Angeles Compton, Crenshaw, Exposition Park, Florence, Watts, Jefferson Park, Leimert Park, Lynwood, Paramount, University Park, North University Park, South Central LA For Countywide Assistance with healthcare advocacy, troubleshooting and training Long Beach Dept. of Health and Human Services Pasadena Public Health Department LAUSD CHAMP Helpline Venice Family Clinic Maternal & Child Health Access California Hospital Medical Center Community Health Councils Worksite Wellnes LA Health Consumer Center of Los Angeles Maternal & Child Health Access Go Online to Find Help Near You: 8/2013