medical - san francisco health plan · 7/16/2014 · traditional or “pre-2014” medi-cal,...
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MediCal:
Learning About the Nuances
July 2014
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The following presentation is not for consumer use and is for
informational purposes for the 2014 Stronger Bridges to Health
Forum.
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•MAGI Medi-Cal Review
•Non- MAGI Medi-Cal Programs
•Covered California Review & Processes
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Revised 11/19/13
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The California Medical Assistance Program, also
known as Medicaid, serves low-income families,
seniors, persons with disabilities, children in foster
care, pregnant women, and certain low-income
adults. It is jointly administered by the California
Department of Health Care Services (DHCS) and
the Centers for Medicare and Medicaid Services
(CMS), with many services implemented at the local
level mainly by the counties of California.
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Traditional or “pre-2014” Medi-Cal, consisted of a large number of different programs. Although Medi-Cal programs usually provide the same level of medical coverage, applicants are evaluated for Medi-Cal programs based on the specific category they fall into.
Each Medi-Cal Program has it’s own eligibility criteria and rules.
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Most Medi-Cal programs are free of cost. If an individual is not eligible for free Medi-Cal they’ll have what’s called a Share-of-Cost.
An individual is always placed in the lowest cost Medi-Cal program they are eligible for.
No coverage for Childless non-disabled adults 21-64 years
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Effective 1/1/2014, some traditional Medi-Cal programs are “sunsetting”. Individuals who would have qualified for these programs will now have their eligibility determined in a new way. This new way of determining eligibility uses IRS/tax-based rules.
This new eligibility determination process is called the “MAGI” methodology.
MAGI stands for Modified Adjusted Gross Income
This new eligibility method will be considered MAGI Medi-Cal
Many Medi-Cal programs are not sunsetting. So even after 1/1/2014 while some individual’s eligibility will be based on MAGI rules other’s will continue to have their Medi-Cal eligibility based on traditional or Pre-ACA rules. This eligibility determination processes will be considered Non-MAGI Medi-Cal
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Children (Under 19 years old)
Parents/Caretaker Relatives
Pregnant and Post-Partum Women
Former Foster Care
Adults 19-64 years old
› this is a new category of individuals who were not eligible under traditional Medi-Cal
rules
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Individuals “deemed” eligible as a result of other
programs:
› SSI, CalWORKS, Foster Care, AA Program
Aged (65 or over), Blind or Disabled
Families (Parents living with children under 21)
Pregnant and post partum women
Adults with Medi-Care
Adults in Long Term Care
Individuals needing HCBS Waiver Services
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SSI, CalWORKS, Foster Care, AA Program
MI/MN or MI/MN-Sneede
Pickle Program
Disabled Adult Child
A&D FPL Program
250% Working Disabled
Medicare Savings Program
Long Term Care Program
Home and Community Based Services
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MAGI California Resident
No property test
Full and Restricted coverage (based on
citizenship)
Uses tax-based rules
› HH and Income
Eligibility Rules reside in Cal-HEERS
Eligibility starts 1/1/14
Non-MAGI California Resident
Property test (MC007)
Full and Restricted coverage (based on
citizenship)
Uses AFDC & SSI rules › HH, income & property
Eligibility Rules reside in CalWIN
Eligibility prior to 1/1/14
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Doctor Visits
Hospital Care
Prescriptions Drugs (except if Part D eligible)
Pregnancy-Related Services
Eye Care*
Dental Care
Emergency Services
* Adults only receive routine eye care and exams
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• All Medi-Cal applicants must be evaluated under MAGI Medi-Cal FIRST
• Simplified rules
• No asset test
• As of 1/21/2014 an automatic CalWIN-CalHEERS
interface went live
• Not all will qualify for Medi-Cal under MAGI rules
• Some groups of individuals, ineligible under MAGI rules may be evaluated for Non-MAGI Medi-Cal or covered California
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