As of 9/26/16, CalHEERS implemented a change to introduce the Carry Forward Status to reduce gaps in coverage while consumers transition between Covered California and Medi-Cal pending county eligibility determinations.  The flag in CalHEERS triggers a new notice to inform individuals of CFS.

Previously, DHCS and counties used Express Lane aid codes in a batch process pending county final eligibility determinations during the Covered California annual redetermination or change in circumstances reporting.  This, however, could result in a gap in coverage when, during the final eligibility determination, a person was found not to be eligible for Medi-Cal and was referred back to Covered California without retroactive coverage.  This process has been discontinued.

Now, CalHEERS will automatically place individuals into CFS when redetermination of eligibility results in potential MAGI Medi-Cal eligibility.  The individual will continue with Covered California coverage until the county completes a full Medi-Cal determination.  CFS will apply when a consumer reports a change that results in MAGI eligibility, when a consumer is determined MAGI eligible during the renewal period, when a consumer reports a change after the renewal is complete, and when a consumer reports a change after Covered CA eligibility has gone into effect.

During the CFS process, counties must treat cases as a new application for benefits.  Counties are required to send notices to affected beneficiaries.  Applicants transitioning from Covered CA to Medi-Cal may be eligible for the three-month retroactive Medi-Cal coverage period.

DHCS ACWDL 17-07 (February 24, 2017).

Between 10/1/16 and 6/30/17, CalHEERS will assign MCAP-eligible pregnant women into aid code 0G.  This will allow MCAP eligibles to receive full-scope Medi-Cal services through fee for service until the end of their post-partum period.

MCAP eligible pregnant women are those with MAGI incomes between 213 and 322 percent FPL.  Prior to 10/1/16, these women were enrolled in contracted health plans with no copays or deductibles.  Those still in health plans will continue receiving services that way until the end of the month of the 60th day following the end of their pregnancy.  New MCAP beneficiaries are being enrolled in FFS.

DHCS MEDIL I 17-03 (February 7, 2017).

DHCS has issued guidance on how Medi-Cal applications should be assessed during eligibility determinations.  In this hierarchy, an application (which includes reporting change of circumstance, annual redetermination, and initial screening) should be determined by progressing through the chain of programs.  Workers must determine eligibility at each group with potential eligibility, and the applicant must be placed into the program that is most beneficial.

First, the county must look at Mega Mandatory groups.  These are programs that are categorical or mandatory under federal law, or the programs where eligibility for Medi-Cal is linked to eligibility for another program.  If an applicant is not eligible here, the next check is with the MAGI programs, including MCAP and CCHIP.  Next would the the Non-MAGI Optional Categorical programs, followed by Medically Needy/Medically Indigent programs, and Non-MAGI State Only programs.

If an applicant is not eligible for any Medi-Cal program at the MAGI stage, the applicant should be evaluated for APTC eligibility.  Pregnant applicants have the option to enroll in either MCAP or Covered California, and may move from Covered California to MCAP during pregnancy and the post-partum period.  Counties must evaluate all Medicare-eligible applicants for Medicare Savings Programs.

DHCS ACWDL 17-03 (January 25, 2017).

DHCS issued an All Plan Letter providing instructions on what tobacco prevention and cessation services should be covered by managed care plans.  DHCS points to the US Preventive Services Task Force in setting coverage requirements for both pregnant and non-pregnant beneficiaries, including:

1. Assessments of tobacco use for all adolescent and adult beneficiaries
2. FDA-approved medications for non-pregnant adults, at least one of which must be available without prior authorization requirements
3. Counseling services for tobacco user beneficiaries of any age
4. Tailored counseling services for pregnant tobacco users
5. Prevention of tobacco use for children and adolescents
6. Training of managed care-contracted providers
7. Systems to identify tobacco users for assessment and reporting purposes
8. Systems to track utilization of tobacco cessation treatment

APL 16-014 (November 30, 2016).

DHCS updated its guidance to managed care plans regarding covered services for transgender beneficiaries.  Under the state Insurance Gender Nondiscrimination Act and the federal Affordable Care Act, plans cannot discriminate in its health care benefits against individuals based on gender, including gender identity and expression.  Services that are available based on gender should not be denied or limited based on a beneficiary’s gender assigned at birth.  Federal regulations also prohibit categorical exclusions or limitations for services related to gender transition.

The DHCS All Plan Letter reminded plans that they must cover medically necessary services (services which are reasonable and necessary to protect life, to prevent significant illess or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury) and reconstructive surgery (surgery performed to correct or repair abnormal structures of the body . . . to create a normal appearance to the extent possible).  Plans do not have to cover cosmetic surgery (surgery that is performed to alter or reshape normal structures of the body in order to improve appearance).

The letter prescribes the use of nationally recognized guidelines to review requested services, specifically naming the WPATH Standards of Care for the treatment of gender dysphoria.  Identified core services for the treatment of gender dysphoria include behavioral health services, hormone therapy, psychotherapy, and a variety of surgical procedures to conform primary and secondary gender characteristics with a person’s gender identity.

Evaluation of requested services must be made by a qualified and licensed mental health professional and the treating provider in collaboration with a primary care provider.  Plans must provide in a timely manner all medically necessary services that are otherwise available to non-transgender beneficiaries.  Plan decisions are subject to review through the plan appeal and grievance process, the State Fair Hearing process, and/or the DMHC IMR process.

DHCS APL 16-013 (October 6, 2016).