Demystifying the Covered California – Medi-Cal …sdahu.org/Resources/Documents/SDHCCSDAHUPPT31Oct14.pdfDemystifying the Covered California – Medi-Cal Connection ... plans. Data

Demystifying the Covered California – Medi-Cal Connection

Getting it Right the First Time is a Good Start

San Diego Association of Health Underwriters October 31, 2014 9:00 – 11:00 am

Jan C Spencley, Executive Director San Diegans for Healthcare Coverage

[email protected] 619-231-0333

mailto:[email protected]

Agenda Topic

Welcome and Introductions

Who We Are – Meeting Objectives

The Work We Share

Tax Households

The Great Sorter: CalHEERS

Modified Adjusted Gross Income (MAGI)

Income: Depends on Program and Preferences

Medi-Cal : What is Best for Clients

Medi-Cal: Where is My Application?

Consumer Assistance: Getting Out of a Fix

General Discussion – Questions and Answers

Evaluation – Adjourn October 31, 2014 SD Association of Health Underwriters 2

Who We Are: A not-for-profit, 501(c)3 organization, formed in 2002.

With a Mission: A Coalition for Health San Diegans for Healthcare Coverage advances meaningful coverage, care and health for all San Diegans. We serve as a trusted community leader, unbiased resource and catalyst for action and collaboration, while connecting and amplifying our collective resources and voice. Activities: Convene - Bridge - Educate - Advocate - Enroll - Access - Continuity

October 31, 2014 SD Association of Health Underwriters 3

SDHCC Collaborative – Forums Purpose and Objectives

To share information and resources that will assist Enrollment Counselors with • Submitting “complete” applications that result in successful

eligibility and enrollment • Resolving issues encountered by applicants/enrollees

To bring subject matter experts together with Enrollment Counselors to review protocols and share and resolve issues and concerns (County – Legal Aid – Others)

To identify issues and resource needs to assist counselors and consumers with efficient/effective enrollment


SDHCC Info Warehouse (Drop Box)

Resources and Desk Aids • Access to Care • Citizenship/Immigration Status • Community Clinics • Covered CA Renewals • Income • MAGI • Medi-Cal Renewals • Presumptive Eligibility • Special Enrollment • Verifications

References

5 October 31, 2014 SD Association of Health Underwriters

Today’s Meeting Objectives

Share key logic and interfaces between Covered CA and Medi-Cal through CalHEERS (and some issues)

Share significant Medi-Cal eligibility changes and how they have been, and are, managed

Identify known issues – workarounds

Share tools and desk aids developed for counselors

Share resources to assist consumers with resolving issues

Identify opportunities for future sharing/follow-up and advocacy


7

Health Coverage Expansion - 2014 Individuals and Families – Small Employers

ACA

Covered California

(CA Exchange)

Small Business Health Options

Program

2-50 Employees Premium Tax

Credits (35-50%)

Individuals and Families

(>138% FPL)

Premium Tax Credit (400%FPL)

OOP Subsidy

Medi-Cal Expansion

Adults 19 – 64 (<138%)

MAGI

Privately Insured All 222,000 Under 400% 122,000 Under 250% 60,000

October 31, 2014 SD Association of Health Underwriters

Eligible Not

Enrolled 200,000

Covered California – San Diego Enrollment (Initial April 15, 2014)


Minimum Coverage 647 0.6% 1,328 8.3% 1,975 1.6%Bronze 24,865 23.5% 5,806 36.2% 30,671 25.2%Silver 68,804 65.0% 4,405 27.5% 73,209 60.1%Gold 6,332 6.0% 2,125 13.3% 8,457 6.9%

Platinum 5,222 4.9% 2,366 14.8% 7,588 6.2%Grand Total 105,870 100.0% 16,030 100.0% 121,900 100.0%

Metal LevelSubsidized Unsubsidized

CategoryTotal

Notes: Data tables include enrollments in Covered California health insurance plans. Data tables do not consider enrollees' effectuation in a health plan, which requires the payment of premiums. Data under review (not final)

http://hbex.coveredca.com/data-research/

Covered CA Enrollments Month and Pathway


Medi-Cal Enrollments


Increase in Beneficiaries (Oct 2013 to Sept 2014) = 155,000 (55%) Denials (22%) Backlog (10%)

< 45 days (3.5%) Duplicates/Withdrawn (10%)

To Maximize and Stabilize Coverage Resources – Systems – Collaboration – Inclusion

Education/Sales - Enrollment – Retention - Transitions - Renewal

Public Individuals & Families

Exchange Individuals &

Families

Exchange Business


Commercial Market

Public Programs

Tax Households

A new world Tax definitions v

program definitions Families are diverse


Tax Households: The Simple Approach


Tax Filer(s)

Tax Dependents




Desk Aid Tax Households

Example: Three Generation Household

Mary lives with and supports her 61-year old mother, Cecelia and a 7-year old daughter, Anna

Mary is the Tax Filer and claims Cecelia and Anna as Dependents

Family Member Tax Filing Status Covered Ca

HH Size Medi-Cal HH Size

Mary Tax Filer Mary, Anna, Cecilia

Mary, Anna, Cecilia

Anna Claimed as dependent Mary, Anna, Cecilia

Mary, Anna, Cecilia

Cecelia Claimed as dependent Mary, Anna, Cecilia

Cecilia


Example: Three Generation Household

Mary lives with her 61-year old mother, Cecelia and a 7-year old daughter, Anna

Cecelia is the Tax Filer and claims Mary and Anna as Dependents

Family Member Tax Filing

Status Covered Ca

HH Size Medi-Cal HH Size

Cecelia Tax filer Cecilia, Mary, Anna Cecilia, Mary, Anna

Mary Claimed as Dependent

Cecilia, Mary, Anna

Cecilia, Mary, Anna

Anna Claimed as Dependent

Cecilia, Mary, Anna

Mary, Anna


Question and Answer


Affordability Programs by Family Poverty Level


Program Eligibility by Annual Income/Family Size Federal Poverty Level (FPL)

Household Size

No Cost Medi-Cal Eligible

Eligible for Premium Assistance (PA)

Cost Share Reduced

Medi-Cal Kids Eligible

< 100% 138% 150% 250% 400%

1 $11,670 $16,105 $17,505 $29,175 $45,680

2 $15730 $21,708 $23,595 $39,325 $62,920

3 $19,790 $27,311 $29,685 $49,475 $79,160

4 $23,850 $32,913 $35,775 $59,625 $95,400

The Sorter: CalHEERS Affordability Program Decision Tree - Systems


Work- Arounds

Stuck??


Note: This is a general description and not inclusive of all applicable income or deductions for each Affordability program/individual (See Desk Aid)

Desk Aid

Income: What Counts for What (Desk Aid)


Income: What Counts for What (Desk Aid)


Self Employed Income Estimates - Documentation Profit and Loss from Business

Category Month 1 Month 2 Average

Receipts ($ Received) X,XXX X,XXX X,XXX

Cost of Goods Sold (X,XXX) (X,XXX) (X,XXX)

Gross profit X,XXX X,XXX X,XXX

Expenses

Mileage XXX XXX XXX

Supplies XX XX XX

Licenses XXX XXX XXX

Rent XXX XXX XXX

Other Expense XX XX XX

Total Expenses X,XXX X,XXX X,XXX

Net Profit/(Loss) X,XXX X,XXX X,XXX

Future versus past income

Estimating benefit year Current v. annual Documenting estimates System issue (gross v.

net income)


Income: Different Interpretations

Covered California uses the tax household and estimated annual income.

Medi-Cal uses the tax household and CURRENT income Mid Year eligibility and enrollment may require that an

earlier period of income be excluded • Loss of Job that makes them eligible for Medi-Cal • Hit and miss if client wants Covered California and all periods

are entered “System” may modify income in application based on

electronic verifications


Question and Answer


Medi-Cal Coverage Groups MAGI and Non-MAGI

MAGI

Childless adults 19-64*

Pregnant (full/limited)

Children up to age 19 (or 21 if a full time student)

Foster Youth

Parent/Caretaker Relative

Disabled (pending)

*Newly Eligible

Non-MAGI

• Aged (>65)

• Blind (Medicare)

• Disabled (Medicare)

• Long Term Care

• MN/Medically Indigent (MI)

• MN Sneede

28 October 31, 2014 28 SD Association of Health Underwriters

MAGI Medi-Cal Hierarchy (Desk Aid)

Cannot be in New Adult Group (NAG) if eligible for mandatory group

Start with NAG for Potential Disability

If declare pregnancy at time of application, must go to mandatory group.


Pregnant Women: A Conundrum

Applicants: Have Option of Covered California (APTC/CSR) and/or Pregnancy Only Medi-Cal (if over 100% FPL) • If applicant wants BOTH, process Covered CA Application

without indicating Pregnancy (Health ) and refer for processing of Medi-Cal through County (workaround)

• If applicant wants Pregnancy Only Medi-Cal, indicate Pregnancy (Health ) and proceed with Application

Enrollees: Can be enrolled in Covered CA and apply for Pregnancy Only Medi-Cal through County. Must use work around (Covered CA first).

Why: Pregnancy Only Medi-Cal is being allowed as Minimum Essential Coverage for 2014 and MAY be allowed for 2015 (not confirmed yet). Covers Co-pays/expanded services.


Presumptive Eligibility (PE) Pregnancy PE: Prenatal providers may enroll Medi-Cal

eligible individuals in presumptive eligibility for prenatal care only while full application is pending. Allows woman to start prenatal care without delays.

Child PE: Pediatric providers may enroll Medi-Cal eligible children (<19) in presumptive eligibility while their full application is pending. Time limited. Allows child to get care for a short period

Hospital PE: Some hospital providers may enroll Medi-Cal eligible individuals with EMERGENCY conditions in presumptive eligibility for the current and following month, or until determination is made, whichever is first.

www.ccc-sd.org/health-centers/ October 31, 2014 SD Association of Health Underwriters 31

Immediate Medical Need?

FRC!


Desk Aid


Desk Aid

Using the MC 13 for Immigrants (State Form)


Medi-Cal Renewals/Redeterminations

June – December = January thru December Renewals

(Priority is Backlog of Applications)

New Process for Redetermination (Pre-ACA Cases) • Redetermination • Tax Household Information (MAGI Hierarchy)

Process for January 2015 renewals (New Populations) began

end of September 2014 October 31, 2014 SD Association of Health Underwriters 35

Where is My Application?

Consumers County Access Line (Status/Worker) • 1-866-262-9881 • Access can provide case worker contact info

County workers cannot share information on client status unless you provide authorization from the client • Authorized Rep – Release Form • MC 206 Authorized Rep Release Form • Client present with you during call


10/29/2014: Backlog (> 45 Days) = 22,000

Question and Answer


Timely Access to Care Requirements (Blue)

Summary of Requirements

Triage/Screening 24/7 – Wait Time < 30 minutes

48 Hours of Urgent Care Appointments (No Auth)

96 Hours for Urgent Care Appointments (Requiring Auth)

10 Business Days Non-Urgent PCP or MH Appointments

15 Business Days Non-Urgent Specialist Appointments

15 Business Days for Non-Urgent Ancillary Services What to Do if You Have a Problem with Your Health Plan

(Handout) October 31, 2014 SD Association of Health Underwriters 38

How Consumer Center Can Help (1-877-734-3258)

Partnership with Covered California – DMHC - DHCS Independent consumer assistance Addresses barriers to accessing health insurance and health

care benefits (eligibility & services) All consumers, regardless of income Both public programs and private insurance


Consumer Center Help Specific to Covered California problems

To dispute Denials of eligibility of individual insurance Mistakes or denials of Advanced Premium Tax Credit or Cost

Sharing Mistakes in assigning plans or providers Delays in processing Failure to refer for Medi-Cal where appropriate Mistakes in payment processing


Discussion – Common Issues
