1 Medi-Cal Programs

2 This lesson will provide you with the basic understanding of the Medi-Cal programs available to patients. At the end of this course, you will have a basic understanding of: Standard Medi-CalFamily PACT Medi-Cal RestrictedMedi-Cal Obstetrical Presumptive Eligibility Medical Managed CareMedi-Cal Share of Cost Out of State Medicaid Recognize the different programs and their billing needs to facilitate an accurate registration. Understand the basic terminology and the key components for each of these programs. Understand how UCSD manages these programs. Medi-Cal Programs

3 Medi-Cal is the program name used in the State of California for the Federally mandated health insurance program called Medicaid. Medicaid is a jointly funded Federal and State health insurance program designed to help meet the needs of eligible low-income people needing health care coverage. Currently Medi-Cal covers approximately 36 million individuals nationally including children, the aged, blind and or disabled, and people who are eligible to receive federally assisted income maintenance payments such as CAL Works. What is Medi-Cal?

4 The Federal government provides each state with national guidelines and allows them to: Establish their own eligibility standards Determine the type, amount, duration, and scope of the services Set the rate of payment for services Administer their own programs In California, Medi-Cal is managed by the Department of Health Services (DHS). What is Medi-Cal cont….

5 There are multiple Medi-Cal funded programs and within each of these programs there are several categories under which an individual can qualify. The final eligibility determination will be based on the patient’s residency, income and resource level as well as the medical need. Are there different types of Medi-Cal?

6 Medi-Cal (Standard) Medi-Cal Share of Cost Medicaid (non-California) Within the Medi-Cal standard and the Medi-Cal Restricted programs there are additional categories that further identify the type of coverage available to the recipient. Because the programs have different authorization and billing requirements, each has been assigned a unique payor code.

7 Medi-Cal Restricted Family Pact Medi-Cal Obstetrical Presumptive Eligibility

8 Medi-Cal Standard is the basic program by which all the other Medi-Cal programs are modeled after. This can also be referred to as straight Medi-Cal, regular Medi-Cal, fee for service Medi-Cal, unrestricted Medi-Cal and full scope Medi-Cal. Note: “Unrestricted does not mean that services are unlimited, it only means that services are not restricted to predefined or limited services. Medi-Cal Standard (Unrestricted)

9 Medi-Cal Restricted has benefits which have been approved for specific types of services such as emergency care or pregnancy-related services only. There are also restricted services available specifically for the detection and treatment of cervical or breast cancer. Medi-Cal Restricted

10 This is a managed care modeled program for Medi-Cal recipients. Medi-Cal has contracted with several different health plans in San Diego to provide HMO services to Medi-Cal recipients. Once the patient enrolls in a Medi-Cal Managed care plan, the standard Medi-Cal benefits will no longer cover them. This type of Medi-Cal program will be discussed separately in the Medi-Cal Managed Care lesson. Medi-Cal Managed Care

11 Recipient has been granted Medi-Cal coverage but earns more than the monthly maintenance need. In these cases the State requires the recipient to pay for health care charges that are in excess of the allowable maintenance need. This amount is referred to as a Share of Cost. Because this is based on income, the Share of Cost amount can change from month to month. Once the recipient has paid their SOC amount for that month, they become Medi-Cal eligible for that given month. This is not a deductible or an insurance premium, they are only required to pay this amount in a month where they receive health care services. Medi-Cal Share of Cost

12 Out of State Medicaid. This is used only for patients who are pre-authorized or seen in the emergency room department. Medicaid Non-California

13 This state program includes funding for services including: Contraception Fertility awareness Pregnancy testing Female and male sterilization Reproductive health education and counseling Testing and treatment for sexually transmitted diseases (STD’s) Hepatitis B Vaccination HIV Testing Family PACT is a highly confidential program and covers only the services mentioned above. If a woman becomes pregnant, Family PACT will no longer provide coverage. Family PACT (Planning, Access, Care and Treatment)

14 Referred to as Medi-Cal PE/OB, this is an outpatient Medi-Cal funded program which provides immediate and temporary funding for women in need of prenatal care and other pregnancy-related services. Applicants must sign a declarative application stating that they have no other medical coverage and that they meet the program income guidelines. The patient would then be eligible for ambulatory prenatal care for up to 60 days and the coverage starts when the initial mini application is completed in the physician’s office. The benefit period ends at the end of the next calendar month or upon completion of the full Medi-Cal application and eligibility determination. Medi-Cal Obstetrical Presumptive Eligibility

15 If at the end of the calendar month the full application has not been completed, the Presumptive Eligibility will end. At that time it is possible for the patient to apply again for Presumptive Eligibility. The final eligibility determination may move the patient’s coverage to Standard Medi-Cal, SOC Medi- Cal, or Restricted Medi-Cal Medi-Cal Obstetrical Presumptive Eligibility, con’t

16 1.Identifying existing Medi-Cal recipients 2.Verifying eligibility each month the patient accesses healthcare services. 3.Determining the patient’s share of cost (if applicable) and collecting, waiving, or clearing it according to policy. 4.Collecting the CIN#, County code and Aid code. 5.Identifying the EVC number associated to the patient What are the critical registration concerns for Medi- Cal patients?

17 Registration Staff who have any information related to suspected fraud or abuse occurring with Medi-Cal should notify their manager or supervisor. Fraud Indicators: Individuals who are non-residents of California Individuals who give or lend their Medi-Cal cards to any person other than a Medi-Cal provider. Individuals who fail to report that they have other health insurance. It is UCSD policy to refer all inquiries regarding potential fraud to the UCSD Healthcare Privacy Office (619) Fraud Prevention

18 Eligibility for Medi-Cal is based on an established financial need that is determined by an application process administered by the State of California Department of Social Services. Several factors and guidelines are used to determine Medi-Cal eligibility. Generally, individuals or families on public assistance, with low income, or with certain disabling conditions, may qualify for benefits under the Medi- Cal program. An individual must be a California resident and meet some of the additional criteria: Minors under 21 years of ageBlind or disabled people Some parents and adults Persons age 65 and older Pregnant women Individuals in nursing homes People who receive Cal Works Minors under 21 applying for Supplemental Security Income confidential services on their own (SSI) receive Medi-Cal automatically. Called “Minor Consent” or “Sensitive Services” Who is eligible for coverage?

19 Newborns are automatically covered under the mother’s Medi-Cal benefits and can use the mother’s benefit card information to receive services in their month of birth and the following calendar month only. After that time, the newborn must have their own eligibility in order to be covered by Medi-Cal Are newborns eligible?

20 Medi-Cal recipients are issued a white, plastic Benefit Identification Card (BIC). This plastic card is a permanent identification card, but it does not guarantee eligibility. Eligibility must be verified through one of the eligibility verification systems every month that the patient received services. The card has all the information that is needed to verify the eligibility and the program they are enrolled in. The card will provide: Name Date of birth Sex Card Identification Number Date the card was issued How do we identify the patient has Medi-Cal?

21 No. However, patients may receive approval for Medi-Cal benefits under one program until they are eligible for another one. Examples: Patient has presumptive Medi-Cal while they apply for and are granted Medi-Cal benefits. Patient is approved for standard Medi-Cal until they are enrolled into a Managed Care Medi-Cal health plan. Can a patient be covered by more than one Medi- Cal payor at the same time?

22 Aid codes identify the specific eligibility grouping under which the applicant has qualified for public assistance. There are over 150 aid codes. Each aid code has two characters with the first character identifying the primary aid category. The second character further identifies the aid code within the category. Looking at the first aid code, the following is a list of different aid codes. (The ”X” represents the second character which will not be identified in this example.) 0X- Special Circumstances5X- Restricted Services 1X- Aged6X- Disability Linkage 2X- Blind7X- Special Needs 3X- CalWorks/AFDC8X- Medically Indigent Adult 4X- Adoption/Foster/Guardianship etc 9X- Special Needs (Healthy Families,CCS, GHPP, Linkage) What are aid codes?

23 Standard Medi-Cal Covers : Medi-Cal office visits, hospitalizations, prescription medicines, mental health, substance abuse services and necessary medical tests. Restricted Medi-Cal Covers : Pregnancy related services or emergency services. Coverage might also be provided for breast or cervical cancer treatment only. Any type of restrictions will be listed in the response when verifying eligibility. What coverage is provided at UCSD for Medi-Cal patients?

24 Its possible for an individual with Standard Medi-Cal to have another type of coverage such as Medicare or an Employer Group Health Plan. If Medi-Cal shows that the patient has additional coverage you will still need to verify it with the identified program. What other coverage might a patient have?

25 From the Payor / Plan selection screen, search under the heading “Medi-Cal ” to view the different Medi-Cal programs and select the plan. What Coverages should be used?

26 Primary Payor- Medi-Cal is the payor of last resort, therefore should never be primary unless there is no other coverage. Secondary Payor- Medi-Cal should always be a second payor, except for a CCS or GHPP authorized service. When is Medi-cal Primary/Secondary?

27 Medi-Cal eligibility is granted on a month to month basis. Therefore needs to be verified each month that the patient accesses care. There are three available sources for eligibility: RTE (Real Time Eligibility) System Medi-Cal Website: AEVS (Automated Eligibility Verification System)- Telephone verification system. Out of State Medicaid can not be verified through either of these systems. How do you determine if a patient is eligible for Medi-Cal?

28 If you ever see County Aid codes of 53 or 55 you should not code these cases as Medi-Cal. This is because Medi-Cal will only pay for services for Long Term Care which UCSD does not provide. If you receive an eligibility response for CCS or GHPP this should also not be coded as Medi-Cal. You will receive a response with this information only because Medi-Cal is electronically processing their claims. These patients DO NOT have Medi-Cal. What special situations should you watch out for?

29 Routine care will not be covered by an out of state Medi- caid program. Only specialty services which are scheduled and authorized in advance would be eligible for payment. How can I verify an out of state Medicaid patient?

30 The out of pocket responsibilities for a Medi-Cal patient includes their share of cost liability, if required, or Medi-Cal non-covered services. What is the out of pocket responsibility for each patient?

31 If a SOC amount is determined for a given month, it must be paid for each month the patient is accessing services. This is called “meeting” the SOC. Once the provider accepts payment for the SOC it is then “cleared” through Medi-Cal. Once cleared, Medi-Cal will begin to provide coverage for services rendered within the specified calendar month and an EVC number will be provided. What do you need to collect at the point of service for SOC (Share of Cost)?

32 A patient’s Share of Cost can be collected and cleared through the Medi-Cal website at the point of check in. All payments will be posted to the Medical Center. How do you clear a SOC?