Maximizing Government Program Identification and Eligibility … › docs ›...

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Today’s Accomplishments…

Learn about the 20 different eligibility and enrollment process

Learn how to enhance your current identification process

Learn how to incorporate Covered California

Learn how to apply a proactive approach that helps to secure future benefits

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Change your approach ~ Think Proactively

Create your own “Community Enrollment Center”

Think of ways to get patients covered proactively

Covered California considerations

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Create an Enrollment Center

Enhance your current business model to include screening of all uninsured patients at registration or point of service

Understand how all Government Eligibility Programs work

Federal

State

County4

Understand Covered California and MAGI-Medi-Cal

Non-MAGI Medi-Cal

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Income

0-138% FPL

Income

138-200% FPL

Income

138-400% FPL

Income

400% FPL +

MAGI-Medi-Cal

*exempts assets

County Program Covered California

*exempts assets

Self Pay

(Under 21, Over 65 yrs, pregnant, children in the home with deprivation, disabled and/or requires skilled nursing care)

MAGI – Medi-Cal

Modified Adjusted Gross Income

Aid Codes:

AFDC 40, 45, 4H, 4L, 4K, 5K

Pregnancy 44, 48, 5F, 5W, 76, 86, 87

Pregnant Undocumented/Unverified D8, D9

Children 47, 69, 72, 74, 7A, 7C, 8N, 8P, 8R, 8T, 8U, 8V

Adoption 04, 30, 32, 33, 35, 3A, 3C, 3D, 3E

Calworks 3G, 3H, 3L, 3M, 3P, 3R, 3U, 3W, 4A, 4G, 4P, 4R

Families and Children 2A, 34, 37, 3N, 3V, 82, 83, C5, C6, C9, D1

Other Federal Programs 4M, 58, 6P, 71, 7H, F1-F4, G1-G4 6

Lets start with understanding the program hierarchy

Federal Programs

State Programs

County Programs

Charity Care7

Covered California

Federal Program Overview

Medicare

Medicaid (mandatory eligibility )

Social Security Retirement/Disability

Compassionate Allowance (CAL)

Low Income Health Program (LIHP) – terms 12/31/2013

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State Program Overview

Medi-Cal

250% Working Disabled Persons

Victims Compensation Program (VCP)

California Children Services (CCS)

IMPACT

BCCTP – Breast and Cervical Cancer Treatment Program

Genetically Handicapped Persons Program (GHPP)

Major Risk Medical Insurance Program (MRMIP)

Health Insurance Premium Program (HIPP)9

County Program Overview

Medically Indigent Adult (MIA)

County Medical Service Indigent Program (CMISP)

Medical Service Program (MSP)

Medical Service Initiative (MSI)

County Medical Services (CMS)

And many more…..

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Let’s Start with the Federal Programs

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Medicaid vs. Medi-Cal

Medi-Cal is California’s Medicaid Program.

Each state can have their own “optional state programs”

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Social Security Administration Programs

Social Security Disability Income (SSDI)

Supplemental State Income (SSI)

Medicare

Medicare Disability: Renal Dialysis & Lou Gehrig’s Disease (ALS)

Retirement13

Compassionate Allowance (CAL)

Compassionate Allowances (CAL) provides quick benefits to applicants whose medical conditions are so serious that their conditions obviously meet disability standards.

SSA has identified 200 medical conditions that range from Traumatic Brain Injuries, Dementia to rare diseases.

Benefits can occur within a month without having to wait for years! All you need is confirmed diagnosis!

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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 residency

Medicaid Coverage Expansion (MCE)

Health Care Coverage Initiative (HCCI)

Income: 0-133% FPL Income: 134-200% FPL

Assets: Exempt Assets: Within Medi-Cal Limits

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Understanding the State Programs

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Medicare/Medi-Cal Integration– Dual Eligible

Cal MediConnect Counties:

Alameda

Los Angeles

Orange

San Diego

San Mateo

Riverside

San Bernardino

Santa Clara

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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

Maintain independence

Dignity and Quality of Life

Emergency Care

Day Center

Home care services

Transportation

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www.healthcareoptions.dhcs.ca.gov

Eligibility

Income eligible

Asset eligible

Benefits

Pays monthly Medicare

Part A or/and B premiums

Prescription Drug Assistance

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Low Income Medicare Beneficiary(QMB/SLMB)

Basic Medi-Cal Linkage

Under 21 years of age

Over 65 years of age

Pregnant

Parents with deprived children

Requires Long Term Care

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Medi-Cal Disability …

Never assume; always ask and confirm!

Understand the difference about the 3 different Disability (DDSD) Programs:

Medi-Cal Regular

Medi-Cal Presumptive Disability “PD”

Medi-Cal Urgent Presumptive Disability “Urgent”

Reminders Always assess the patient’s inability to perform the jobs that they’re accustomed to performing.

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250% Working Disabled Program

Disabled

Citizenship must be verified

Earned income: 1-250% of FPL

All disability-based income does not count (workmen’s compensations, SSA, state and private disability income)

$20 deduction for income (earned or unearned)

Property: 401k exempted

Premiums: All eligible persons must pay a monthly premium based upon countable income, ranging from $20 to $250 (for an individual). 22

Victims Compensation Program (CalVCP)

Enrollment: 3 years from incident date

Expenses that can be covered by the Program include:

Medical and Dental Care

Mental Health Treatment

Funeral Expenses

Income and Support Loss

Rehabilitation

Relocation 23

Cancer Programs

IMPACT – Prostate Cancer Program

BCCTP – Breast and Cervical Cancer Treatment Program

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Genetically Handicapped Persons Program (GHPP)

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•Must 21 years or older

•No income limit

•Enrollment fee based on income

•Can be applied for as a 2ndry program

MRMIP (Major Risk Medical Insurance Program )

PCIP (Pre-Existing Condition Insurance Plan)

STATE Program

You are a resident of California.

You have a pre-existing condition

You are not eligible for Medicare Part A and Part B(except for end-stage renal disease) or for COBRA orCal-COBRA benefits.

Still open for enrollment

FEDERAL Program

You are a resident of California.

You have a pre-existing condition

You are not enrolled in Medicare Part A and B, COBRA, or Cal-COBRA benefits.

You are a U.S. Citizen or Lawful Resident

No longer taking applications!26

Health Insurance Premium Program (HIPP)

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•Must have full scope or fee-for-service Medi-Cal

•Have a medical condition

•Have current health insurance coverage (or access to health coverage through an employer at the time of application) – policy must cover the health condition

•Health insurance coverage must not be court-ordered

Enrollment Methods

County Office, Service Center, Certified Entities

Online

Mail

Fax

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What to expect in January 2014!

Income determine the route for eligibility and enrollments

Income under 138% Medi-Cal linkage with asset waiver

Income over 138% Eligible for county program assistance or subsidized insurance enrollment through the “Marketplace”. Assets count!

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To subscribe to our yearly distribution of

Reference Guides and Resources

Email: core@diversifiedhealthcare.org

Contact: Ana Gonzalez

Direct: (415) 446-8116

Email: ana@diversifiedhealthcare.org

Technical Questions: askanexpert@diversifiedhealthcare.org

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