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Understanding Medi-Cal Basics: Eligibility, Financial Criteria, and Rights

This comprehensive training session covers the essentials of Medi-Cal, focusing on eligibility criteria, including personal characteristics, financial conditions, immigration status, and residency requirements. Key topics include distinguishing between mandatory and optional eligibility categories, the impact of the Deficit Reduction Act of 2005 on citizenship proof, and specific guidelines for immigrants and children. Attendees will gain insight into the rights associated with Medi-Cal applications, ensuring a clear understanding of application processes, eligibility maintenance, and necessary documentation for access to this vital healthcare program.

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Understanding Medi-Cal Basics: Eligibility, Financial Criteria, and Rights

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  1. LAAC- Armchair Training Medi-Cal Program Basics March 13, 2008 Doreena Wong, Staff Attorney National Health Law Program 2639 S. La Cienega Blvd. Los Angeles, CA 90034 (O)(310) 204-6010, ext. 107 (F)(310) 204-0891 E-mail: wong@healthlaw.org Website: www.healthlaw.org

  2. Medi-Cal Overview Eligibility: “The Worthy Poor” Requirements for Eligibility Personal Characteristics Financial Condition Proper Immig. Status or Proof of Citizenship State Resident Low Income Limited Resources Category of Worthy

  3. Medi-Cal Overview Mandatory & Optional Eligibility Categories Eligibility Categories Mandatory Groups Optional Groups Eligible for, but not applied for SSI or CalWORKs Families, Children, Pregnant Women Pregnant women, Infants up to 185% FPL Persons who are Aged, Blind, or Disabled Medically Needy 65 or older or disabled up to 100% FPL Persons losing TANF/CalWORKs

  4. Proof of Citizenship or Immigration Status • Deficit Reduction Act of 2005 (DRA) changed how citizens must prove their citizenship in Medicaid (Medi-Cal in California) • Prior to the DRA, citizens signed an affidavit declaring their citizenship • U.S. Citizens and nationals will have to submit proof of citizenship • Satisfactory Immigration Status

  5. What about immigrants? • The DRA did NOT change any requirements for immigrants to show proof of their immigration statuses. • Immigrants do not need to show any new documents. • Immigrants need only show documentation of their immigration status (as before) in order to get Medi-Cal coverage other than restricted scope coverage • Immigrants can continue to get the same types of Medi-Cal as before.

  6. Who does the law affect? • Many U.S. citizens and… • People born in the U.S., including people born in Puerto Rico, U.S. Virgin Islands, Guam • People who were naturalized as U.S. citizens • U.S. Nationals… • People who were born in American Samoa including Swains Island • Who are applying for or continuing to receive Medi-Cal as citizens

  7. Residency • Certain state and local benefit programs require California or county residency for eligibility • Different from immigration status • Resident if : physically present and living in the state/county with the intent to remain permanently or for an indefinite time • Required to sign a declaration and provide supporting documents

  8. Children’s Residency • Normally based on parents’ residency • Parents who do not have residency can establish residency for their children if the parents: • Intend for the children to remain in the state/county on other than a temporary basis, and; • Have made arrangements for the children to remain independent of the parent

  9. Medi-Cal OverviewFinancial Eligibility General rule: Look to the cash assistance category (i.e. SSI or CalWORKs) that the beneficiary is most closely linked to. • Income • Earned • Unearned • Exempt income • Resources or assets • Individual: $2000, Couple: $3000 • Exempt resources (e.g. home) • Availability of income or resources • Deeming - Whose income/property is counted? Who has a financial obligation to provide financial support?

  10. Medi-Cal Eligibility Overall Principles & Rights • Right to Apply • Reasonable Promptness • 45 days, 90 days if disability determination • Retention • Ex Parte Re-Determination - before cutting eligibility, county must see if eligible for another program • Continuous eligibility regardless of changes in income • Children for 12 months • Families losing CalWORKS/1931b due to increase in child or spousal support

  11. Medi-Cal Eligibility Overall Principles & Rights • Inter-county transfers • No need to re-apply; no interruption • Bridging • Continued eligibility when moving between Medi-Cal and Healthy Families • Retroactivity • Services covered for three months prior to application • Notice and Hearing Rights • Denials, terminations, reductions, and delays

  12. Medi-Cal Eligibility Cash-related Categories • CalWORKs • Supplemental Security Income (SSI) • Foster Care and Adoption Assistance • Refugee Medical Assistance/Refugee Cash Assistance (First eight months in U.S.) • No Share of Cost

  13. Medi-Cal Eligibility Section 1931 • Families with net income up to 100% FPL with no share of cost • Transitional Medi-Cal • Families who lose CalWORKs or 1931 due to increased earnings • Received CalWORKs/1931 during 3 of last 6 months before losing benefits • Covers up to 12 months • First six months: Regardless of income • Second six months: Up to 185% FPL

  14. Medi-Cal Eligibility Programs for Children • Federal Poverty Level/Percent Programs • Infants up to 200% FPL • Ages 1-5 (6th birthday) up to 133% FPL • Ages 6-18 (19th birthday) up to 100% FPL • No share of cost • No property/resource test • No deprivation requirement • Children Leaving Foster Care at age 18 • Must be under state control on 18th birthday • Medi-Cal until 21st birthday • No income or assets test • No share of cost • May receive all EPSDT services

  15. Medi-Cal Eligibility Pregnancy-related Programs • 200% FPL Program • Presumptive Eligibility • To encourage prenatal care • Apply at prenatal care provider’s office • Must complete application for Medi-Cal • Sixty Days Postpartum Coverage • Infant deemed eligible up to one year

  16. Medi-Cal Eligibility Other Medi-Cal Programs for Women and Children • Minor Consent • No Longer Disabled Children • Breast and Cervical Cancer Treatment Program (BCCTP) • Accelerated eligibility

  17. Medi-Cal Eligibility Medically Needy • Income too high for cash aid • Look like CalWORKs (AFDC-MN) • Look like SSI (ABD-MN) • Must meet either: • Cash assistance deprivation requirements • SSI disability requirement • Share of cost? • Yes, if income above medically needy level • SOC = income minus MNL for that size family • No, if income below medically needy level

  18. Medi-Cal Eligibility Medically Indigent • Children and pregnant women who do not meet deprivation requirements • Some children receiving foster care • Children receiving adoption assistance • People 21-65 residing in nursing homes who are there short-term and not disabled • Individuals without satisfactory immigration status in nursing homes

  19. Medi-Cal Eligibility Programs for Persons who are Elderly or with Disabilities • Those receiving SSI, Aged & Disabled Medi-Cal, 250% Working Disabled • Those not receiving public assistance • Linked to case assistance program but not receiving payments; Pickles; Disabled Adult Children; Disabled widow/ers; misc.

  20. Medi-Cal Eligibility Programs for Persons who are Elderly or with Disabilities • Medicare Savings Programs – pay Medicare premiums and/or deductions but do not provide Medi-Cal coverage • Qualified Medicare Beneficiary; Specified Low Income Medicare Beneficiary; Qualifying Individual; Qualified Disabled Working Individuals • Dialysis, Tuberculosis, Total Parenteral Nutrition • Not disabled; limited services; sliding scale • Nursing Facility Waivers • Income disregarded; need high level of care but allowed to live at home or in the community

  21. Medi-Cal Eligibility Simplifying and Expediting the Application Process • Apply by mail, no face-to-face interview • Single Point of Entry (SPE) for Healthy Families and Medi-Cal for children and AIM • SPE screening: Children appearing eligible for free Medi-Cal get Accelerated Eligibility • Express Lane Eligibility • Food Stamp Statement of Facts • Applications for School Lunch Program • CHDP Gateway • Child Health and Disability Prevention program

  22. Notice & Hearing Rights • Notices must: • Describe the intended action • Give the reasons for the action • Specify the legal support for the action • Explain hearing rights and how to get one • Explain the right to be represented • Explain the right to continued benefits, pending the appeal • Generally must be sent at least 10 days prior to the action occurring

  23. Notice & Hearing Rights • For hearings: • Give reasonable notice to the beneficiary of the time & place of the hearing • Impartial hearing officer • Right to representation • Access to the file and the state’s information • Right to bring witnesses, present arguments, and cross-examine • Assistance with costs of transportation to hearing

  24. Medi-Cal Services Principles & Standards • Sufficient amount, duration, and scope to reasonably achieve the service’s purpose • Reasonable promptness • Comparability—to what others receive • Statewideness—rules must be applied in all parts of the state • Freedom of choice—choose one’s own providers • Managed care waives this requirement • Medi-Cal is payer of last resort • Medicare and private insurance pay first • Medi-Cal is Payment in Full

  25. Federal Mandatory Services • Hospital inpatient • Hospital outpatient • Rural health clinic • Federally qualified health clinics (FQHC) • Labs & X-rays • Nursing facilities

  26. Federal Mandatory Services • EPSDT • Pregnancy-related (including post-partum) • Family planning • Physician services • Nurse-midwife services • Pediatric or family nurse practitioner • Home health services

  27. Federal “Optional” Services • Podiatry • Optometry, eyeglasses • Prescription drugs • Chiropractics • Home health for non-nursing facility people • Private duty nursing • Clinical services rendered outside a clinic • TB-related drugs & care • Targeted case management • Non-emergency medical transportation services

  28. Federal “Optional” Services • Dental services, dentures • Physical therapy • Other rehabilitative services • Hospice • Case management • Respiratory care • Community care • Personal care services • Primary Care Case Management • Alcohol & drug treatment • Certain care for people in mental institutions or for people with mental disabilities

  29. Language Services • Title VI of the 1964 Civil Rights Act • All LEP persons must have “meaningful access’ to health care services • State Requirements • Govt. Code §11135 • Dymally-Alatorre Bilingual Services Act (Govt. Code §7290 et seq.) • Kopp Act (Health & Safety Code §1259) • Medi-Cal contract requirements

  30. Budget Updates • Budget deficit - Gov’s proposal for 10% across board cuts to nearly all General Fund programs • Elimination of 10 optional services • 10% cut to already low provider rates, including cuts to disproportionate share hospitals • Reinstatement of Quarterly Status Reports for adults and children • Eliminating payment of Medicare Part B Premiums for beneficiaries who do not qualify for Medi-Cal without a share of cost • IHSS cuts

  31. Where to go for more information • National Health Law Program www.healthlaw.org; (310) 204-6010 • Health Consumer Alliance www.healthconsumer.org • Health Insurance Counseling and Advocacy Program (HICAP). www.calmedicare.org; (800) 434-0222 • Benchmark Institute: • http://www.benchmarkinstitute.org/ourtraining/index.htm

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