Medi-Cal Program Health Care Reform WebEx Presentation II April 22, 2014
Scenario #1 On the CalHEERS Assistant Summary screen, we are able to see the names of the participants, however, we also see the names of the absent parent or names of those that at one time were on the Medi-Cal Case. Is this correct? Are they supposed to be there? YES. All Client Index Numbers (CINs) known to the case will be displayed. MCP WebEX Presentation II 2
Scenario #2 When we place a check mark on the Request Evaluation for MAGI, APTC/CSR [Y/N] it places the check mark on everyone that was listed. Is there any way we can Let LEADER know, that we do not want an evaluation on the person that is no longer in the Home? No, the request for MAGI evaluation by CalHEERS is at case level. However, in order for LEADER not to include those individuals the following needs to be done: Case Individual Summary screen person(s) should be identified as Not Applying for Aid and Not In The Home. Click Detail Button Case Individual Information screen person(s) should be identified as: Applying For Aid (N); In Household (N); Data Collection (N). MCP WebEX Presentation II 3
Scenario #2 When we place a check mark on the Request Evaluation for MAGI, APTC/CSR [Y/N] it places the check mark on everyone that was listed. Is there any way we can Let LEADER know, that we do not want an evaluation on the person that is no longer in the Home? No, the request for MAGI evaluation by CalHEERS is at case level. However, in order for LEADER not to include those individuals the following needs to be done: Case Individual Summary screen person(s) should be identified as Not Applying for Aid and Not In The Home. Click Detail Button Case Individual Information screen person(s) should be identified as: Applying For Aid (N); In Household (N); Data Collection (N). MCP WebEX Presentation II 4
Scenario #3 What does the following mean: Error processing MAGI results? We see these in the eligibility summary screen under reason for failure or pending. This is a LEADER error. Please submit a Service Request (SR) MCP WebEX Presentation II 5
Scenario #4 Pre ACA combo (CalFresh/Medi-Cal) cases, may we run SFU/EDBC for a CalFresh recertification? If so, do we also authorize the Medi-Cal segment or leave it pending? For Combo cases (same case number), CalFresh is priority and SFU/EDBC should be run. The pending Medi-Cal segment should not be authorized until all CalHEERS screens are updated and the Request For Tax Household Information (RFTHI) is received and updated on LEADER to determine MAGI benefits. MCP WebEX Presentation II 6
Scenario #5 The HH size is 4 (2 undocumented, employed parents, mother is pregnant, with 2 US-born children, ages 7 & 10). Total factored HH income is $30,353.40 (limit for 4 is $32,500). Medi-Cal should be "PASSING" and MAGI should be "FAILING," but Medi-Cal fails incorrectly for "No Linkage" (MAGI fails correctly). The EW initiated a Meds Add On for the pregnant mother and is asking if we can submit a PA6043 to reopen a Medical segment alone (without MAGI) for the entire family. 1. Household is five. Dad, Mom, 2 children, and unborn. 2. Eligibility determination is for MAGI first. This household is potentially MAGI eligible. 3. MAGI Medi-Cal should pass for the children (Aid Codes: P5 and M5). The adult parents should be eligible to restricted Medi-Cal under new aid codes (M0 and M4). 4. No, this should be one case for the entire household under MAGI. 5. NOTE: Linkage is no longer a requirement under Affordable Care Act (ACA). 6. Please refer to Call-Out 14-07. MCP WebEX Presentation II 7
Scenario #6 How does LEADER and Covered California treat same sex marriages. I have married female couple applying for aid. One of the ladies file taxes as single. Her partner, has earning, but low enough where she does not have to file taxes. The partner does not file taxes nor is she a dependent of the one who does file. Questions: How do we relate them in LEADER? How is the income counted? Do we open one case or separate cases? 1. There is no logic in LEADER for same sex marriages. 2. Income is applied to each individual working. 3. In this scenario, we would have two Medi-Cal cases as one files as a single individual and the other does not file. MCP WebEX Presentation II 8
Scenario #7 Consumer who is 67 years old with no income, failing for Medi-Cal for excess property, failing for MAGI due to his age, we will deny both Medi-Cal and MAGI. The Consumer is passing for Covered CA and no APTC/CSR. I believe this is incorrect because he has no income. Do we need to troubleshoot this or do we refer him to Covered CA? 1. This is correct eligibility determination. 2. 67 year old is not eligible to MAGI or APTC/CSR due to age and eligibility to Medicare. 3. However, as a Medicare recipient [Minimum Essential Coverage (MEC)] he already has health coverage and does not need to apply for Medi-Cal or additional health insurance. If he chooses to apply for Medi-Cal, to supplement his Medicare coverage, he will need to spend down on property in order to qualify. MCP WebEX Presentation II 9
Scenario #8 CalHEERS case 5000XXXXXX consumers is John C. Doe. CalHEERS is showing he is Medi-Cal eligible with aid code M1 but on MEDS he is showing aid code 20 and is an SSI recipient. I remember it was mentioned in the last conference call not to work with those with a 60 aid code. Does that apply for this case also? Yes. The consumer stated that he didn't complete the Covered California application. He said his current health plan (Blue Cross) might have sent his information. Is this possible? No. Something else I want to add is that he is self-employed and didn't have to file taxes last year. If I need to verify income in the future, what should I ask as verification of income? We should cancel this CalHEERS case. Based on the aid code displayed on MEDS (20), the beneficiary is blind and receiving SSI benefits that also includes Medi-Cal. Social Security Administration administers SSI cases. Therefore, the County does not have to verify any documents. Note: Aid code 10 (Aged)/Aid code 20 (Blind)/Aid Code 60 (Disabled). SSI Recipient. MCP WebEX Presentation II 10
Scenario #9 In processing our cases today, we have discovered a few that are erroneously failing for MAGI. The case scenario is this: Single female 32 years old, she reported $200.00 income per month. Income was also verified by HUB. However, case fails MAGI and states APTC/CSR ineligible as well with an aid code of X7. Customer should pass MAGI, correct? Yes. Check the Financial Assistance page in CalHEERS to see how the consumer responded to the question, Yes or No? If No, then it must be changed to a Yes. If Yes, submit a Trouble Ticket. MCP WebEX Presentation II 11
Scenario #10 Single 21 yr. old Male with zero income. Case failing MAGI for same reason, APTC/CSR ineligible, aid code X7. Similar to previous scenario. Check the Financial Assistance page in CalHEERS to see how the consumer responded to the question, Yes or No?. If No, then it must be changed to a Yes. If Yes, submit a Trouble Ticket. MCP WebEX Presentation II 12
Scenario #11 The following CH application 5001XXXXXX is for a household of 2. Unmarried couple w/no dependents. They each file their separate taxes but applied together. They both want health insurance benefits. Now because they are both primary tax filers, they should both have their separate cases. How should we proceed? Should we process the primary applicant and do an add-on on LDR for her boyfriend? No, these will be two separate cases. The boyfriend gets his own case. MCP WebEX Presentation II 13
Questions? MCP WebEX Presentation II 14
MEDI-CAL PROGRAM AND POLICY For questions please email us at: HCR@dpss.lacounty.gov Visit our Health Care Reform webpage at: http://www.ladpss.org/dpss/health/reform/default.cfm To download WebEX presentations, please use this link: http://www.ladpss.org/dpss/health/reform/publications.cfm MCP WebEX Presentation II 15