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Yolanda Arias Legal Aid Foundation of Los Angeles
Medi-Cal Yolanda Arias Legal Aid Foundation of Los Angeles
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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
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I. Objectives cont’d • Calculating SOC
• Other Insurance Affordability Programs • IHSS • County Programs
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Medi-Cal Match -the ultimate match game
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Medi-Cal Match This plastic device is issued to Medi-Cal beneficiaries and used by Medi-Cal providers to verify eligibility.
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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.
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Aid Codes Prmy aid code: 13 Medi-Cal eligible w/LTC SOC of $1000
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Medi-Cal Match A Medi-Cal procedure for a provider to get advance approval for a service in non-emergency situations.
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Treatment Authorization Request
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Medi-Cal Match An increase in benefits based on the increase in the cost of living.
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Cost of Living Adjustment
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Medi-Cal Match Modified adjusted gross income – a way to determine financial eligibility for Medi-Cal under Obamacare.
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MAGI
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Medi-Cal Match Legislation enacted in 2010 that expands Medicaid as part of a broader plan to cover millions of uninsured Americans.
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Affordable Care Act
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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.
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Share of Cost (SOC)
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Medi-Cal Match Many Medi-Cal and other affordable health insurance programs use this federal measure as financial eligibility guidelines.
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Federal Poverty Level (FPL)
LBJ announcing the War on Poverty at the home of some poor folk.
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Medi-Cal Match Subtracting medical expenses from total income resulting in reducing countable income and making a person eligible for Medi-Cal coverage.
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Spending Down
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Medi-Cal Match Full range of Medi-Cal services including doctor visits, hospital stays, surgeries and other procedures.
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Full Scope Medi-Cal
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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.
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Restricted Scope Medi-Cal
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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.
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Managed Care
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Medi-Cal Match State marketplace established under federal legislation that connects Californians to accessible, quality health coverage.
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III Medicaid/Medi-Cal
A. Federal /State Program Uniformity + variation
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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
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III. Medicaid/Medi-Cal
D. Key Terms & Concepts 1-13. Medi-Cal Match 14. SB 87
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IV. Medi-Cal Programs Pre-ACA A. Aged, Blind, Disabled Linked to SSI
B. Families CalWORKs Related ACA C. MAGI Medi-Cal
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Medi-Cal Programs Linked Aged, Disabled SSA/SSI Linked or Related
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Aged, Blind, Disabled Linked to SSI
SSI Recipients Section 1619(b) Recipients
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Aged, Blind, Disabled Linked to SSI
Aged & Disabled FPL
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Aged, Blind, Disabled Linked to SSI
250% Working Disabled FPL
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Aged, Blind, Disabled Linked to SSI
MN Aged-Blind-Disabled
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Aged, Blind, Disabled Linked to SSI
Pickle Program
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Medi-Cal Programs Families, CalWORKs/AFDC Related
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Families, CalWORKs/AFDC Related
CalWORKs Recipients
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Families, CalWORKs/AFDC Related
AFDC/Medically Needy
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Medi-Cal Programs MAGI Medi-Cal
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MAGI Medi-Cal Parents/ Caretaker Relatives 109% FPL
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MAGI Medi-Cal Adults - ages % FPL
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MAGI Medi-Cal Pregnant Women 213% FPL
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MAGI Medi-Cal Access Program
Pregnant Women/ Newborns % FPL
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MAGI Medi-Cal Targeted Low-Income Children’s Program (TLICP) 266% FPL
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Covered California Subsidies
APTC—Advance Premium Tax Credit CSR—Cost Sharing Reduction
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V. Conduct Eligibility Similar to CalWORKs – less demanding
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VI. Procedural Eligibility
Right to apply Must report Annual redetermination of eligibility
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Single Streamlined Application ACL 14-14 (2/7/14)
SSApp Single Streamlined Application ACL (2/7/14)
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VII. Benefits Coverage Prior authorization “Medically necessary” EPSDT
Transitional Medi-Cal underutilized
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VIII. Immigrants Chart Handbook 9/25
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IX. Fair Hearing Process
Same as CalWORKs except that DHCS gets involved in some aspects of the hearing process. IMR
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X. Other Health Programs
IHSS – In-Home Supportive Services Handbook 2/55
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Other Health Programs AIDS Assistance County Programs
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XI. Access to Healthcare
Federally mandated language access Handbook 2/83 California Law Handbook 2/89
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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
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XII. Resources Getting and Keeping Health Care Coverage for Low-Income Californians: A Guide for Advocates Maternal and Child Health Access
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