Health Program Eligibility 101


Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Health Program Eligibility 101

  1. 1. Maternal & Child Health AccessHealth Care Programs Eligibility 101 March 11, 2010 Presented by, Donald Nollar, Training Specialist Liz Ramirez, Director of Training
  2. 2. MCHA Mission StatementMaternal and Child HealthAccess’s mission is toimprove the health of low-income women and theirfamilies throughadvocacy, education,training and services.
  3. 3. Medi-Cal• Medi-Cal is a program that pays for medically necessary health and mental health services for many low-income people.• Unfortunately, not all families with low income or health care needs qualify.• There are certain requirements one has to meet in order to be eligible for Medi-Cal
  4. 4. Requirements for Medi-Cal Eligibility 1. Linkage 2. CA Residency 3. Income 4. Immigration Status - determines level of benefits
  5. 5. Linkage• Under age 21• 65 and older• Disabled or blind• Pregnant• A parent with minor children• Caretaker Relative• Breast or Cervical Cancer• TB
  6. 6. Linkage• End Stage Renal Disease• Cal WORKs• Foster Care• Supplementary Security Income (SSI)• Refugee or Political Asylee• In a nursing home
  7. 7. California Residency• California residency means that the person wants to live and stay in California and does not have any plans to leave.• State residency has nothing to do with federal immigration status.
  8. 8. Is Medi-Cal Free?Family’s income determines whether their Medi-Calwill be:• No cost Medi-Cal • All services and visits provided free of cost• Share of Cost Medi-Cal • Each month the family may have to pay, or agree to pay, some of their health care bills before Medi-Cal will pay for their family’s medical expenses. This is called “Share of Cost” • Families DO NOT have to pay anything in months that they do not have medical or dental bills or don’t get medical or dental care.
  9. 9. RESOURCES SOMETIMESCOUNT• Resources, stuff you own and money in the bank, counts for some Medi-Cal programs.• You can have up to $2000 in resources for 1 person, • $3000 for 2 people, • For each additional person add $150.00• Resources are not counted for pregnant women or children in the Percentage Programs
  10. 10. How does Immigration Status Impact Eligibility? Immigration status will determine the level of benefits your client can be eligible for. Restricted Medi-Cal • Pregnancy-related - up to 90 days postpartum, including family planning, abortion, perinatal care, basic dental services, nursing home and renal dialysis services. • Emergency services - danger to life or limb. Maternal and Child Health Access
  11. 11. PRUCOLPRUCOL stands for: Permanently Residing in the U.S. Under Color Of Law• Undocumented immigrants who would otherwise only be eligible for restricted scope benefits can get full-scope benefits if they are in the process of adjusting their immigration status.• PRUCOL will only determine the scope of benefits. The family or individual still has to have a link to the Medi-Cal program.
  12. 12. More Medi-CalPrograms & Medi-Cal Covered Services
  13. 13. PRESUMPTIVE DISABILITY• People with the following disabilities can have their Medi-Cal approved immediately while the state makes a final disability determination : • Amputation of leg at the hip • Total deafness or blindness • Certain Stroke cases • Cerebral Palsy • Down Syndrome • HIV with specific disease manifestations • End stage renal disease • ALS • Terminal illness with a life expectancy of 6 months For a complete list see: cal/eligibility/Documents/c304.pdf
  14. 14. Presumptive Eligibility (PE)ELIGIBILITY All pregnant women who declare they are income eligible (200% of poverty) and state residents are presumed to be eligible for Medi- Cal for their pregnancyWHERE TO APPLY At the clinic or doctor’s office where woman receiving prenatal care. Maternal and Child Health Access
  15. 15. What Does PE Cover? PE covers all ambulatory pregnancy-related services except hospitalization.- Prenatal care- Tests- Preventive and emergency dental care- Ultrasound- Medications- Miscarriage- Mental Health- Abortion Maternal and Child Health Access
  16. 16. MINOR CONSENT Medi-Cal Also know as “Sensitive Services”, Minor Consent is a program that allows minors between the ages of 12 and 21 to apply for Medi-Cal on their own without their parents consent. There are no immigration or income requirements Services are limited to: Pregnancy Care Abortion Contraception Sexual assault and STD treatment Mental Health services Drug and Alcohol treatment Babies born to a mother with Minor Consent Medi-Cal are “Deemed Eligible” Maternal and Child Health Access
  17. 17. DENTI-CAL For Adults; What’s Left?Pregnant women can still get some preventiveservices,Denti-Cal Bulletin - Volume 25, Number 22, May 2009Emergency services are covered under the FederallyRequired Adult Dental Services (FRADS) listed in the aboveDenti-Cal Bulletin. Maternal and Child Health Access
  18. 18. Newborns – Deemed Eligibility“Deemed Eligible” If a baby is born to a mother on Medi-Cal, the baby is guaranteed Medi-Cal eligibility until his/her 1st Birthday without filling out a Medi-Cal application. To get the baby’s Medi-Cal (BIC) Card you can: Call the Eligibility Worker to report the baby’s birth, or Fax a Newborn Referral form to DPSS, or The baby can go through the CHDP Gateway. Maternal and Child Health Access
  19. 19. NEWBORN REFERRAL FORMWHERE CAN I GET THE FORM?  Some hospitals  Some clinics  MCHA - middle of the page at:  or  /MC%20330.pdfWHO FILLS IT OUT?  Doctor, Nurse, Advocate, Medi-Cal Eligibility Worker at Clinic, Mom, anyone can help Maternal and Child Health Access
  20. 20. Treatment Program (BCCTP)• The Breast and Cervical Cancer Treatment Program provides Medi-Cal coverage to individuals who have received a diagnosis of breast or cervical cancer.• Applicants must apply through a participating provider.• The income limit is 200% of the Federal Poverty Level.• U.S. Citizen and Qualified Immigrant women can obtain full scope Medi-Cal coverage through this program.
  21. 21. Healthy FamiliesHealthy Families is a state program that provides low-cost health insurance for many low-income children between the ages of 0-18 that do not qualify for free, full scope Medi-Cal.• There is a monthly cost of between $ 4.00 - $24.00, depending on the family’s income.• There are also $ 5.00 to $ 15.00 co-payments when receiving certain non-preventive health and dental services.• Children need to be U.S. citizens or legal permanent residents.
  22. 22. Kaiser Permanente Child HealthPlan• A program that provides health coverage for children between the ages of 0-18 who are not eligible for free cost Medi-Cal or Healthy Families.• This program requires a monthly payment of $8- $15 depending on you income.• There are small co-payments when receiving certain non preventive health and dental services.• Immigration status does not matter.• Program is currently open ONLY in some Northern California Counties.
  23. 23. California Kids• California Kids provides moderately priced preventative and primary health care benefits to children ages 2-18.• There is no income limit and immigration status doesn’t matter.• Monthly premiums are $49 per child• Co-pays range from $5 to $110• Emergency Room limit $1000 per year (provided for emergency’s only)• Does not cover hospitalization.
  24. 24. Access for Infants and Mothers AIM is Managed Care based Full coverage, except dental Restrictions:  A woman must apply before her 30th week of pregnancy.  Immigration status should not be an issue  Entering into a contract - continue to pay regardless of miscarriage – 1st trimester exception.  Baby can be enrolled in Healthy Families after birth, for first two years. (Even if income is between 250% and Child Health Access Maternal and 300% FPL), then reevaluated.
  25. 25. Child Health and Disability Prevention (CHDP)• The CHDP Program is a Federal and Statepreventive health care program that provides freehealth check-ups for many low-income infants,children, teens, and young adults age 0-21• CHDP helps identify and prevent healthproblem• Immigration status does not matter Maternal and Child Health Access
  26. 26. CHDP GATEWAY Is an online application process for Medi-Cal and Healthy Families that takes place during a regularly scheduled CHDP visit. Eligibility for this process is based on the child’s family size and income, as it is for the CHDP program. Eligible children will receive Temporary Full Scope Medi-Cal for the rest of the month and the following month. “ Deemed Eligible “ infants can use the gateway to get their BIC card; this is guaranteed Medi-Cal eligibility until his/her 1st Birthday Maternal and Child Health Access
  27. 27. California Children’s Services (CCS)• CCS is a statewide program that coordinates and pays for medical care and therapy services for children under 21 years of age with certain physically disabling conditions or diseases.• CCS provides:• Treatment, such as doctor services, hospital and surgical care, physical therapy and occupational therapy, laboratory tests, X-rays, orthopedic appliances and medical equipment.• Medical case management to help get special doctors and care for your child when medically necessary, and referral to other agencies, including public health nursing and regional centers.• A Medical Therapy Program (MTP), which can provide physical therapy and/or occupational therapy in public schools for children who are medically eligible.• Generally, there are no costs. Families who earn more than $40,000 per year may have small costs. All Healthy Families children are automatically eligible.
  28. 28. Family PACT• Family PACT provides family planning services, sexually transmitted disease diagnosis and treatment and gynecological exams to men and women who do not qualify for Medi-Cal.• Income must be at or below 200% FPL.• Immigration status does not count.• Women over 40 may also receive a screening mammogram.
  29. 29. Cancer Detection Program: “Every Woman Counts”• Formerly known as “BCEDP”• Includes mammograms for women over 50 and cervical cancer screening for women over 25 with income under 200% FPL.
  30. 30. WEBSITES THAT CAN HELP!Maternal and Child Health Access: www.mchaccess.orgHealth Consumer Alliance: www.healthconsumer.orgAll County Letters: byyear.aspxMedi-Cal .aspxDenti-Cal: Managed Care, Health Care px
  31. 31. Contact us!Maternal and Child Health Access 1111 W. 6th St., Fourth Floor Los Angeles, CA. 90017 (213) 749-4261 (213) 745-1040 fax Maternal and Child Health Access