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The basics of Medi-Cal and how it works with Covered California

Kevin Knauss
The basics of Medi-Cal and how it works with Covered California.

The basics of Medi-Cal and how it works with Covered California.

Medi-Cal was one of the biggest mysteries during open enrollment in the new ACA health plans. Even though Covered California advertised a “no wrong door” approach to signing up for health insurance, when a client had to go through the Medi-Cal door, not even Covered California could tell them what to expect. Finally, seven months into the expanded Medi-Cal program, the Department of Health Care Services has finally put together a presentation that goes over the various parts of Medi-Cal and how the system works. New Covered California – Medi-Cal guide available for download at end of post.

Covered California has made numerous changes to their online enrollment application including changes to reporting income. For a review of the changes and to download documents visit 2016 income and application change for Covered California enrollment.

Counties play a big role in Medi-Cal

Medi-Cal, California’s version of Medicaid is big and complicated. It starts with the federal government funding to California for the Medi-Cal program. On the state level, the Department of Health Care Services, which is under California’s Department of Managed Health Care, administers the overall program. However, each county is actually responsible for enrolling residents in one of the numerous managed health care plans. Each county will have anywhere from one to four different choices of HMO plans that a resident eligible for Medi-Cal will have to enroll into. Currently there are over 10 million people enrolled in Medi-Cal programs.

See: 2015 California Medi-Cal Health Plans by County

DHCS MAGI Medi-Cal individual household size flow chart.

New -> DHCS MAGI Medi-Cal individual household size flow chart.

Covered California doesn’t administer Medi-Cal

The role of Covered California is to determine if the applicant is Medi-Cal eligible by the stated annual income and then hand the information off to the respective county of the applicant’s residence. Individuals and families eligible for Medi-Cal can upload their income and residency documents into the Covered California system to be verified by county. Even though the expanded Medi-Cal program under the ACA is open to every household with an annual income less than 138% of the Federal Poverty Line, there are many different programs within Medi-Cal and programs specific to certain counties that people may qualify for beyond straight enrollment through Covered California.

Medi-Cal basics overview

The Medi-Cal Essentials presentation was a webinar developed for Certified Insurance Agents to answer the numerous questions agents and their clients had about enrollment. The webinar is approximately 2 hours long and can be opened via this link.

http://hbex.coveredca.com/agents/webinars/

Select view Medi-Cal Essentials Webinar July 31st 2014

I found the audio was garbled when the recorded presentation was viewed through Window Media Player. I was able to improve the audio by switching to Adobe Flash Play by clicking on one of the icons next to the refresh media button.

Should you report your pregnancy to Covered California?

This blog post reviews how some women may be placed into Medi-Cal after they report that they are pregnant. Covered California is now screening women for Medi-Cal pregnancy programs when they indicate they are pregnant. Even if you were determined eligible for a private health plan with the premium subsidy, indicating you are pregnant changes the household size and drops the woman into Medi-Cal potentially losing her OBGYN who may not accept Medi-Cal. – Updated February 11, 2016

Medi-Cal Essentials power point presentation

The power point presentation is a fairly good overview of everything they participants discussed during the recorded webinar. There were some clarifications in the audio portion that are not displayed in the power point presentation slides. It was also evident that there are certain Medi-Cal rules that are different from Covered California. For instance, Covered California gives households 30 days to update their income when it changes, but Medi-Cal wants to be notified in 10 days if the income increases.

Below I have tried to hit some of the main points of the presentation. For additional information you should review the power point presentation or actually listen to the webinar. You can download the full power point presentation with all the slides and commentary at the end of the post.

How is Medi-Cal eligibility verified?

What determines Medi-Cal eligibility?

What’s covered in a Medi-Cal health plan?

What about Access for Infants & Mothers?

County Children’s Health Insurance Program C-CHIP

What about Former Foster Youth ageing out of the system?

What are the two types of Medi-Cal?

Types of managed care plans

Is Medi-Cal free?

Do current Medi-Cal beneficiaries, pre-ACA, need to re-apply?

Are medical bills covered prior to Medi-Cal?

Medi-Cal questions?

What are the Medi-Cal Income and Asset tests?

Who qualifies for Non-MAGI Medi-Cal?

How is MAGI used to determine Medi-Cal eligibility?

What comprises a household for MAGI?

What are the residency requirements for Medi-Cal?

Can immigrants receive Medi-Cal?

What is full scope Medi-Cal?

What is restricted scope Medi-Cal?

What about Dream Act or Deferred Action for Childhood Arrivals (DACA)?

Why do families have children in Medi-Cal and the parents in a private plan?

What is a pregnancy wrap?

How is residency verified?

When do individuals and families notify Medi-Cal of Changes?

What about self-employed people with fluctuating income?

How can a family dis-enroll from Medi-Cal?

Is everyone 65 years old eligible for Medi-Cal?

Are people over 65 eligible for the advance premium tax credits (APTC)?

When will Medi-Cal enforce Estate Recovery to get repaid?

Can an individual have Medi-Cal and receive a tax credit for a private plan?

Is losing Medi-Cal coverage a qualifying event?

When can individuals enroll in Medi-Cal?

Can an individual get temporary Medi-Cal in case of an emergency?

How does CalFRESH work with Medi-Cal?

What happens if the household is determined eligible for Medi-Cal?

Enrollment tips for a confusing Covered California website

What is the date of Medi-Cal eligibility?

What if an individual needs health care before receive Medi-Cal card?

How does someone cancel Medi-Cal?

Why does Covered California show eligibility for both tax credits and Medi-Cal?

What if the individual has an old Legal Permanent Resident Card?

What document types can be uploaded for verification?

If Medi-Cal is denied can the consumer appeal?

Will Certified Insurance Agents be paid for enrolling individuals and households into Medi-Cal?

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New Covered California Medi-Cal comprehensive guide

Covered California in coordination with the Department of HealthCare Services has produced a comprehensive guide to Medi-Cal and how it works. The Medi-Cal Eligibility, Benefits and Options Advance Study Course provides high level details regarding the often times mysterious workings of Medi-Cal. For more detail on the items outlined below, download the guide at the end of the post.

There are many different programs under the Medi-Cal umbrella and most all of them are administered by each county within California.

MAGI versus Non-MAGI

There are two broad groups of Medi-Cal programs: MAGI and Non-MAGI programs. MAGI based programs are available to individuals and families based solely on their Modified Adjusted Gross Income as determined through Covered California enrollment. Non-MAGI based Medi-Cal programs and assistance considers the assets of the individual or family. Non-MAGI based Medi-Cal is most often associated with assistance for people in skilled nursing facilities. Estate recovery rules apply to both types of Medi-Cal for individuals over 55 years of age.

Full and Restricted Medi-Cal Benefits

Full Scope benefits include coverage for all the essential health benefits of a private plan plus dental, mental health services, pharmacy, vision and drug and alcohol treatment coverage. There is also coverage for durable medical equipment such as wheelchairs, hearing aids, occupational therapy and chiropractic services.

Restricted Scope benefits are usually confined to emergency and prenatal care services. The type of restricted or limited services will vary by the program.

Applying for Medi-Cal

Covered California only determines the eligibility for MAGI based Medi-Cal programs. Eligibility and coverage will start the first day of the month of the individual’s application. Applications for Non-MAGI based Medi-Cal should be made through the individual’s respective county social services office. Residents of San Francisco, San Mateo and Santa Clara counties will get a higher FPL income percentage making more children eligible for Medi-Cal kids. Families in these counties who think they qualify with the higher incomes should contact their local county social services department. Medi-Cal enrollment is open year round.

Medi-Cal Household

Different rules apply for determining a Covered California household or a Medi-Cal household. The Medi-Cal rules are more lenient. A pregnant woman is counted as two individuals under Medi-Cal but only one under Covered California. There are also other rules concerning adult dependents such as a mother-in-law living with her son or daughter. The guide covers many of these complicated relationships but it is always best to contact your local county social services department for definitive clarification.

Optional Targeted Low-Income Children’s program

The Optional Targeted Low-Income Children’s Program (OTLICP) offers healthcare coverage for children previously in the Healthy Families Program (HFP) that were transition into Medi-Cal. OTLICP provides full-scope Medi-Cal benefits at no- or low-cost to children with eligible immigration status and household income up to 266% of the FPL.

Cost is based on the family’s household income. Children are eligible at no cost with an income limit at or below 160% of the FPL. Families with incomes greater than 160% of the FPL will be subject to a health insurance premium of:

MAGI Medi-Cal for Pregnant Women

Medi-Cal Access Program, formerly Access for Infants and Mothers (AIM), includes infants whose mother’s income is above 266% up to and including 322% FPL. These infants are registered into the DHCS Medi-Cal Access Infant Program back to their date of birth once registered by the mother, plan, provider, or hospital. The infant is eligible for up to two years of coverage through the Medi-Cal Access Infant Program as long as the family income stays within the Medi-Cal Access Program’s income eligibility levels at the one year renewal.

Pregnant women qualify for MAGI Medi-Cal up to 213% of the FPL with different coverage levels. Pregnant women with income:

Residency and Citizenship

Medi-Cal requires that individuals and families verify that they reside in the county in which they will receive Medi-Cal benefits. The guide also details the various types of immigration statuses and documentation to be determined eligible for Medi-Cal if the individual or family are not citizens of the U.S.

Medi-Cal Share of Cost

Share of Cost (SOC) means that the individual will have to pay a portion of their medical expenses out-of-pocket. In some instances, Medi-Cal beneficiaries must pay a fixed monthly dollar amount toward their medical expenses before they qualify for Medi-Cal benefits. A Medi-Cal beneficiary’s SOC is similar to a private insurance plan’s out-of-pocket deductible.

The SOC amount is calculated by the County Social Services office using the beneficiary‘s household monthly income and the Medi-Cal Maintenance Need Income Level (MNIL), which is a calculated amount that is needed monthly to pay for living expenses.

SOC Medi-Cal does not qualify as minimum essential coverage. Therefore, beneficiaries can request that their local County Social Services office review their case for MAGI Medi-Cal eligibility.

Medi-Cal Managed Care

While some Medi-Cal beneficiaries will be in Fee-For-Service plans where they may have to pay a share of cost (SOC), most individuals will select a manage care or HMO plan for their benefits. Medi-Cal HMO plans are either non-profit plans run by the county or a private plan that has contracted with the county to provide Medi-Cal full scope benefits. Each county may have different plans available to the Medi-Cal beneficiaries. Some counties may have only one plan. In almost all instances, the individual or family will have to select a managed care plan or one will be chosen for them.

Presumptive Eligibility Programs

Medi-Cal provides certain individuals with temporary and immediate coverage before they are formally determined eligible for a Medi-Cal program. These programs grant individuals with presumptive eligibility (PE), meaning they are presumed eligible without a full eligibility determination. However, a full Medi-Cal application must be submitted within 60 days of PE coverage or PE will be terminated. Depending on the program, Individuals are enrolled in PE by participating providers and not done through the County Social Services office or CoveredCA.com. There are specific presumptive eligibility guidelines for pregnant women, women diagnosed with breast or cervical cancer, and individuals in need of hospital services.

Former Foster Care Children’s Program

Effective January 1, 2014 as part of the Medi-Cal expansion, the Former Foster Care Children’s Program (FFCCP) extended coverage to youth, up to the age of 26, who were in foster care on their 18th birthday regardless of income. If an individual previously aged out of the FFCCP, but is under the age of 26, the individual still qualifies for no-cost, full-scope Medi-Cal benefits up to their 26th birthday. The FFCCP group does not go through MAGI income determination.

Estate Recovery

Since Medi-Cal pays for medical care for some people whose savings and income are too low for them to pay for their own care, the cost of an individual’s medical care, or the premiums paid for care may be required to be repaid to Medi-Cal upon the individual’s death. The costs that Medi-Cal will evaluate are those incurred over the age of 55 or for nursing home or long term care incurred prior to the age of 55. Medi-Cal will also not seek reimbursement for services that are also covered under Medicare if the beneficiary is enrolled in a Medicare Savings Program. Repayment is never more than the value of the assets the individual had at the time of death. The amount repaid will be used to pay for medical care for others who need it.

Using Medi-Cal and private insurance plans

It is possible to have Medi-Cal and other types of health coverage. In most cases, when an individual is enrolled in Medi-Cal and private or employer-sponsored health insurance, Medi-Cal will pay for services not covered by the primary insurance. Under federal law, anyone currently enrolled in restricted-scope Med-Cal or with a SOC may purchase subsidized coverage through Covered California, because these forms of Medi-Cal are not considered minimal essential coverage under the ACA.

It is not possible to qualify for MAGI Med-Cal and Covered California with subsidized coverage at the same time. However, if a consumer is enrolled in a Covered California health plan and is subsequently determined to be eligible Medi-Cal, they will receive the tax credit for the time they were enrolled in the Covered California health plan.

Western Center on Law and Poverty

Getting and Keeping Health Coverage for Low-Income Calfornians: A Guide for Advocates, March 2016

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