Medi-Cal

Medi-Cal Eligibility and the 2017 SSA COLA and Medicare Premiums

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DHCS has issued guidance and provided resources on dealing with the 2017 SSA Cost of Living Adjustment (COLA) and the new Medicare premiums.  In 2017, the COLA is 3%.  Meanwhile, Part B premiums will be either $109 (current Medicare beneficiaries paying through SS deductions and low income Medicare beneficiaries who are not new to Medicare) or $134 (Medicare beneficiaries without the SS deduction or those who are new to Medicare).

For Medi-Cal only beneficiaries who do not pay the Part B premium (as well as for Pickle eligible individuals), the current SSA gross amount is multiplied by 1.003 for the 2017 gross SSA amount, then rounded down to the nearest dollar.  This amount is used for any relevant share of cost calculation.

For beneficiaries who have the Part B premium deducted from their SS benefit, the 2017 gross benefit is determined by adding the Part B premium to the net 2016 benefit, multiplying by the COLA, and rounding down to the next lower $0.10 increment.  From there, the 2017 Part B premium is subtracted and rounded down to the nearest dollar.  This amount will be used to determine share of cost.

For a Pickle applicant who pays the Part B premium through SS deduction, the 2017 gross benefit amount is calculated in the same manner as those with Part B deductions described above.  That amount is then multiplied by the relevant Pickle disregard multiplier, then rounded down to the nearest whole dollar to determine the 2017 disregard amount.  The disregard amount is then subtracted from the 2017 gross benefit amount.

Note that processing the 2017 COLA will not affect MAGI eligibility groups via CalHEERS.

DHCS ACWDL 17-02 (January 13, 2017).

County of Responsibility for Incarcerated Medi-Cal Beneficiaries

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DHCS issued clarification to the counties about how to deal with Medi-Cal Inmate Eligibility Program (MCIEP) applications for beneficiaries who reside in one county (County of Residency) but are incarcerated in a different county (County of Incarceration) in order to ensure proper billing to inmate claims to the correct county.  As of July 1, 2016, an inmate’s full scope and restricted scope inmate coverage can coexist in the MEDS system, along with the proper county of responsibility.

Under MCIEP, the county of incarceration is responsible for paying the non-federal portion of fee-for-service services provided to eligible inmates.  The county of incarceration is responsible for completing the eligibility determination for MCIEP.  Where the county receiving the MCIEP program is not the county of incarceration, the application will be forwarded to the county of responsibility.

DHCS MEDIL I 16-23 (December 23, 2016).

DHCS MEDIL I 16-23E (January 12, 2017).

Restoration of Acupuncture Services as a Medi-Cal Benefit

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As of July 1, 2016, the State has reinstated outpatient acupuncture services as a Medi-Cal managed care benefit.  Acupuncture will be covered as needed to prevent, modify, or alleviate the perception of severe, persistent chronic pain resulting from a generally recognized medical condition.  Services are limited to two sessions per month, though additional sessions may granted through medical necessity and prior authorization.

DHCS APL 16-015 (December 1, 2016).

Medi-Cal Coverage of Tobacco Prevention, Cessation Services

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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).

Access to Medi-Cal Services for Transgender Beneficiaries

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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).