Medi-Cal

Hierarchy of Eligibility Determinations for Medi-Cal Programs

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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).

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).