New forms for your clients. A Request for a Welfare to Work Exemption (the 2186A) and a new Plan Rights and Responsibilities. Hopefully a little clearer than the prior forms.
Summaries of select CalWORKs, CalFresh, Health and Housing Regulations
Author: Amy Williams
ACWDL 06-08: New Limits and Disregards for the Aged and Disabled Federal Poverty Level Program For 2006 (2/15/06)
Provides the 2006 federal poverty level for the Medi-Cal Aged and Disabled program, which allows a higher disregard for couples due to SSI/SSP standards. Effective April 1, 2006, an individual’s effective income limit is $1047 ($817 + $230 standard disregard). From January 1 through March 31, 2006, a couple’s effective income limit is $1437 ($1070 + $367 standard disregard) from April 1 through the end of the year, the limit increases to $1472 ($1100 + 372 standard disregard). [Download]
ACWDL 06-07: New Federal Poverty Levels (2/10/06)
Provides the 2006 federal poverty levels for most of the Medi-Cal percentage programs. [Download]
ACWDL 06-06: New Federal Poverty Levels (2/10/06)
Provides the 2006 federal poverty levels for Medicare Savings Program beneficiaries. For one person, the limits for each MSP are as follows: QMB: $817/mo; SLMB: $980/mo; QI-1: $1103/mo. [Download]
Independent Medical Reviews – Experimental and Investigational Therapies – 28 C.C.R. § 1300.70.4
This regulation, effective July 2005, describes the requirements for a plan’s notice to its enrollee when denying coverage on the basis of the treatments’ experimental or investigational status, when it is appropriate to request an IMR for this reason, and the procedure for requesting an IMR. Notably, enrollees applying for IMR under this regulation are not required to participate in the health plan’s grievance system first. [Download]
Independent Medical Review System, 28 C.C.R. §1300.74.30
This regulation, which became effective in September 2005, provides a mechanism for health plan enrollees to challenge their plans’ denials of coverage. The regulation details how applications for Independent Medical Review should be submitted and what supporting materials may be included. It also explains that the IMR process is the exclusive forum for disputes about medical necessity, but allows plans to offer and use their own review process if the situation does not involve medical necessity.
The regulation affords the enrollee six months from receipt of the plan’s written response to the enrollee’s grievance to file the request for IMR. Applications cannot be denied due to lack of supporting documentation, and extensions will be approved if the delay was reasonable under the circumstances. Additionally, the DMHC must advise the enrollee of the most efficient means of completing an IMR application if it lacks necessary information. Additionally, this amended regulation allows Medi-Cal health plan enrollees to file for IMR as long as they have not yet presented the dispute for resolution through the Medi-Cal fair hearing process. Finally, it requires DMHC to notify the enrollee and the plan of the acceptance or rejection of the IMR application within seven calendar days of receipt (48 hours for an expedited review), and mandates that each reviewer issue a thorough written analysis of the decision in plain English. [Download]