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Today’s Accomplishments Learn about the 20 different eligibility and enrollmentprocess Learn how to enhance your current identificationprocess Learn how to incorporate Covered California Learn how to apply a proactive approach that helps tosecure future benefits2
Change your approach Think ProactivelyCreate your own “Community Enrollment Center”Think of ways to get patients covered proactivelyCovered California considerations3
Create an Enrollment CenterEnhance your current business model to includescreening of all uninsured patients atregistration or point of serviceUnderstand how all Government EligibilityPrograms work Federal State County4
Understand Covered Californiaand MAGI-Medi-CalIncomeIncomeIncomeIncome0-138% FPL138-200% FPL138-400% FPL400% FPL MAGI-Medi-CalCounty ProgramCovered CaliforniaSelf Pay*exempts assets*exempts assetsNon-MAGI Medi-Cal(Under 21, Over 65 yrs, pregnant, children in the home withdeprivation, disabled and/or requires skilled nursing care)5
MAGI – Medi-CalModified Adjusted Gross IncomeAid Codes:AFDC 40, 45, 4H, 4L, 4K, 5KPregnancy 44, 48, 5F, 5W, 76, 86, 87Pregnant Undocumented/Unverified D8, D9Children 47, 69, 72, 74, 7A, 7C, 8N, 8P, 8R, 8T, 8U, 8VAdoption 04, 30, 32, 33, 35, 3A, 3C, 3D, 3ECalworks 3G, 3H, 3L, 3M, 3P, 3R, 3U, 3W, 4A, 4G, 4P, 4RFamilies and Children 2A, 34, 37, 3N, 3V, 82, 83, C5, C6, C9, D1Other Federal Programs 4M, 58, 6P, 71, 7H, F1-F4, G1-G46
Lets start with understanding theprogram hierarchyFederal ProgramsState ProgramsCounty ProgramsCovered CaliforniaCharity Care7
Federal Program OverviewMedicareMedicaid (mandatory eligibility )Social Security Retirement/DisabilityCompassionate Allowance (CAL)Low Income Health Program (LIHP) – terms 12/31/20138
State Program OverviewMedi-Cal250% Working Disabled PersonsVictims Compensation Program (VCP)California Children Services (CCS)IMPACTBCCTP – Breast and Cervical Cancer Treatment ProgramGenetically Handicapped Persons Program (GHPP)Major Risk Medical Insurance Program (MRMIP)Health Insurance Premium Program (HIPP)9
County Program OverviewMedically Indigent Adult (MIA)County Medical Service Indigent Program (CMISP)Medical Service Program (MSP)Medical Service Initiative (MSI)County Medical Services (CMS)And many more .10
Let’s Start with the FederalPrograms11
Medicaid vs. Medi-CalMedi-Cal is California’s Medicaid Program.Each state can have their own “optional stateprograms”12
Social Security AdministrationProgramsSocial Security Disability Income (SSDI)Supplemental State Income (SSI)MedicareMedicare Disability: Renal Dialysis & Lou Gehrig’sDisease (ALS)Retirement13
Compassionate Allowance (CAL)Compassionate Allowances (CAL) provides quickbenefits to applicants whose medical conditions areso serious that their conditions obviously meetdisability standards.SSA has identified 200 medical conditions that rangefrom Traumatic Brain Injuries, Dementia to rarediseases.Benefits can occur within a month without having towait for years! All you need is confirmed diagnosis!14
Low Income Health Program(LIHP)Medical care for the uninsured adult population“childless adults” 19-64 years of age Must be a county resident US Citizen or legal immigrant with 5 years residencyMedicaid CoverageExpansion (MCE)Health Care CoverageInitiative (HCCI)Income: 0-133% FPLIncome: 134-200% FPLAssets: ExemptAssets: Within Medi-CalLimits15
Understanding the StatePrograms16
www.calduals.orgMedicare/Medi-Cal Integration– Dual EligibleCal MediConnect Counties:AlamedaLos AngelesOrangeSan DiegoSan MateoRiversideSan BernardinoSanta Clara17
www.healthcareoptions.dhcs.ca.govProgram For All-Inclusive Carefor the Elderly (PACE) Plans55 or older and need a higher level of care to live athome and have chronic conditions . Alternative to LTC.Maintain independenceAlamedaDignity and Quality of LifeSanta ClaraEmergency CareLos AngelesDay CenterSan DiegoHome care servicesTransportation18
Low Income Medicare Beneficiary(QMB/SLMB)EligibilityBenefitsIncome eligible Pays monthly MedicareAsset eligiblePart A or/and B premiums Prescription Drug Assistance19
Basic Medi-Cal LinkageUnder 21 years of ageOver 65 years of agePregnantParents with deprived childrenRequires Long Term Care20
Medi-Cal Disability Never assume; always ask and confirm!Understand the difference about the3 different Disability (DDSD) Programs:Medi-Cal RegularMedi-Cal Presumptive Disability “PD”Medi-Cal Urgent Presumptive Disability “Urgent”Reminders Always assess the patient’s inability to perform the jobsthat they’re accustomed to performing.21
250% Working DisabledProgramDisabledCitizenship must be verifiedEarned income: 1-250% of FPLAll disability-based income does not count (workmen’scompensations, SSA, state and private disability income) 20 deduction for income (earned or unearned)Property: 401k exemptedPremiums: All eligible persons must pay a monthlypremium based upon countable income, ranging from 20to 250 (for an individual).22
Victims CompensationProgram (CalVCP)Enrollment: 3 years from incident dateExpenses that can be covered by the Program include:Medical and Dental CareMental Health TreatmentFuneral ExpensesIncome and Support LossRehabilitationRelocation23
Cancer ProgramsIMPACT – Prostate Cancer ProgramBCCTP – Breast and Cervical Cancer TreatmentProgram24
Genetically HandicappedPersons Program (GHPP) Must 21 years or older No income limit Enrollment fee based onincome Can be applied for as a2ndry program25
MRMIP (Major Risk MedicalInsurance Program )PCIP (Pre-Existing ConditionInsurance Plan)STATE ProgramFEDERAL ProgramYou are a resident of California.You are a resident of California.You have a pre-existing conditionYou have a pre-existing conditionYou are not eligible for MedicarePart A and Part B(except for end-stage renaldisease) or for COBRA orCal-COBRA benefits.You are not enrolled in MedicarePart A and B, COBRA, or CalCOBRA benefits.You are a U.S. Citizen or LawfulResidentStill open for enrollment26No longer takingapplications!
Health Insurance PremiumProgram (HIPP) Must have full scope or fee-forservice Medi-Cal Have a medical condition Have current health insurancecoverage (or access to healthcoverage through an employer atthe time of application) – policymust cover the health condition Health insurance coverage mustnot be court-ordered27
Enrollment MethodsCounty Office, Service Center, Certified EntitiesOnlineMailFax28
What to expect in January 2014!Income determine the route for eligibility andenrollmentsIncome under 138% Medi-Cal linkage with assetwaiverIncome over 138% Eligible for county programassistance or subsidized insurance enrollmentthrough the “Marketplace”. Assets count!29
To subscribe to our yearly distribution ofReference Guides and ct:Ana GonzalezDirect: (415) 446-8116Email: ana@diversifiedhealthcare.orgTechnical Questions:askanexpert@diversifiedhealthcare.org30
www.calduals.org. Program For All-Inclusive Care for the Elderly (PACE) Plans 55 or older and need a higher level of care to live at home and have chronic conditions . Alternative to LTC. Alameda Santa Clara Los Angeles San Diego Maintai
