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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
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
October 31, 2014 SD Association of Health Underwriters 4
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
October 31, 2014 SD Association of Health Underwriters 6
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)
8 October 31, 2014 SD Association of Health Underwriters
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/
Medi-Cal Enrollments
10 October 31, 2014 SD Association of Health Underwriters
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
October 31, 2014 SD Association of Health Underwriters 11
Commercial Market
Public Programs
Tax Households
A new world Tax definitions v
program definitions Families are diverse
12 October 31, 2014 SD Association of Health Underwriters
Tax Households: The Simple Approach
13 October 31, 2014 SD Association of Health Underwriters
Tax Filer(s)
Tax Dependents
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
17 October 31, 2014 SD Association of Health Underwriters
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
18 October 31, 2014 SD Association of Health Underwriters
Affordability Programs by Family Poverty Level
20 October 31, 2014 SD Association of Health Underwriters
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 $95,400
The Sorter: CalHEERS Affordability Program Decision Tree - Systems
21 October 31, 2014 SD Association of Health Underwriters
Work- Arounds
Stuck??
October 31, 2014 SD Association of Health Underwriters 22
Note: This is a general description and not inclusive of all applicable income or deductions for each Affordability program/individual (See Desk Aid)
Desk Aid
Self Employed Income Estimates - Documentation Profit and Loss from Business
Category Month 1 Month 2 Average
Receipts ($ 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)
25 October 31, 2014 SD Association of Health Underwriters
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
October 31, 2014 SD Association of Health Underwriters 26
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.
29 October 31, 2014 SD Association of Health Underwriters
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.
October 31, 2014 SD Association of Health Underwriters 30
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!
Using the MC 13 for Immigrants (State Form)
34 October 31, 2014 SD Association of Health Underwriters
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
October 31, 2014 SD Association of Health Underwriters 36
10/29/2014: Backlog (> 45 Days) = 22,000
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
October 31, 2014 SD Association of Health Underwriters 39
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
October 31, 2014 SD Association of Health Underwriters 40