Presentation on theme: "Lake County Tribal Health CONTRACT HEALTH SERVICE PROGRAM."— Presentation transcript:
Lake County Tribal Health CONTRACT HEALTH SERVICE PROGRAM
What makes someone CHS eligible?? Must be a patient of LCTH Must be California Native (proof must be submitted) Must live in Lake County Must have a referral from LCTH The CHS program is the payer of last resort (42 CFR § 36.61) for persons defined as eligible for CHS. All alternate resources and entitlements must be used before CHS funds can be utilized
Referrals Patients must have a current referral with payment approval on file. Referrals are good for 6 months for a specific number of visits. Any visit to the Emergency Room must be reported to the CHS dept. within 72 hours (30 days for patients over 55 or disabled patients).
What if someone applied for an alternate resource? Do they qualify for CHS? Not until the entire Medi-Cal application process is complete. CHS dept. must have either a valid Medi-Cal card, private insurance card or valid Denial before payment approval is granted on a referral. In the meantime, there will be no payment approval on non-formulary Rx’s, referrals, X-rays, eyeglasses
CHS Eligible Patients & Alternate Resources Kaiser Insurance – NOT VALID IN LAKE COUNTY. Patient must apply for alternate resource (i.e., Medi-Cal, Healthy Families). Medicare – If patient only has Medicare and no other coverage aside from Medicare, the patient MUST also APPLY for Medi-Cal and follow through with the application process in order to continue being eligible for CHS funds. Out-of-County Medi-Cal –Patient MUST APPLY for Lake County Medi- Cal and follow through before he/she may become eligible for CHS funds.
Out-of-State Natives & Non-Natives Close Social & Economic Ties (Out- of-State Native Americans): Employed with a tribe whose reservation is located within Lake County (work for Tribe, not Casino) Marriage to, or being the child or parent of a local tribal member Must meet all other CHS eligibility requirements. Pregnancy: Non-native woman pregnant with Native Child Eligible for pregnancy and post-partum related services only If married, must submit marriage cert If not married, must submit declaration of paternity from native father Must meet all other CHS eligibility requirements
Out-of-State Natives & Non-Natives (continued)… Children under the age of 19: Natural or adopted child, step-child, foster-child, legal ward, or orphan of an eligible Indian living in the household of the eligible Indian Must meet all other CHS eligibility requirements Non-Natives Living in Indian Household: Our provider determines that services are necessary to control: a public health hazard; or An acute infectious disease that constitutes a public health hazard. Only services related to the public health hazard or the acute infectious disease are covered. Must meet all other CHS eligibility requirements
Residency Requirements PATIENT MUST LIVE IN LAKE COUNTY Each Tribal Clinic has CHS funds available for the eligible members living in their community (regardless of what tribe they are from). You must obtain CHS funds from the Tribal Clinic in which you permanently live. The place where you live is the physical location where you spend the larger part of the week (work, live, go to school).
“180-day Rule” Resident of another county (i.e., Santa Rosa) moves to Lake County: Must continue to request CHS funds from Sonoma County for 180 days. Patient not eligible for LCTH CHS funds for 180 days until patient establishes residency (proof of residency must be submitted).
“180-day Rule” (continued)… Resident of Lake County moves to another county (i.e., Ukiah): Patient will continue to be eligible for LCTH CHS funds for 180-days After 180 days, patient will fall under Consolidated Tribal Health’s CHS program
Proof of Residency Acceptable documents: Letter from local school (with dates) Letter from local employer (with dates) Utility Bill in patient’s name Valid Lake County Medi-Cal card Lease agreement (Must establish residency in Lake County within past 180 days)
Prescriptions Patients who are potentially eligible for CHS but have not completed the alternate resource process: They will be allowed a 1x Non-Formulary Rx until the M/Cal process is complete. They will still be eligible for all Formulary drugs in the meantime
Eyeglasses Patient must be seen by one of the providers at LCTH first. LCTH provider will decide whether you can be seen by Ophthalmologist or Optometrist. You will get a Retinal screening onsite or see Patty to complete referral. Patient must meet all CHS eligibility requirements
Eyeglasses (continued…) LCTH Pays $90 for exam (once a year) $145 for eyeglasses (once every two years) $60 for replacement/repair of lost or stolen eyeglasses No tint/special features, contacts Patient MUST use alternate resource (cannot use insurance one year and CHS next year – both must be used at same time)
Hearing Aids Patient must meet all previously mentioned CHS eligibility requirements. Hearing aids will be provided every 2 years with a current referral. LCTHC CHS will pay up to $1250 per hearing aid with a maximum of $2500 for 2 hearing aids. All warranties must be utilized before requesting CHS funds for repairs of hearing aids. After warranties have been exhausted, Lake County Tribal Health CHS funds will allow up to $140 for repairs every year. Lake County Tribal Health CHS funds are not responsible for the payment of battery replacements for hearing aids.