MEDI-CAL

What It MeansTo You

CALIFORNIA English/SpanishDEPARTMENT OF HEALTH SERVICES Inglés/Español

Table of ConTenTs

1. MEDI-CAL–WHATITMEANSTOYOU.............................................................................. 12. WHOCANGETMEDI-CAL?.................................................................................................. 13. WHATDOESITMEANTOBE“DISABLED”FORMEDI-CAL?....................................... 44. HOWMUCHMONEYCANIGETANDSTILLGETMEDI-CAL?................................... 55. WHATPROPERTY/ASSETSAREALLOWABLEFORMEDI-CAL?................................. 56. MUSTILIVEINCALIFORNIATOGETMEDI-CAL?.......................................................... 57. WHEREDOIAPPLYFORMEDI-CAL?................................................................................ 68. HOWDOIAPPLYFORMEDI-CAL?.................................................................................... 69. WHATDOINEEDFORVERIFICATION(PROOF)?........................................................... 810. WILLIHAVEASHAREOFCOSTANDHOWMUCHWILLITBE?............................... 911. HOWDOIMEETMYSHAREOFCOST?..........................................................................1012. WHATIFIHAVEPRIVATEHEALTHINSURANCECOVERAGE?..................................1113. WILLMEDI-CALPAYMYPRIVATEHEALTHINSURANCEPREMIUMSIFI

CANNOLONGERAFFORDTOMAKEPAYMENTS?.....................................................1314. ISTHEREANEWMEDI-CALCARD?.................................................................................1315. WHATDOESTHEBENEFITSIDENTIFICATIONCARD(BIC)LOOKLIKE?...............1416. WILLIGETAPAPERMEDI-CALCARD?..........................................................................1417. WHATINFORMATIONISONTHEPAPERMEDI-CALCARD?........................................1418. HOWDOIUSETHEBENEFITSIDENTIFICATIONCARD(BIC)?.................................1419. WHATADDITIONALBENEFITSAREAVAILABLETOPERSONSUNDERTHECHILD

HEALTHANDDISABILITYPREVENTION(CHDP)PROGRAMANDEARLYANDPERIODICSCREENING,DIAGNOSISANDTREATMENT(EPSDT)?..............................16

20. WHATIFILOSEMYBIC,ITISSTOLEN,ORIDONOTGETIT?..................................1721. HOWDOIGETMEDI-CALSERVICES?............................................................................1722. WILLMEDI-CALPAYFORALLMYMEDICAL/DENTALEXPENSES?.......................1823. HOWCANIGETHELPFROMMEDI-CALIFIAMOUTOFSTATE?.........................1824. ISMEDI-CALMANAGEDCARETHESAMEASAHEALTH/DENTAL

CAREPLAN?............................................................................................................................1925. CANIGOTOANYPROVIDERIFIENROLLINAHEALTH/DENTAL

CAREPLAN?............................................................................................................................1926. HOWDOIJOINAMANAGEDCAREPLAN?..................................................................1927. HOWDOIGETOUTOFAMANAGEDCAREPLAN?...................................................1928. WHATCANIDOIFIDISAGREEWITHANYDECISIONABOUTMY

MEDI-CALELIGIBILITYORBENEFITS?............................................................................2029. WHATIFIHAVEBEENHURTBYANOTHERPERSONORHURTATWORK?................2130. WILLMEDI-CALBILLADECEASEDMEDI-CALBENEFICIARY’SESTATE?................2131. WHATISMEDI-CALFRAUD?..............................................................................................2232. WHATDOTHEWORDSMEAN?........................................................................................22SPANISHTRANSLATIONOFPAMPHLET..................................................................................25COUNTYWELFAREDEPARTMENTSLISTING..........................................................................55TRaDUCCIon al esPaÑol Del folleTo ........................................... Página 25

1. MeDI-Cal – WHaT IT Means To YoU

MEDI-CALpaysforhealthcareforcertainneedyresidentsofCalifornia.MEDI-CAL issupportedbyfederalandstatetaxes.Thispamphlettellsaboutwhocan getMEDI-CAL,thehealthcareservicesavailabletothosedeterminedeligible forbenefits,thechoicesforgettingservices,howtousethepermanent plasticCaliforniaBenefitsIdentificationCard(BIC)orthepaperMEDI-CAL card,andyourappealrightsifyoufeelyouaretreatedunfairlyordonotget whatyouareentitledtogetbylaw.

YoumaybeeligibleforMEDI-CALbenefitsregardlessofsex,race,religion, color,nationalorigin,sexualorientation,maritalstatus,age,disability,or veteranstatus.

YourlocalCountyWelfareDepartment(CWD)managesMEDI-CALeligibility determinations.Ifyouhavequestions,youcanfindtheaddressesand telephonenumberoftheCWDinthebackofthispamphlet.

IfyoudonotknowsomeoftheMEDI-CALtermsorwords,youcanturntothe backpagesofthispamphletforthemeaningsofthosewords.

ASpanishtranslationofthepamphletfollowstheEnglish.

2. WHo Can GeT MeDI-Cal?

Evenifyouareworking,ownahouse,oraremarried,youmaybeeligiblefor MEDI-CAL.TogetMEDI-CAL,youmustfallintooneofthefollowingMEDI-CAL programcategories.

A.PUBLICASSISTANCE(PA):Ifyouareaged(65yearsoldorolder),blind,or disabledandyougetSupplementalSecurityIncome/StateSupplementary Paymentprograms(SSI/SSP),youareautomaticallyeligibleforMEDI-CAL andwillbesentaCaliforniaBenefitsIdentificationCard(BIC).CallyourSocial Securitydistrictofficeformoreinformation.

IfyougetCaliforniaWorkOpportunityandResponsibilitytoKids(CalWORKS), youmayalsobeentitledtogetMEDI-CALbenefits.Ifyougetotherkindsof PublicAssistance,youmaybeentitledtoalltheservicescoveredbyMEDI-CAL. Callyourcountyeligibilityworkerformoreinformation.

Ifyouarenotinoneoftheseassistancegroups,youstillmaybeabletoget MEDI-CALbenefitsinadifferentcategory.Somearelistedbelow,suchas MedicallyNeedy(MN)orMedicallyIndigent(MI).MNandMIprogramsare forpeoplewhocannotpayalltheirmedicalexpenses.Evenifyouhaveother privatehealthinsurancecoverage,youmaystillbeeligible.

B.MEDICALLYNEEDY(MN):YouareMedicallyNeedyifyouareage65or

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older,blind,disabled,oryoumeetthefamilycircumstancesrequiredfor CalWORKS(youhavechildrenunderage21whoareneedyanddonot havethesupportorcareofoneparentbecauseofhis/herabsence,death, incapacity,orunemployment).MNpeopledonotgetacashgrantbecause theyhavetoomuchincomeorpropertyordonotwantacashgrant.You maybecomeeligibleforMEDI-CALandgetaCaliforniaBenefitsIdentification Card(BIC)bypayingorpromisingtopaymedicalexpenseswhichequalyour “shareofcost”(SOC)forthemonth.(SeeSections10and11.)

C.MEDICALLYINDIGENT(MI):YouareMedicallyIndigentifyouarea pregnantwomanwithnolinkage(connection)toaPAprogram(CalWORKS); arefugeeinthecountry8monthsorless;orapersonage21to65ina skillednursingfacilityorintermediatecarefacility.Personsunder21years ofage,includingthoseinfostercarewhoseneedsaremetbypublicfunds, childrenwhoqualifyfortheState-onlyAidforAdoptionAssistanceProgram andcertainotherchildrennotlivingwithaparentorrelativemayalsobe includedintheMIgroup.

D.SPECIALPROGRAMS: • PREGNANTWOMEN

Ifyouarepregnantandcannotaffordtopayforhealthcareandsome dentalcare,MEDI-CALcanhelppayformedicalexpensesforyouandyour unborn.ManytimesyoucangetMEDI-CALatnocosttoyou,evenifyou haveincome.OnceyougetMEDI-CAL,increasesinyourfamily’sincome willnotbecounted: •duringyourpregnancy,andpostpartumperiod, •foryourbaby’sfirstyearoflife. ParticipatingperinatalprovidersthroughoutCaliforniacanofferpregnant womenimmediate,temporaryMEDI-CALcoveragependingtheformal MEDI-CALapplicationunderthePresumptiveEligibilityprogram.Ifyouare pregnantandinterestedinthisservice,askifyourproviderparticipatesin thisprogram.

• CHILDREN YourchildmaygetMEDI-CALatnocost,ifyourchildis: •aninfant,or •betweenages1and6,or •betweenages6and18.

• REFUGEES IfyouarearefugeeorentrantnotqualifiedfortheMNorMIprograms,ask yourcountyeligibilityworkerforrefugee/entrantmedicalassistance.

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• CONFIDENTIALMEDICALSERVICESAVAILABLETOPERSONSUNDERAGE21 Ifyouareunder21yearsofage,unmarried,andlivingwithyourparents, youmaygetcertainconfidentialmedicalservices.UndertheMinor Consentprogram,youdonotneedparentalconsenttodetermine eligibility.Medicalservicesincludedunderthisspecialprogramarethose whichrelatetofamilyplanning,pregnancy,drug/alcoholabuse,sexually transmitteddiseases,sexualassault,andmentalhealth.

• FORMERFOSTERCHILDPROGRAM YoucangetMEDI-CALuntilyoureachage21undertheFormerFoster ChildProgramregardlessofyourincomeifyouareinStatefostercareon your18thbirthday.Youareeligibleevenifyoulivewithsomeoneelse, movetoanothercountyorwereterminatedfromMEDI-CAL.

• ADDITIONALSERVICESAVAILABLETOPERSONSUNDERAGE21THROUGH THECHILDHEALTHANDDISABILITYPREVENTION(CHDP)ANDEARLYAND PERIODICSCREENING,DIAGNOSISANDTREATMENT(EPDST)PROGRAMS

Ifyouoryourchildareunderage21,youmaybeabletogetmoreor differentservicesthroughtheChildHealthandDisabilityPrevention(CHDP) orEarlyandPeriodicScreening,DiagnosisandTreatment(EPSDT)programs. Thisissothatchildrenandyoungadultsunder21yearsofagecangetall thehealthcareservicestheyneedtomakesurehealthproblemsarefound andtreatedearly.Regularcheckupsareimportantsomedical,dentalor mentalhealthproblemsarefoundandtreatedearly.(SeeSection19.)

• MEDICALSUPPORTENFORCEMENT Allchildrenhavetherighttobesupportedbybothparents.Ifyouare

applyingforMEDI-CALbenefits,youmustcooperateinestablishing paternityforachild(ren)bornoutofwedlockandobtainingmedical supportforachild(ren)whohasanabsentparent.Youwillbeprovidedall childsupportservicesunlessyounotifytheFamilySupportDivisionDistrict Attorney(FSD/DA)thatyoudonotwanttoreceivethoseservicesthatare unrelatedtoobtainingmedicalsupportandestablishingpaternity.Someof theavailableservicesareasfollows:

•Locatingtheparent(s)forsupportenforcementpurposes; •Establishingpaternity; •Establishingachildand/ormedicalsupport(healthinsurance)order; •Enforcingachildand/ormedicalsupportorder; •Modifyinganexistingcourtorderforchildand/ormedicalsupport; •Enforcingaspousalsupportorderinconjunctionwithachildsupportorder; •Collectinganddistributingsupportpayments. CUSTODYANDVISITATIONSERVICESARENOTPROVIDED

• OTHER Youmightqualifyformedicalassistanceinoneofthemiscellaneous

categories.Askyourcountyeligibilityworkertohelpyou.

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E.SPECIALTREATMENTPROGRAMS:Ifyouneeddialysistreatmentor parenteralhyperalimentationservices,youmaybeeligibleforservicesunder theseprograms.

F.SPECIALMEDICAREPAYMENTPROGRAMS:SomeMEDI-CALprogramssuchas theBUY-INProgramandtheQualifiedMedicareBeneficiary(QMB)Programwill payforMedicarepremiums,andyouwillnotbebilledforyourco-insuranceand deductibles.TheQualifiedDisabledWorkingIndividual(QDWI)Programpaysthe MedicarePartApremiumandtheSpecialLow-IncomeBeneficiary(SLMB)and QualifyingIndividual-1ProgramspaytheMedicarePartBpremium.

G.IMMIGRANTELIGIBILITYFORMEDI-CAL:ImmigrantswhomeetallMEDI-CAL eligibilityrequirementscangetfullorrestrictedMEDI-CALdependingontheir immigrationstatus.Immigrantswhoarenotinafullscopeeligibleimmigration statuscanqualifyforrestrictedMEDI-CAL,whichcoversemergencyand pregnancy-relatedservices,iftheymeetalleligibilityrequirements.

H.BREASTANDCERVICALCANCERTREATMENTPROGRAM(BCCTP):BCCTP providesnecessaryno-costtreatmenttoeligiblepersonsdiagnosedwithbreast orcervicalcancerwhoarescreenedbyCentersforDiseaseControldoctorsor areFamilyPACT(Planning,Access,CareandTreatment)doctorsandarefound inneedoftreatment.Formoreinformation,call1-800-824-0088(toll-free).

3. WHaT Does IT Mean To be “DIsableD” foR MeDI-Cal?

TogetMEDI-CALasadisabledperson,youmusthaveseverephysicaland/or mentalproblem(s)whichwill: •lastatleast12monthsinarowand, •stopyoufromworkingduringthose12months,OR •possiblyresultindeath. Youmustproveyourdisablingphysicaland/ormentalproblem(s)with medicalrecords,tests,andothermedicalfindings.Themedicalproblem mustbethemainreasonwhyyoudonotwork.

TogetMEDI-CALforadisabledchild,thechildmusthaveseverephysical and/ormentalproblem(s)which:

• areonalistofdisablingchildhoodconditionsOR • aresoseverethathe/shewouldnotbeabletododailyactivitieswhich

ahealthychildwouldbeabletodo. Ifyouhaveaseverephysicaland/ormentalproblemthatisonalistof disablingconditions,youmaybeabletogetMEDI-CALbasedon disabilitypriortothefinaldeterminationofdisability.(Thisalsoappliesto children.)Askyourcountyeligibilityworkerformoreinformationabout PresumptiveDisability.

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250PercentWorkingDisabledProgram–Eligibledisabledworking individualscangetMEDI-CALfromthe250PercentWorkingDisabled program.Youmusthavecountableincomebelow250percentofthe federalpovertylevelandpayapremiumbasedonyourincome.Disability incomeisnotcounted.Formoreinformation,contactyourCWDorcounty eligibilityworker.

4. HoW MUCH MoneY Can I GeT anD sTIll GeT MeDI-Cal?

YoucangetMEDI-CALregardlessofhowmuchmoneyyouget.However, themoremoneyyouget,themoreyouwillhavetopayorpromiseto paytowardyourmedicalbillsbeforeMEDI-CALwillhelppayyourother medicalbills.(SeeSections10and11.)

5. WHaT PRoPeRTY/asseTs aRe alloWable foR MeDI-Cal?

Thereareproperty/assetslimitsfortheMEDI-CALprogram.Ifyourproperty/ assetsareovertheMEDI-CALpropertylimit,youwillnotgetMEDI-CAL unlessyoulowerthemaccordingtoprogramrules.Thecountylooksat howmuchyouandyourfamilyhaveeachmonth.Ifyourproperty/assets arebelowthelimitatanytimeduringthatmonth,youwillgetMEDI-CAL, ifotherwiseeligible.Ifyouhavemorethanthelimitforawholemonth, youwillbediscontinued.Thehomeyoulivein,furnishings,personal items,andonemotorvehiclearenotcounted.Asinglepersonisallowed tokeep$2000(or$3000insomesituations)inproperty/assets,moreif youaremarriedand/orhaveafamily.Ifachildhasproperty/assetsorifa stepparentwantsMEDI-CALforastepchild,otherrulesmayapply.

IMPORTANT:Ifyouoryourspouse(husbandorwife)wentintoamedical institutionornursingfacilityonorafterSeptember30,1989,andwere expectedtoremainfor30dayswhilethespousewasstillhome,thespouse athomemaykeepupto$99,540insomecases.(Thisamountmaychange inJanuaryofeachyear.)

FormoreinformationonMEDI-CALproperty/assetsrules,pleaseask yourCWDforaformcalled“MEDI-CALGeneralPropertyLimitations”(MC InformationNotice007).Ifyouoryourspousewereinanursingfacility beforeSeptember30,1989,alsoaskforaformcalled“CommunityProperty –PersoninLong-TermCare(LTC)”(MCInformationNotice005).

6. MUsT I lIVe In CalIfoRnIa To GeT MeDI-Cal?

Yes.YoumustbearesidentofCaliforniainordertogetMEDI-CAL.

YoumustalsogiveevidencethatyouarearesidentofCaliforniabefore yourMEDI-CALcanbeapproved.Evidencemaybeoneofthefollowing:

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1.ArecentCaliforniarentormortgagereceiptorutilitybillinyourname,or 2.AcurrentandvalidCaliforniamotorvehicledriver’slicenseor

IdentificationCardissuedbytheCaliforniaDepartmentofMotorVehiclesinyourname,or

3.AcurrentandvalidCaliforniamotorvehicleregistrationinyourname,or 4.AdocumentshowingyouareemployedinCalifornia(suchasapay

stub),or5.Adocumentshowingyouareregisteredwithapublicorprivate

employmentserviceinCalifornia,or6.EvidencethatyouoryourchildrenareenrolledinschoolinCalifornia,or 7.Evidencethatyouarereceivingpublicassistance,otherthanMEDI-CAL,

inCalifornia,or 8.EvidencethatyouareregisteredtovoteinCalifornia,or 9.OtheracceptableevidenceofyourCaliforniaresidence,ifyoudeclare,

underpenaltyorperjury,thatyoudonothaveanyofthedocuments orevidencelistedinnumbers1through8above.

However,youdonothavetogiveevidenceif: 1.YouareapplyingforMinorConsentservices,or 2.YouarethechildofaparentwhohasalsoappliedforMEDI-CALand

givenevidenceofCaliforniaresidence,or3.YourwifeorhusbandhasappliedforMEDI-CALandgivenevidenceof

Californiaresidence,ifsheorhelivesatyoursameaddress.

7. WHeRe Do I aPPlY foR MeDI-Cal?

CallyourCWDtohaveaMEDI-CALapplicationsenttoyourhome.The phonenumberandaddressofyourCWDareinthebackofthispamphlet. Ifyouwanttoapplyinperson,askyourCWDwhereyoucanapply. MEDI-CALcountyeligibilityworkersalsoarelocatedatsomehealthclinics andhospitals.

IfyougetanSSI/SSPgrant,MEDI-CALeligibilityisautomaticallysetupbyyour SocialSecuritydistrictoffice.

8. HoW Do I aPPlY foR MeDI-Cal?

Theusualapplicationprocedureis:

1.CallorgotoyourCWDtogetaMEDI-CALapplication(seepage55).If youhaveanimmediateneedforhealthcareservices(suchassevereillness orpregnancy),completetheMEDI-CALapplicationandtakeittoyourclosest CWDoffice.TelltheCWDthatyouhaveanimmediateneedformedicalor dentalcare.TheCWDwillprocessyourapplicationasfastaspossible.

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2.Fillouttheapplicationform(s)ascompletelyasyoucan.Section9called “WhatDoINeedforVerification?”tellsyouwhatprooftogivetheCWDwhen youapplyforMEDI-CAL.Youcanspeeduptheprocessbyprovidingthe necessaryinformationandpaperworkquickly.

3.YoumayapplyforMEDI-CAL“retroactivebenefits”ifyouhadmedical/ dentalservicesinthethreemonthsbeforethemonthyouapplyforMEDI-CAL, andneedhelpfromMEDI-CALtopaythebills.IfyouwereeligibleforMEDI-CAL duringanyofthethreemonthsbeforethemonthyouapply,evenifyouhave paidthebills,MEDI-CALmaypaythesebills.Youcanapplyfor“retroactive” MEDI-CALwhenyouapplyforMEDI-CAL.IfyouaskforretroactiveMEDI-CAL later,youhaveuptooneyearaftertheretroactiveMEDI-CALmonthtoask MEDI-CALtopaythatmedicalbill.

4.WhenyouapplyforMEDI-CAL,youwillgetalistofyourrightsand responsibilities.Forexample,youmustgiveanychangesinaddress, property,income,familycomposition,othercircumstances,andprivate healthinsurancecoveragetoyourcountyeligibilityworkerwithintendays.

NOTE:OnceyouapplyforMEDI-CAL,MEDI-CALwillonlypayforthecovered servicesyougetfromanenrolledMEDI-CALprovider.Youmustconfirmthat theproviderisanenrolledMEDI-CALproviderbeforeyougetservicesifyou wantMEDI-CALtopayfortheservices.

5.Mailortakethecompletedapplicationandnecessaryverification(proof)tothe CWD.Ifyouwantconfidentialminorconsentservices,gotothenearestCWD.

NOTE:Insomecounties,whenyouareaMEDI-CAL“beneficiary”(that’swhat youarecalledwhenyougetMEDI-CAL)youmayberequiredtosignupfora MEDI-CALhealthcareplanand/ordentalplan.Ifyouarerequiredtosignup foramedicalordentalplan,youmaychooseapersonaldoctorand/ordentist fromalistgiventoyoubythemedicalanddentalplans.

IfyouliveinoneofthosecountieswherethereareMEDI-CALmedicaland dentalplans,youwillreceiveadditionalinformationaboutthechoicesyou haveavailableforgettingyourMEDI-CALbenefitsandtheplansofferedto you.Youwillreceivethisinformationatthetimeyouapplyforbenefits,or whenthecountyredeterminesyourbenefits.Insomecases,youwillreceive informationaboutthemedicalanddentalplansavailable,andinformation abouttoenrollintheplansthroughthemail.

6.Itmaytakeupto45daystoprocessyourMEDI-CALapplication.Ifyouapply forMEDI-CALbasedondisability,yourapplicationmaytake90days.

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7.YouwillgetaletterinthemailtellingyouifyourMEDI-CALapplicationis approvedordenied.IfyouhaveaMEDI-CALhealthcareplan,youwillgeta healthcareplanidentificationcardinadditiontotheState-issuedBIC.

8.IfyoudonotgetananswertoyourMEDI-CALapplicationwithinamonth afteryouapply,callyourcountyeligibilityworker.

9. WHaT Do I neeD foR VeRIfICaTIon (PRoof)?

YoumustgivecertaininformationbeforeyourMEDI-CALcanbeapproved. Yourcountyeligibilityworkerwilltellyouwhatproofisneeded.

Youmayapplywithouttheproof,butyouwillhavetogiveitlater.Ifyou cannotgettheproofyourself,askyourcountyeligibilityworkertohelpyou.

ITEMSREQUIREDforfullMEDI-CALbenefits(ifapplicable):

1. SocialSecuritycard(s). 2. Medicarecard(s). 3. Naturalizationdocument(s). 4. Alienregistrationcard(s). 5. Pregnancyverification. 6. Incomeverification:

a. Employeepaystubsorastatementfromyouremployershowinggross earningsanddeductions.

b.Awardletterorchecksshowingamountofpensionorbenefits,including SocialSecurityandV.A.

c. StateUnemploymentorDisabilityawardletter. d.StudentLoangrantawardletter(s)orloangrantpapers. e. Statementfromprovidersofotherincome(contributions,refunds,child

support,etc) f. Self-employmentinformation:Lastyear’staxreturnorcurrentledgers,

currentinventory,includingbusinessequipmentandsupplies. g.Carecostsforchild/incapacitatedperson(s).

7. PropertyTaxstatementsforallproperty. 8. VehicleRegistration(s)forautomobiles,boats,campersandtrailers. 9. Allcheckingandsavingsaccountstatementsandtrustaccountdocuments. 10.Allstocks(brokeragestatements),bonds(includingU.S.Savingsbonds)and

mutualfunds. 11.Alldeedsoftrust,mortgages,otherpromissorynotesandcontractsofsale. 12.Alllifeinsurancepolicies,includingcashsurrendervalue. 13.Allannuitypolicies.

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14.Allburialtrusts/prepaidburialcontracts/informationonburialplots. 15.Documentationregardingthecurrentvalueofalltrusts. 16.Paymentbook(s)forallencumberedproperty. 17.Allpolicies/cardsforhealthinsuranceyoucurrentlyhaveorwhichare

availabletoyou. 18.Application(s)forpossibleavailableincome(i.e.unemploymentbenefits,

statedisabilitybenefits). 19.Courtordersrelatingtoincomeandproperty. 20.Leaseagreements. 21.Lifeestatedocuments. 22.Copiesofpatienttrustaccountledgers. 23.Rentreceipts,currentutilitybills,orhousingstatement. 24.Copiesofchildsupportordersordivorcedecree. 25.SocialSecuritydisabilityorSSIdenialordiscontinuancenotice(if

applyingfordisability-basedMEDI-CAL). 26.EvidenceofCaliforniaresidency.

10. WIll I HaVe a sHaRe of CosT anD HoW MUCH WIll IT be?

Dependinguponyourmonthlyincome,MEDI-CALmaydeterminethatyou havetomeetashareofcost(SOC)beforeMEDI-CALwillpayforyour,oryour family’s,medicalexpensesforthemonth.Thenextsectionexplains“meeting ashareofcost.”

WhetheryouwillhaveaSOCforamonth,andthesizeofyourSOC,depends onhowmuchmoneyorincomeyouandyourfamilygetforthemonth. MEDI-CALallowsyoutokeepacertainamountofyourfamily’sincomefor yourlivingexpenses(thisportioniscalledyourMaintenanceNeed).MEDI-CAL mayalsoallowyoutokeepadditionalamountsofyourfamily’sincome.Any incomeforthemonthwhichismorethantheamountyouareallowedto keepbecomesyourSOCforthemonth.

Insomefamilies,theincomeofonepersoncannotbeusedtodecideif anotherpersonhasaSOC.Forexample,incomeofachildcannotbeusedto decidewhetherabrotherorsister,parent,stepparentorcaretakerrelativehas aSOC.IncomeofastepparentcannotbeusedtoseeifastepchildhasaSOC.

Ifyoudon’thaveanymedicalexpensesduringamonth,youdonotneed tomeetyourSOCforthatmonth.However,keepyourBICincaseyouneed medicalservicesinupcomingmonths.

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11. HoW Do I MeeT MY sHaRe of CosT?

YoumaymeetyourSOCforthecurrentmonthbyshowingMEDI-CALthatyou paid,orhavepromisedtopay,foryourmedicalexpensesanamountofmoney thesameasyourSOC.TherearetwowaystoshowMEDI-CALthatyouhave paidorpromisedtopayyourSOCforacertainmonth.Thesetwomethodsare:

1.IneverymonththatyouhaveaSOC,yourCWDwillnotifytheStateofthe amountofSOCyoumustpay.Whenyougotoamedicalproviderandgive theprovideryourBIC,yourproviderwillgetinformationfromacomputer systemaboutyourSOC.Aftertheprovideracceptsyourpromisetopayfor themedicalservices,oryoupayforthoseservices,theproviderwillforward theamountofSOCpaid,orpromisedtobepaid,throughthecomputer systemtotheState.TheStatewillimmediatelyupdatetheSOCsystemsothat futureprovidersthatmonthwillknowtheamountofSOCthatremains,ifany. WhenyouhavemetyourSOCforthemonth,allfutureproviderswillreceive informationthatyouhavemetyourSOCforthemonthandwhetherornot youareeligibleforcoveredMEDI-CALservices.

2.AnotherwaytoshowyouhavepaidorpromisedtopayyourSOCistogive yourmedicalbillsdirectlytoyourcountyeligibilityworker.Youmaygiveyour billsformedicalservicesyougotduringthecurrentmonthtoyourcounty eligibilityworkertoapplytowardyourSOC.Youmustgiveoldmedicalbills frompreviousmonths(forwhichyoustillowemoneyandwhichyouwant toapplytowardyourSOC)toyourcountyeligibilityworker.Yourprovider cannotusetheSOCcomputersystemforyouroldmedicalbills.

Medicalbillsgiventoyourcountyeligibilityworkermustcontaincertain kindsofinformationbeforeyourcountyeligibilityworkercanapplythese billstowardyourSOC.

Yourmedicalbillsmustshowthisinformation:

1.Provider’snameandaddress. 2.Nameofpersonwhogotthemedicalservice. 3.Descriptionofthemedicalservicereceived. 4.ProcedureCode(amedical/dentalreferencenumber)formedical/dental

servicesreceived–yourproviderwillknowwhatthisnumberis. 5.Provider’sMEDI-CALprovidernumber,orifnotaMEDI-CALprovider,the

providerlicensenumber,orfederaltaxidentificationnumber. 6.Date(s)medicalservicewasreceived. 7.Dateonwhichbillwasissued.Foroldmedicalbills,thisdatemustbewithin

90daysofthedateyougivetheoldmedicalbillstoyourcountyworker. 8.Amountbilledtopersongettingtheservice.

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Ifanyofthisinformationismissingfromamedicalbill,youmusttrytogetit fromyourprovider.Ifyouareunabletogetit,yourcountyeligibilityworker willtrytohelpyou.Billingstatementsfromcollectionagenciesandcredit cardstatementssometimesmaybeusedasevidenceofmedicalexpenses. Undercertainconditions,youmaygivethemissinginformationbymakinga swornstatement.

Ifyourcountyeligibilityworkerisunabletoacceptamedicalbill,youwillget alettergivingthereasonforthedisapprovalofthebill.Youwillhavetendays tofixtheproblemandbring/sendthebillagain.Ifyoudonotdothis,youwill receiveadenialletterwithinthenext30dayswhichwillgivethereasonfor thedenialandtellyouwhatyoumustdobeforeyoumaybring/sendyour medicalbillagain.Youwillgetaseparateletterformedicalbillswhichhave beenacceptedandappliedtowardyourSOC.

12. WHaT If I HaVe PRIVaTe HealTH InsURanCe CoVeRaGe?

YoucanhaveMEDI-CALeventhoughyouhaveprivatehealthcoverage.If youareaMEDI-CALbeneficiaryandhaveindividualorgroupprivatehealth insurancecoverage,youarerequiredbyfederalandstatelawtoreportit. ThisinformationmustbegiventoyourCWD,toyourhealthcareprovider, and/ortotheFamilySupportDivisionDistrictAttorney(FSD/DA),whenthere isanabsentparentwhomayberesponsibleforyourchild(ren)’smedicalcare, orinapaternityestablishmentwhenachildisbornoutofwedlock.Ifyou failtoreportanyprivatehealthinsurancecoveragethatyouhave,youare committingamisdemeanor.

Underfederallaw,healthinsurancebelongingtoaMEDI-CALrecipientina childormedicalsupportenforcementcaseisusedasfollows:

TheproviderofservicewillbillMEDI-CAL.MEDI-CALwillpaytheprovider ofservice.ThenMEDI-CALwillseekrepaymentfromtheotherhealth coverage.Youwillnotbeliableforanyinsurancecost-sharingamount (coinsuranceordeductible)unlessaMEDI-CALSOCmustbemet.Ifyourother healthinsuranceisa PrepaidHealthPlan(PHP)oraHealthMaintenance Organization(HMO),youmustusetheplanfacilitiesforregularmedicalcare. OutofareaservicesoremergencycareshouldalsobebilledtothePHP/HMO.

Therefore,youmusttellyourcountyeligibilityworkerand/ortheFSD/DA: • ifyou,yourchild(ren),ortheotherparentofyourchild(ren)hasprivate

healthinsurancecoverage. • whentheprivatehealthinsurancecoverageisthroughyouremployer,

yourunion,oragroupororganization. • withintendays,whenyourprivatehealthinsurancecoveragechanges

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orstops. • aboutanycourtorder(suchasdivorcejudgmentortemporary

supportorder)whichmakestheotherparentresponsibleforprovidinghealthinsurance.

Youmust: • giveyourmedicalprovideranyinformationneededtobillyourprivate

healthinsurancecoverage, • sendtotheCaliforniaDepartmentofHealthServices’(CDHS’)Third

PartyLiabilityBranchanypaymentyougetdirectlyfromaninsurance carrierforservicespaidbyMEDI-CAL.Theaddressis: CaliforniaDept.ofHealthServicesThirdPartyLiabilityBranchHealthInsuranceP.O.Box997424,MS4719Sacramento,CA95899-7424

Youmust: • sendtotheCHDS’ThirdPartyLiabilityBranchanymedicalsupport

paymentyougetfromtheabsentparent.Theaddressis: CaliforniaDept.ofHealthServicesThirdPartyLiabilityBranchHealthInsuranceP.OBox997422,MS4719Sacramento,CA95899-7425

• useyourhealthmaintenanceorganization(HMO),and/orprepaid healthplan(PHP),suchasKaiserHealthPlan,CHAMPUS,ormilitary coverage,forregularmedicalcare.Outofareaservicesforemergency careshouldalsobebilledtotheHMO/PHP.

• useyourBIConlyforMEDI-CALcoveredservicesthatyourprepaidor healthmaintenanceplanormilitaryinsurancedoesnotcover.

Ifyouhaveotherhealthinsurancecoverage,thecomputersystemwillbecoded toshowotherhealthinsurance.

Aprovider(doctororpharmacy)maynotrefusetoprovideserviceorfillyour prescriptionsolelybecauseyouhaveotherhealthinsurancecoverage(in additiontoMEDI-CAL).Ifyoudonothaveotherhealthinsurancecoverage andthecomputersystemiscodedthatyoudo,askyourcountyeligibility workertocorrectthecodingonthecomputersystem.IfyouhaveSSI/SSP andthecomputersystemisincorrectlycodedtoshowotherhealthinsurance coverage,andyoudonothaveit,pleasecalltheCDHS’HealthInsurance Sectionat1-800-952-5294(toll-free)tocorrectthecodingonthecomputer system.

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Ifyouarehavingaclaimspaymentproblemwithaprovider,youmaycallthe ElectronicDataSystemsBeneficiaryInquiryUnitat(916)636-1980.

NOTE:BeginningJanuary1,2006,ifyouareeligibleforMedicare,Medicare (notMEDI-CAL)willpayformostprescriptiondrugsforMEDI-CALbeneficiaries whoareeligiblleforMedicarePartA(hospital)orPartB(outpatient).For informationonthisnewdrugcoverage,pleasecontact1-800-MEDICARE.

13. WIll MeDI-Cal PaY MY PRIVaTe HealTH InsURanCe PReMIUMs If I Can no lonGeR affoRD To MaKe PaYMenTs?

IfyouareaMEDI-CALbeneficiaryandyouhaveaveryhigh-costmedical conditionwhichrequiresaphysician’scare,theCDHSmaypayyourprivate healthinsurancepremiums,ifitiscosteffective,undertheHealthInsurance PremiumPayment(HIPP)program.Therearespecificrequirementstoqualifyfor theprogramandnotallapplicantsareapprovedforHIPP.Formoreinformation onHIPP: •askyourcountyeligibilityworkertoreferyou,or •calltheCDHS’HIPPProgramat1-866-298-8443 (toll-free). AHIPPrepresentativeinSacramentowillexplaintheprocessandrequirements fortheprogram.Ifitappearsthatyoumaymeettheeligibilityrequirements,an applicationwillbesenttoyou.

14. Is THeRe a neW MeDI-Cal CaRD?

FromJanuary2005throughJune2005,MEDI-CALissuednewplastic BenefitsIdentificationCards(BICs)toallbeneficiaries.YourBIChasanew identificationnumbermadeupof14numbersandletters.Yourhealthcare providersneedyournewBICtoprovideservicesandtobillMEDI-CAL.

NOTE:YOURBICDOESNOTGUARANTEEMEDI-CALELIGIBILITY.Takeyour BICtoyourdoctor,pharmacy,hospitalorothermedicalprovider.The providerwillusethiscardtoobtaininformationtodetermineifyouare eligibleforMEDI-CAL.

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15. WHaT Does THe benefITs IDenTIfICaTIon CaRD (bIC) looK lIKe?

ABIClookslikethis: Actualcardsize=31/8x23/8inches;whitecardwithbluelettersonfront, blacklettersonback.

Recipient Information on face of card: 1. Your ID Number (a 14 character identification number).

4 5

1

2

3

2. Your name 4. Date of Birth 3. Gender Code (male or female) 5. Date card was issued to you

16. WIll I GeT a PaPeR MeDI-Cal CaRD?

YourcountywillgiveyouapaperMEDI-CALcardifyouhavean“Immediate Need”orgetConfidentialMedicalServices(MinorConsent)asdescribedin Section2D.

17. WHaT InfoRMaTIon Is on THe PaPeR MeDI-Cal CaRD?

Yourpaperidentificationcardwillshowyourname,MEDI-CAL identificationnumber,gender,dateofbirth,issuedateandgoodthrough date.“ImmediateNeed”cardsareissuedforaonemonthperiodandMinor Consentcardsareissuedforuptoayear.

NOTE:Ifyouareabeneficiary18yearsofageorolderwhoisnotinlong­termcare,andnotgettingemergencyservices,youmustsignanddate yourpaperMEDI-CALcardorBICwhenyougetitandbeforeyougivethe paperMEDI-CALcardorBICtoaproviderforanycare.

18. HoW Do I Use THe benefITs IDenTIfICaTIon CaRD (bIC)?

YoushouldalwayscarryyourBICwithyou.

REMEMBER:FindoutiftheprovidertakesMEDI-CALpatientsbeforeyou gofortreatment.Theproviderhasarighttorefusetotake MEDI-CAL.Ifyouforgottotelltheproviderthatyouhave MEDI-CAL,youmayhavetopayyourbill.

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AskyourlocalmedicalsocietyforproviderswhotakeMEDI-CALpatients. CalltheDeltaDentalofficefordentalreferralsat1-800-322-6384.

Foreachserviceyouget,givetheprovideryourBICsoMEDI-CALcanpay theprovider(ifyouareeligibleforMEDI-CAL.)

SomeservicesmustbeapprovedbyMEDI-CALbeforeyoumaygetthem. Theproviderwillknowwhenyouneedpriorapproval.

Someservicesarerestrictedtotwopermonth.Thereareafewexceptions, butgenerallyyoucanonlygetatotaloftwoofthefollowingservices:

•Acupunctureservices •Audiologyservices •Chiropracticservices •OccupationalTherapy •Podiatryservices(some) •Psychologyservices •SpeechTherapy

Ifyouneedanyoftheaboveservices,discussyourtreatmentplanand appointmentswithyourdoctor.

Thefollowingservicesarenotautomaticallylimitedbutyourdoctor mayneedtogetapprovalfromMEDI-CAL.Yourdoctorwilldecidewhich servicesyouneedandwillaskforapprovalwhenitisneeded.Someofthe serviceswhichrequirepriorapprovalare:

• Hemodialysisservices(kidneytreatment) • Medicaltransportation • Artificiallimbs,braces,andeyes • Hearingaids • Inpatienthospitalcare(SeeMEDI-CALterms) • Physicaltherapy • Crutches,wheelchairs,andotherdurablemedicalequipment • Hospicecare • PrescribeddrugsnotontheMEDI-CALdruglist • Nursinghomecare • MedicalsuppliesnotontheMEDI-CALmedicalsupplieslist • Somedentalservices(e.g.gumtreatment,rootcanals,crowns,

dentures)• Homehealth–HomeandCommunity-basedservicesasapossible

alternativetohospitalornursinghomecare

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Thefollowingservicesarenotautomaticallylimitedanddonotneed priorapproval:

• Mostdoctor’sservicesandmostclinicvisits • Manydentalservices(e.g.exams,x-rays,cleanings,preventiveservice,

fillings) •Eyeglassesandeyeappliances • Laboratory,X-ray,andradiationtreatment •Bloodandbloodderivatives • Medical/dentalscreeningsandreferralsareavailableforpersonsunder

21toidentifyandtreatmedical/dentalproblems(seeSection19) • Ifyouarepregnant,youcangetprenatalcareguidancetohelpyouget

thecareyouneedtohaveahealthybaby,includingsomedentalcare • PrescribeddrugsontheMEDI-CALdruglistifprescribedforthe

conditionsspecifiedonthelist(IfyougetMedicare,seeSection22)• MedicalsuppliesontheMEDI-CALmedicalsupplieslistifprescribed

fortheconditionsspecifiedonthelist

FederallyQualifiedHealthCenter(FQHC)andRuralHealthClinic(RHC)services donotrequirepriorapproval.However,theseservicesmaybelimited.

19. WHaT aDDITIonal benefITs aRe aVaIlable To PeRsons UnDeR CHIlD HealTH anD DIsabIlITY PReVenTIon (CHDP) anD THe eaRlY anD PeRIoDIC sCReenInG, DIaGnosIs anD TReaTMenT (ePsDT) PRoGRaMs?

Ifyouoryourchildisunder21,theChildHealthandDisabilityPrevention (CHDP)Programprovidesregularcheck-upsandneededimmunizations tokeepyouhealthy.CHDPservicesincluderegularscreeningformedical, dental,vision,hearingormentalhealthproblems.Ifyouneedhelpwithan appointmentortransportation,theCHDPprograminyourcountycanhelp you.Lookforthephonenumberundercountygovernmentinyourlocal phonebook.

TheEarlyandPeriodicScreening,DiagnosisandTreatment(EPSDT) programprovidesextraMEDI-CALservicesifyouareunder21andhave fullscopeMEDI-CAL.EPSDTservicescorrectorimprovemedical,dental, ormentalhealthproblems.Youmaygettheextraservicesifyouandyour doctor,healthcareprovider,clinic,countyCHDPorcountymentalhealth departmentagreeyouneedthem.Youcanaskforservicesasoftenasyou thinkyouneedthem.

Ifyouhavesevereemotionalproblems,contactyourcountymental healthdepartment.Lookinthegovernmentsectionofyourphonebook underMentalHealthDepartment.Ifyoucannotreachthecountymental healthdepartment,callthestatementalhealthombudsmantoll-freeat 1-800-896-4042.

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Ifyouoryourdoctorthinkthathealthserviceswhicharenotusually coveredbyMEDI-CALmaybeneeded,youshouldtalkto: •YourlocalcountyCHDPProgram •YourManagedCarePlan •YourCountyMentalHealthDepartment

Oraskyourdoctortocontact: •YourlocalMEDI-CALFieldOffice,or •TheCaliforniaChildren’sServicesprogram

20. WHaT If I lose MY bIC, IT Is sTolen, oR I Do noT GeT IT?

YoumayaskforaBICfromyourCWDwhenyouareeligibleforMEDI-CALbut youhavenotgottenacard,youlostyourcard,yourcardwasstolen,orthe cardyougotinthemailhaswronginformationonit.

IfyourBICisstolen,youmusttellyourlocalpoliceandyourCWD.You shouldgiveasmuchinformationaboutthetheftaspossible.

IfyougetSSI/SSPorCalWORKS,youshouldautomaticallygetaBICinthe mail.Ifyoudonotgetacard,youshouldcontactyourCWD.Eventhough thecountydoesnotmakeSSI/SSPeligibilitydeterminationsorsendSSI/SSP checks,theyhelpwithBICproblemsforpeoplewhogetSSI/SSP.Thecounty canorderareplacementBICforyou.TheCWDwilltellyouifyoualsoneedto contactaSocialSecurityofficetocorrecttheproblemwithyourBIC.

21. HoW Do I GeT MeDI-Cal seRVICes?

TherearetwowaystogetyourMEDI-CALservices.Howyougetyour MEDI-CALserviceswilldependontheareayoulivein.Insomeareas,you maychooseyourprovidersfromthosewhoacceptMEDI-CAL,oryoumay choosetosignupforaMEDI-CALhealthand/ordentalcareplanifthere areanyinyourarea.Inotherareas,someMEDI-CALbeneficiariesmust signupforahealthand/ordentalcareplan.Intheareaswhereyoumust signupforahealthcareplan,thereareexceptions.Theexceptionswill beexplainedtoyouatthesametimeyourchoicesforgettingMEDI-CAL servicesareexplainedtoyou.

Youwillgetinformationabouthealth/dentalcareplansatthetimeyouapply orreapplyforbenefits.Youmayberequiredtogotoapresentationatthe CWDwheretheytellyouaboutthehealthcareplansyoucansignupfor.You mayalsogetinformationinthemailaboutthehealthcareplansinyourarea.

1.Inthoseareaswhereyoucanchooseyourownproviders,youshould knowhowtousetheBICbeforeyouseeadoctororotherproviderof healthservices.Pleasereadthesectionscalled“HowDoIUseTheBIC?”and “WhatInformationIsOnThePaperMEDI-CAL?”(SeeSections17and18).If

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youarenotenrollinginahealthcareplanandchoosingyourownproviders, youmusttellthehealthcareproviderthatyouhaveMEDI-CALbeforeyoufirst getcare.IfyoudonottelltheproviderthatyouhaveMEDI-CAL,theprovider maylegallybillyouforallservicesyouget.Providersofhealthcaredonothave totakeMEDI-CALpatientsormayonlytakeafewMEDI-CALpatients.If you don’t use your bIC correctly, you may have to pay for the services you get.

2.IfyousignupforaMEDI-CALhealth/dentalcareplan,youmaychoosea providerfromaproviderlisttheplangivesyou.Asaplanmember,youcan getalloftheservicescoveredbyregularMEDI-CAL.Someplansofferextra serviceswhichyoucannotgetwithyourMEDI-CALcard.Inaddition,you donothavetopaya“co-payment”whenyouareaplanmember.

22. WIll MeDI-Cal PaY foR all MY MeDICal/DenTal eXPenses?

YourBICwillpayformanykindsofmedical/dentalexpenses.Whenyour providerusesyourBICtoverifyyourMEDI-CALeligibility,yourproviderwill knowifMEDI-CALwillpayforamedical/dentaltreatmentorifyouneedto makea“co-payment”foranytreatment.Youmayhavetopay$1.00eachtime yougetamedical/dentalserviceorprescribeddrugand$5.00ifyougotoa hospitalemergencyroomwhenyoudonotneedanemergencyservice.You donothavetopayifyouareenrolledinaMEDI-CALhealth/dentalcareplan.

NOTE:IfyouhaveMEDI-CALandMedicare,Medicare(notMEDI-CAL)paysfor mostofyourprescribeddrugs.

23. HoW Can I GeT HelP fRoM MeDI-Cal If I aM oUT of sTaTe?

TakeyourBICorproofofenrollmentinaMEDI-CALhealthcareplanwithyou whenyoutraveloutsideCalifornia.MEDI-CALcanhelpinlimitedsituations; forexample,inanemergencyduetoaccident,injury,orsevereillness,or whenyourhealthwouldbeendangeredbypostponingtreatmentuntilyou returntoCalifornia.MEDI-CALmustfirstapproveanyout-of-statein-patient medicalservicesbeforeyougettheservice.Youwillberesponsiblefor medicalcostsforservicesyougotout-of-stateifthemedicalproviderisnota MEDI-CALproviderordoesnotwishtobecomeaMEDI-CALprovider.

Theprovidershouldfirstverifyeligibilitybycontactingthefiscalintermediary at(916)636-1960.Theprovidermaygetinformationoncoverage, authorizationandbillingproceduresbycontactingthefollowing:

MEDICALSERVICES DENTALSERVICES CaliforniaDept.ofHealthServices DeltaDental MEDI-CALFieldOffice Denti-Cal P.O.Box193704 11155InternationalDrive,BuildingC SanFrancisco,CA94119-3704 RanchoCordova,CA95670 (415)904-9600 1-800-541-5555

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IfyouliveneartheCaliforniastatelineandusedoctorsorotherproviders ofmedicalserviceintheotherstate,someoftheserestrictionsdonot apply.(However,medicalservicesinMexicoorCanadaarenotcovered exceptforemergencyhospitalization.)

YouwillnotgetMEDI-CALifyoumoveoutofCalifornia.Youmayapplyfor Medicaidinthestateinwhichyoulive.

24. Is MeDI-Cal ManaGeD CaRe THe saMe as a HealTH/DenTal CaRe Plan?

Yes.MEDI-CALManagedCareisaprogramwherebytheStatecontracts withvariousmedicalproviderstoprovideservicestoyouinanorganized andcoordinatedmanner.Themanagedcareplansmustdirectlygive,or arrangefor,allMEDI-CALservicestoyou.

25. Can I Go To anY PRoVIDeR If I enRoll In a HealTH/DenTal CaRe Plan?

Ifyouenrollinahealth/dentalcareplan,youmustusetheplanproviders andclinicsunlessemergencycareisneeded.

26. HoW Do I JoIn a ManaGeD CaRe Plan?

Youcanaskyourcountyeligibilityworkerifmanagedcareisavailableandhow tocontacteitherthehealthcareplanorthelocalhealthcareoptionsworker.

27. HoW Do I GeT oUT of a ManaGeD CaRe Plan?

InsomeareasservedbyaCountyOrganizedHealthSystem(COHS),ifyou arewithaprovider,eitherthroughvoluntaryenrollmentorthroughbeing assigned,youwillhavetostaywiththatproviderforaperiodofsixmonths. Ifyoujoinorareassignedtoaprovideryoudon’twant,youmaydisenroll (cancel)foranyreasonanytimewithinthefirst30dayswiththatprovider, orafteryouhavebeenwiththeprovidersixmonths.

IfyouareinaCOHScountywhereyouhavetostaywithaproviderforsix monthsbeforedisenrolling,youwillgetmoreinformationaboutthiswhen yousignupforthehealthcareplan.

IfyouliveinaTwo-PlanModelorGeographicManagedCarecounty,andthe optiontojoinahealthcareplanisvoluntary,youmaydisenroll(cancel)at anytime.(Youcontacttheplanmembershipstaffatthephonenumber providedinthepapersyougotwhenyousignedup.)Itusuallytakes45days tobecancelled.IfyouhavequestionsaboutyourenrollmentinaTwo-Plan ModelorGeographicManagedCarehealthplan,youcancallHealthCare

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Optionsat1-800-430-4263.Ifyouarenotdisenrolledin45days,contact yourcountyeligibilityworkerforhelp.

28. WHaT Can I Do If I DIsaGRee WITH anY DeCIsIon aboUT MY MeDI-Cal elIGIbIlITY oR benefITs?

STATEHEARING:YougetaNoticeofAction(NOA)inthemailfromthe CWDwheneveryourMEDI-CALeligibilitychanges.Ifyoudisagreewith adecision,youshouldtalktoyourcountyeligibilityworker.Ifyouare stilldissatisfied,youmayaskforaStatehearingthroughtheCWDorthe CaliforniaDepartmentofSocialServices.OnthebackoftheNOA,you willfindouthowyoucanrequestaStatehearingandwheretosendyour request.Ifyoudisagreewiththedenialofahealthbenefit,youcanalsoask foraStatehearingby:

Writingto: Orbycalling: CaliforniaDept.ofSocialServices CaliforniaDept.ofSocialServices StateHearingDivision PublicInquiryandResponseUnit POBox944243,MailStation19-37 Toll-freeNumber:1-800-952-5253OR Sacramento,CA94244-2430 Hearingimpaired(TTY)only: 1-800-952-8349

YoumustaskforaStatehearingwithin90daysfromthedateonwhich youbelievethewrongactiontookplace.Ifyouaskforahearingbeforethe effectivedateoftheactionwhichstoppedorloweredyourMEDI-CALbenefits, youmaycontinuetogetthesameMEDI-CALbenefitsuntilthehearing.

YouoryourrepresentativecanreadtheregulationsabouttheMEDI-CAL programandmostofthefactsinyourcase.Helpisalsoavailableinsome languagesotherthanEnglish,includingSpanish.Atthehearing,an AdministrativeLawJudgewillreviewtheCWD’sactionstoseeifsomeone madeamistake.Youmusteithergotothehearingorgivewrittennotice forsomeonetogoinyourplace.Youmaybringotherstorepresentyou aswitnesses.Youmayaskquestionsofthecountyrepresentativeorany CountyorStatewitnesses.

DISCRIMINATION:Ifyoubelieveadecisionaboutyourrighttoget MEDI-CALbenefitswasunfairlymadebecauseofyoursex,race,religion, color,nationalorigin,sexualorientation,maritalstatus,age,disability orveteransstatus,youmayfileawrittenortelephonecomplaintwith theCaliforniaDepartmentofHealthServices,OfficeofCivilRights,MS 0009,POBox997413,Sacramento,CA95899-7413,(916)440-7370.Your complaintofdiscriminationwillbeinvestigated.

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29. WHaT If I HaVe been HURT bY anoTHeR PeRson oR HURT aT WoRK?

Ifyouarehurtbyanotherpersonorhurtatwork,youmayuseyourBIC togetservices.Youmustreporttheaccidentorinjurytoyourcounty eligibilityworkersothattheMEDI-CALprogramcanbepaidbackbythe responsibleparty.

Also,sendorfaxtheinformation listedbelowto:

OR Youmaycall:

CaliforniaDept.ofHealthServices RecoveryPersonalInjuryUnit P.O.Box997425,MS4720 Sacramento,CA95899-7425 FAX(916)650-6581

(916)650-0490

1.Yourname,address,andphonenumber. 2.YourBICnumber,andSocialSecurityNumber. 3.Thedateyouwerehurtandwhathappened. 4.Thename,address,andphonenumberofyourattorney,ifyouhiredone. 5.Thename,address,andphonenumberofthepersonwhohurtyou. 6.Thename,addressandphonenumberoftheliableinsurancecompany;

alsoaddthepolicynumber. 7.Ifyouwerehurtatwork,thename,addressandphonenumberofyour

employer.

30. WIll MeDI-Cal bIll a DeCeaseD MeDI-Cal benefICIaRY’s esTaTe?

MEDI-CALmayclaimagainsttheestateofaMEDI-CALbeneficiarywhohas diedafterOctober1,1993,onlyif:

• MEDI-CALpaidforcertainmedicalservicesafterthebeneficiary’s55th birthday,andthedeceasedMEDI-CALbeneficiaryhadnosurviving spouse,minor,ortotallydisabledchild(ren),and

• theMEDI-CALclaimagainsttheestatedoesnotcreateasubstantial hardshipontheheirsofthedeceasedMEDI-CALbeneficiary.

MEDI-CALshallimposealienupontheequityinterestinthehomeorother propertyofaninstitutionalizedMEDI-CALbeneficiaryifcertainconditions aremet.Suchclaimsandliensmaybereducedifitcanbedemonstrated thatasubstantialhardshipiscreatedonthesurvivorsorheirsofthe deceasedMEDI-CALbeneficiary.

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IfthesurvivingspouseofadeceasedMEDI-CALbeneficiarydies,MEDI-CAL maybilltheestateofthesurvivingspouseforeithertheamountpaidby MEDI-CALformedicalassistance,orthevalueoftheestatereceivedbythe survivingspouse,whicheverisless.

Theestateofindividualsofanyagemayalsobebilledifthatindividualhadbeen aresidentofanursingfacility.

31. WHaT Is MeDI-Cal fRaUD?

Ifyouaregettingtreatmentfrommorethanonedoctor,youshouldtelleach doctorabouttheotherdoctor(s)givingcaretoyou.Itisyourresponsibility nottoabuseorimproperlyuseyourMEDI-CALbenefits.Itisacrimeto: •allowotherstouseyourMEDI-CALbenefits,and •getdrugsthroughfalsestatements

ItisacrimeforyoutosellorlendyourBICtoanypersonorfurnishyourBIC toanyoneotherthanyourproviderofservicesasrequiredunderMEDI-CAL guidelines.MisuseofBIC/MEDI-CALbenefitsisacrimethatcouldresultin administrativeactionorcriminalprosecution.Ifyoususpectsomeoneof misusingMEDI-CALbenefits,youmaymakeaconfidentialreportto: 1-800-822-6222(toll-free)

32. WHaT Do THe WoRDs Mean?

1.BENEFICIARY–ApersonwhohasbeendeterminedeligibleforMEDI-CAL.

2.COUNTYWELFAREDEPARTMENT(CWD)–SeetheCountySocialServices Departmentlistingatthebackofthispamphlettocontactyourcounty MEDI-CALoffice.

3.(MEDI-CAL)HEALTHCAREPLAN–TheCDHScontractswithprepaidhealth plans,healthmaintenanceorganizations,andprimarycarecasemanagement systemtogivecoveredMEDI-CALservicestoMEDI-CALbeneficiaries.MEDI­CALbeneficiarieswhoenrollinaplanareguaranteedaccesstoafullrangeof qualityhealthcare,includingpreventivemedicalservices.

4.HOMEANDCOMMUNITY-BASEDCARESERVICES–Healthcareservicesthat cansometimebegivenathometopersonswhousuallywouldneedtostayin ahospitalornursinghome.Theseservicesareonlyavailabletocertainpeople gettingMEDI-CALwhomeetspecialrequirements.Askyoudoctororhospital dischargeplannertocontactthelocalMEDI-CALFieldOfficeifyouthinkyou mightneedtheseservices.

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5.INPATIENTHOSPITALCARE–Careyougetwhenyouareadmittedto ahospital.InsomeareasoftheState,youcanonlygetinpatientcareat hospitalscontractingwiththeState.Ifyouneedcare,youshouldcontact yourdoctor,andifnecessary,yourdoctorwillmakearrangementsfor hospitalization.Inalife-threateningemergency,orifyouareapregnant womaninactivelabor,anyhospitalcangiveyoucare.

6.LINKAGE–Personswhomeetthefederaldefinitionofage(65yearsor older),blindness,ordisability,orparentsandtheirchildrenwhoaredeprived ofparentalsupportorcareareconsidered“linked”(orconnected)tooneof thesecategories.

7.MAINTENANCENEED–TheamountofmonthlyincomeMEDI-CALhas determinedthatapersonorfamilyneedforfood,clothing,housing,etc.The amountwillchangewiththenumberofpeopleinthefamily.

8.MEDI-CAL–California’snameforMedicaid,thefederalandstateprogram ofmedicalassistanceforneedyandlow-incomepersons.

9.MEDICARE–Afederalhealthinsuranceprogramadministratedbythe SocialSecurityAdministrationwhichisavailableregardlessofincome. Mostpersons65yearsofageorolderandcertaindisabledorblindpersons regardlessofage,arecovered.MedicarePartAcovershospitalization. MedicarePartBcoversdoctorbills.BeginningJanuary1,2006,Medicare PartD(notMEDI-CAL)coversmostprescribeddrugs.AMedicarecardisred, white,&andblue.

BUY-IN–Ifyouareaged,blind,disabled,gettingTitleIISocialSecurity paymentsorRailroadRetirementdisabilitybenefits,ordialysis-related healthcareservices,youmustapplyforMedicareattheSocialSecurity officeinordertoqualifyforMEDI-CAL.IfyouqualifyforbothMedicare andMEDI-CAL,MEDI-CALwillpayyourmonthlyMedicarePartBinsurance premiumsandMEDI-CALmaypayyourmonthlyPartAinsurance premiums.PleasetellyourdoctoryouhavebothMedicareandMEDI-CAL, soyouwillnotbebilledfortheMedicareco-insurance.

10.OTHERHEALTHCARECOVERAGE–anyprivatehealthbenefitplanor healthinsurancecoverage(whetherindividualorthroughaunion,group, employer,ororganization)underwhichpaymentcanbemadeforhealth careservicesprovidedtothepersonscoveredbythatpolicyorplan.

11.PERSONALPROPERTY–Allliquidandnon-liquidassets(otherthanreal property)suchascash,savingsaccounts,checkingaccounts,stocks,bonds jewelry,boats,lifeinsurancepolicies,recreationalvehicles,etc.

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12.PROPERTYRESERVE–Thetotalnetmarketvalueofcountableproperty assetsofthosepersonsapplyingforMEDI-CAL.

13.REALPROPERTY–Landandimprovementswhichgenerallyinclude anyimmovablepropertyattachedtothelandandanyoil,mineral,timber orotherrightrelatedtotheland.

14.SHAREOFCOST(SOC)–Theamountyoumustpayorpromisetopay eachmonthtowardthecostofyourhealthcarebeforeMEDI-CALwillpay. YourSOCmaychangewhenyourmonthlyincomechanges.Youonlypaya SOCinamonthwhenyougethealthcareservices.ASOCisnotamonthly chargethatyoumustpaywhetherornotyouhavemedicalbills.

15.VERIFICATION–Acceptableevidence(documents)whichgivesproofof statementsmadebyanapplicant/beneficiary.

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State of California Butte County Health and Human Services Agency

COUNTY SOCIAL SERVICES AGENCIES Departamentos de Bienestar de los Condados

Please contact your nearest County Social Services Office for complete MEDI-CAL Eligibility information or other health-related services. Please verify the location and phone number in your telephone book or at www.dhs.ca.gov/ mcs/medi-calhome/default.htm. Some county web sites may provide additional health-related information.

Por favor póngase en contacto con la oficina del Departamento de Bienestar del Condado más cercana a usted para obtener la información completa sobre la Elegibilidad de MEDI-CAL u otros servicios relacionados a la salud. Por favor verifique la dirección y el teléfono en su guía telefónico o en www. dhs.ca.gov/mcs/medi-calhome/default. htm. Algunos de los sitios web del condado pueden darle más información sobre servicios relacionados a la salud.

Alameda County Health and Human Services 8477 Enterprise Way Oakland, CA 94621 (510) 383-8523

www.alamedasocialservices.org/public/ services/medical_care/

Alpine County Department of Social Services 75A Diamond Valley Rd. Markleeville, CA 96120 (530) 694-2235

www.co.alpine.ca.us/dept/health/ ssmedical.html

Amador County Department of Social Services 1003 Broadway Jackson, CA 95642 (209) 223-6550

www.co.amador.ca.us/depts/social/ index.htm

Department of Employment and Social Services

78 Table Mountain Blvd., Oroville (530) 538-7711 2445 Carmichael Dr., Chico (530) 879-3479 Mailing address: P.O. Box 1649 Oroville, CA 95965

www.buttecounty.net/dess/Medical_ Services.html

Calaveras County Calaveras Works and Human Services 509 East Saint Charles Street San Andreas, CA 95249-9701 (209) 754-6444

www.co.calaveras.ca.us/departments/ welfare.asp

Colusa County Department of Health and Human Services 251 East Webster Street Colusa, CA 95932 (530) 458-0250

No county website available

Contra Costa County Employment and Human Service 1275A Hall Avenue Richmond, 94804 (866) 663-3225

www.cchealth.org

Del Norte County Department of Social Services 880 Northcrest Drive Crescent City, CA 95531-3485 (707) 464-3191

www.co.del-norte.ca.us:82/cf/topic/ topic4.cfm?Topic=Social%20Services& SiteLink=200012.html

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El Dorado CountyDepartment of Human Service3057 Briw RoadPlacerville, CA 95667-1637(530) 642-7300

www.co.el-dorado.ca.us/ socialservices/

Fresno CountyDepartment of Employment & Temporary AssistanceCall for nearest office (area code 559)Regional Offices Heritage Center, Fresno 453-3544 or 453-4934 University Med Center 453-6447 Coalinga Regional Center 935-6300Selma Regional Center 898-5100Reedley Regional Center 637-7580

www.fresnohumanservices.org/ MedicalCare.htm

Glenn County Human Resources Agency P.O. Box 611420 East Laurel StreetWillows, CA 95988-0611(530) 934-6514

www.hra.co.glenn.ca.us/

Humboldt CountyDepartment of Health and Human Services Social Services 929 Koster StreetEureka, CA 95501(707) 269-3590(800) 891-8851 (Limited Service Area)

www.co.humboldt.ca.us/portal/ health.asp

Imperial CountyDepartment of Social Services2995 South Fourth Street, Suite 105El Centro, CA 92243(760) 337-6800

www.imperialcounty.net/ socialservices/

Inyo CountyDepartment of Social Services912 N. Main StreetBishop, CA 93514(760) 872-1394

www.inyocounty.us/Admin/vision_ statement.htm

Kern CountyDepartment of Human Services100 E. California AvenueBakersfield, CA 93307(661) 631-6807

www.co.kern.ca.us/dhs/

Kings CountyHuman Services Agency1200 South DriveHanford, CA 93230(559) 582-3241

www.co.kings.ca.us/HSA/best.htm

Lake County Department of Social Services 15975 Anderson Ranch Parkway P.O. Box 9000Lower Lake, CA 95457-9000(707) 995-4200

www.dss.co.lake.ca.us/

Lassen CountyLassen WORKSRoosevelt Annex720 Richmond RoadSusanville, CA 96130(530) 251-8152

www.co.lassen.ca.us/welfare_mission.htm

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County of Los Angeles Dept. of Public Social Services (Apply at the nearest District office. Refer to the White Pages under COUNTY GOVERNMENT of your phone book) (877) 597-4777 Toll Free (Limited Service Area) (213) 639-6300

www.ladpss.org/

Madera County Department of Social Services, Eligibility 720 East Yosemite Avenue P.O. Box 569Madera, CA 93639(559) 675-2300

www.madera-county.com/ socialservices/

Marin CountyDept Health & Human Services (Public Assistance)120 North Redwood Drive-West WingSan Rafael, CA 94903(415) 473-3400

www.co.marin.ca.us/depts/HH/main/ ss/public.cfm

Mariposa CountyDepartment of Human Services5186 Highway 49 NorthMariposa, CA 95338Toll-free (800) 266-3609(209) 966-3609

www.mariposacounty.org/

Mendocino County Department of Social Services 737 South State Street P.O. Box 8508Ukiah, CA 95482(707) 463-7700

www.mcdss.org

Merced County Human Services Agency 2115 West Wardrobe Avenue P.O. Box 112Merced, CA 95341-0112(209) 385-3000 ext. 5155

www.co.merced.ca.us/countyweb/

Modoc CountyDepartment of Social Services120 North Main StreetAlturas , CA 96101(530) 233-6501

www.modoccounty.us/

Mono County Department of Social Services 85 Emigrant Street P.O. Box 576Bridgeport, CA 93517(760) 932-5600

www.monocounty.ca.gov/ departments.html

Monterey CountyDepartment of Social Services100 South Main Street- Suite 216Salinas, CA 93902(831) 755-8500(831) 755-4650

www.co.monterey.ca.us/dss/ benefits/medi-cal.html

Napa CountyDepartment of Social Services2261 Elm StreetNapa, CA 94559(707) 253-4511Toll-free: (800) 464-4214

www.co.napa.ca.us/GOV/ Departments/DeptPage. asp?DID=50100&LID=939

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Nevada County Human Services Agency 950 Maidu Avenue P.O. Box 1210Nevada City, CA 95959(530) 265-1340Toll Free: (888) 809-1340

www.mynevadacounty.com

Orange CountySocial Services Agency (Call for nearest district office) Anaheim (714) 575-2400Santa Ana (714) 435-5900Laguna Hills (949) 587-8543Garden Grove(714)741-7100

www.ssa.ocgov.com/Agency_ Services/Adult_Services_and_ Assistance_Programs/default.asp

Placer CountyHealth and Human Services11519 B AvenueAuburn, CA 95603(530) 889-7610 Roseville Office (916) 784-6000North Lake Tahoe (530) 546-1900

www.placer.ca.gov/welfare/welfare. htm

Plumas CountyDept of Social Services270 County Hospital Rd, Suite 207Quincy, CA 95971(530) 283-6350

www.countyofplumas.com/

Riverside County Department of Public Social Services (Call for nearest office) (951) 358-3000 Mail only:731 Palmyrita AvenueRiverside, CA 92507

dpss.co.riverside.ca.us/

Sacramento CountyDepartment of Human Assistance2433 Marconi AveSacramento, CA 95821-4807(916) 874-2072

dhaweb.saccounty.net/Services/ Medical_Assistance/index.html

San Benito CountyHuman Services Agency1111 San Felipe Rd, Ste 206Hollister, CA 95023-3801(831) 636-4180

www.sanbenitohhsa.org

San Bernardino County Human Services System Transitional Assistance Department (Call for nearest district office) (909) 388-0245

www.hss.co.san-bernardino.ca.us/HSS/

San Diego County Dept of Health & Human Srvs Agency (Call for the nearest district Office) (858) 514-6885

www2.sdcounty.ca.gov/hhsa/ ServiceDetails.asp?ServiceID=680

City & County of San FranciscoDept of Human Services1440 Harrison StreetSan Francisco, CA 94120(415) 863-9892

www.sfgov.org/site/dhs_page. asp?id=12885

San Joaquin CountyHuman Services Agency333 E. Washington StreetStockton, CA 95202(209) 468-1000

www.co.san-joaquin.ca.us/hsa/Medi-Cal/index.htm

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San Luis Obispo CountyDepartment of Social Services3433 S. Higuera StreetSan Luis Obispo, CA 93403(805) 781-1600

www.slodss.org

San Mateo CountyHuman Services Agency400 Harbor Boulevard, Building “C”Belmont, CA 94002(650) 802-7570

www.smchsa.org/smc/department/ home/ 0,,15587275_18158401_ 19643107,00.html

Santa Barbara CountyDepartment of Social Services234 Camino Del RemedioSanta Barbara, CA 93110(805) 681-4401

www.countyofsb.org/social_services/

Santa Clara County Social Services Agency (Call for nearest district office) (408) 271-5600

www.sccgov.org/site/ 0,4760,sid=136775,00.html

Santa Cruz CountyHealth Services Agency1020 Emeline StreetSanta Cruz, CA 95060(831) 454-4134Watsonville Office (831) 763-8500

www.santacruzhealth.org/admnstr/ 2benefits.htm

Shasta CountyDepartment of Social Services2460 Breslauer WayP.O, Box 496005Redding, CA 96001(530) 225-5767

www.co.shasta.ca.us/Departments/ Social Services/TemporaryAssistance/ tempasst.shtml

Sierra County Social Services 202 Front Street P.O. Box 1019Loyalton, CA 96118(530) 993-6720Downieville Office (530) 289-3711

www.sierracounty.ws/mod.php?mod =userpage&menu=1704&page_id=15

Siskiyou CountyHuman ServicesNorth County Office:818 S. Main Street Yreka, CA 96097(530) 841-2700 South County Office:293 Main Street, Suite BWeed, CA 96094(530) 938-5100

www.co.siskiyou.ca.us/humsvc/etas. htm

Solano County Health and Social Services275 Beck AvenueFairfield, CA 94533 Toll Free: (800) 400-6001

www.co.solano.ca.us/

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Sonoma County Human Services Department 2550 Paulin Drive P.O. Box 1539Santa Rosa, CA 95402-1539(707) 565-5200Toll Free: (800) 354-1277

www.sonoma-county.org/human/ med

Stanislaus County Community Services Agency 251 East Hackett Road P.O. Box 42 (95353)Modesto, CA 95355(209) 558-2777

www.stanworks.com/index.htm

Sutter County Department of Human Services Welfare Social Services Division 190 Garden Highway P.O. Box 1535Yuba City, CA 95992-1535(530) 822-7230

www.co.sutter.ca.us/index. aspx?doc=/depts/hs/wss/wss.xml

Tehama CountyDepartment of Social Services22840 Antelope Blvd.PO Box 1515Red Bluff, CA 96080(530) 527-1911

www.tcdss.org

Trinity CountyDept of Health and Human Services#1 Industrial ParkwayWeaverville, CA 96093-1470(530) 623-1265Toll Free: (800) 851-5658

www.trinitycounty.org/ Departments/HHS/hhsinfo.htm

Tulare CountyHealth & Human Services Agency(Call for nearest Office)In-Take OfficeDinuba (559) 591-5804Lindsey (559) 562-1377Porterville (559) 782-4750Tulare (559) 685-2600Visalia (559) 733-6111

www.co.tulare.ca.us/

Tuolumne County Department of Social Services20075 Cedar Road NorthSonora, CA 95370(209) 533-5711

www.tuolumnecounty.ca.gov

Ventura CountyHuman Services Agency505 Poli Street Ventura, CA 93001(805) 652-7693Regional Offices:Oxnard (805) 385-8654Ventura (805) 658-4100Santa Paula (805) 933-8300Simi Valley (805) 584-4842

www.vchsa.org

Yolo CountyDept of Employment & Social Services25 N. Cottonwood StreetWoodland, CA 95695(530) 661-2750West Sacramento Office500-A Jefferson Blvd.West Sacramento, CA 95605(916) 375-6200

www.yolocounty.org/org/dess/ program/medical.htm

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Yuba CountyHuman Services Agency6000 Linhurst Avenue, No. 504P.O. Box 2320Marysville, CA 95901-9987(530) 749-6311

www.co.yuba.ca.us/content/ departments/hhsd/

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