Yolanda Arias Legal Aid Foundation of Los Angeles Medi-Cal Yolanda Arias Legal Aid Foundation of Los Angeles

I. Objectives  Able to use California Insurance Affordability Programs Income Levels Chart &Major Medi-Cal Programs Chart  Describe & define ­ • MAGI Medi-Cal • Non-MAGI Medi-Cal • Medically Needy Medi-Cal

I. Objectives cont’d • Calculating SOC • Other Insurance Affordability Programs • IHSS • County Programs

Medi-Cal Match -the ultimate match game

Medi-Cal Match This plastic device is issued to Medi-Cal beneficiaries and used by Medi-Cal providers to verify eligibility.

Medi-Cal Match These identify the program under which recipients are covered and the scope of services they are entitled to. BIC is tied to the these.

Aid Codes Prmy aid code: 13 Medi-Cal eligible w/LTC SOC of $1000

Medi-Cal Match A Medi-Cal procedure for a provider to get advance approval for a service in non-emergency situations.

Treatment Authorization Request

Medi-Cal Match An increase in benefits based on the increase in the cost of living.

Cost of Living Adjustment

Medi-Cal Match Modified adjusted gross income – a way to determine financial eligibility for Medi-Cal under Obamacare.

MAGI

Medi-Cal Match Legislation enacted in 2010 that expands Medicaid as part of a broader plan to cover millions of uninsured Americans.

Affordable Care Act

Medi-Cal Match The amount a recipient is obligated to incur in medical expenses in a month before Medi-Cal becomes effective; similar to an insurance deductible.

Share of Cost (SOC)

Medi-Cal Match Many Medi-Cal and other affordable health insurance programs use this federal measure as financial eligibility guidelines.

Federal Poverty Level (FPL) LBJ announcing the War on Poverty at the home of some poor folk.

Medi-Cal Match Subtracting medical expenses from total income resulting in reducing countable income and making a person eligible for Medi-Cal coverage.

Spending Down

Medi-Cal Match Full range of Medi-Cal services including doctor visits, hospital stays, surgeries and other procedures.

Full Scope Medi-Cal

Medi-Cal Match Limited to emergency care, prenatal care, long term care and family planning. Undocumented people, if otherwise eligible, are mostly limited to this.

Restricted Scope Medi-Cal

Medi-Cal Match Health care delivery method that seeks to control costs while coordinating an individual's health care. Plans typically receive a prepaid rate for each member enrolled in the plan as opposed to Fee-for-Service.

Managed Care

Medi-Cal Match State marketplace established under federal legislation that connects Californians to accessible, quality health coverage.

III Medicaid/Medi-Cal A. Federal /State Program Uniformity + variation

PRESIDENT Health & Human Services (HHS) [Center for Medicare & Medicaid Services] [42 CFR §430] Governor Dept. of Health Care Services (DHCS) Dept. of Managed Health Care(DMHC) State Plan [22 CCR § 5000][All County Welfare Director Letters] County Executives 58 CWDs

III. Medicaid/Medi-Cal D. Key Terms & Concepts 1-13. Medi-Cal Match 14. SB 87

IV. Medi-Cal Programs Pre-ACA A. Aged, Blind, Disabled Linked to SSI B. Families CalWORKs Related ACA C. MAGI Medi-Cal

Medi-Cal Programs Linked Aged, Disabled SSA/SSI Linked or Related

Aged, Blind, Disabled Linked to SSI SSI Recipients Section 1619(b) Recipients

Aged, Blind, Disabled Linked to SSI Aged & Disabled FPL

Aged, Blind, Disabled Linked to SSI 250% Working Disabled FPL

Aged, Blind, Disabled Linked to SSI MN Aged-Blind-Disabled

Aged, Blind, Disabled Linked to SSI Pickle Program

Medi-Cal Programs Families, CalWORKs/AFDC Related

Families, CalWORKs/AFDC Related CalWORKs Recipients

Families, CalWORKs/AFDC Related AFDC/Medically Needy

Medi-Cal Programs MAGI Medi-Cal

MAGI Medi-Cal Parents/ Caretaker Relatives 109% FPL

MAGI Medi-Cal Adults - ages 19-64 - 138% FPL

MAGI Medi-Cal Pregnant Women 213% FPL

MAGI Medi-Cal Access Program Pregnant Women/ Newborns 214-322% FPL

MAGI Medi-Cal Targeted Low-Income Children’s Program (TLICP) 266% FPL

Covered California Subsidies APTC—Advance Premium Tax Credit CSR—Cost Sharing Reduction

V. Conduct Eligibility Similar to CalWORKs – less demanding

VI. Procedural Eligibility Right to apply Must report Annual redetermination of eligibility

Single Streamlined Application ACL 14-14 (2/7/14) SSApp Single Streamlined Application ACL 14-14 (2/7/14)

VII. Benefits Coverage Prior authorization “Medically necessary” EPSDT Transitional Medi-Cal underutilized

VIII. Immigrants Chart Handbook 9/25

IX. Fair Hearing Process Same as CalWORKs except that DHCS gets involved in some aspects of the hearing process. IMR

X. Other Health Programs IHSS – In-Home Supportive Services Handbook 2/55

Other Health Programs AIDS Assistance County Programs

XI. Access to Healthcare Federally mandated language access Handbook 2/83 California Law Handbook 2/89

XII. Resources 2/169 National Health Law Program Health Consumer Alliance Disability Rights California Western Center on Law & Poverty National Senior Citizens Law Center CANHR Covered California Certified Enrollment

XII. Resources Getting and Keeping Health Care Coverage for Low-Income Californians: A Guide for Advocates http://wclp.org/advocate-resources/manuals-2/2016-health-care-guide/ Maternal and Child Health Access http://www.mchaccess.org/training_materials.htm