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

2. 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

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

4. Medi-Cal Match
-the ultimate match game

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

11. 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.

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

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

15. Treatment Authorization Request

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

18. Cost of Living Adjustment

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

21. MAGI

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

24. Affordable Care Act

25. 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.

26. Share of Cost (SOC)

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

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

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

31. Spending Down

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

33. Full Scope Medi-Cal

34. 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.

35. Restricted Scope Medi-Cal

36. 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.

38. Managed Care

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

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

43. 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

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

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

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

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

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

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

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

53. Aged, Blind, Disabled Linked to SSI
Pickle Program

54. Medi-Cal Programs
Families, CalWORKs/AFDC Related

55. Families, CalWORKs/AFDC Related
CalWORKs Recipients

56. Families, CalWORKs/AFDC Related
AFDC/Medically Needy

57. Medi-Cal Programs
MAGI Medi-Cal

58. MAGI Medi-Cal
Parents/
Caretaker Relatives
109% FPL

59. MAGI Medi-Cal
Adults - ages % FPL

60. MAGI Medi-Cal
Pregnant Women
213% FPL

61. MAGI Medi-Cal Access Program
Pregnant Women/
Newborns
% FPL

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

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

64. V. Conduct Eligibility
Similar to CalWORKs – less demanding

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

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

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

68. VIII. Immigrants
Chart Handbook 9/25

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

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

71. Other Health Programs
AIDS Assistance
County Programs

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

73. 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

74. XII. Resources
Getting and Keeping Health Care Coverage for Low-Income Californians: A Guide for Advocates Maternal and Child Health Access