Medi-Cal

DHCS MMCD APL 14-011: Interim Policy for the Provision of Behavioral Health Treatment Coverage for Children Diagnosed with Autism Spectrum Disorder (9/15/14)

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Following the release of federal guidance on the matter, DHCS issued interim policy guidance on the provision of BHT services to Medi-Cal beneficiaries 0-21 diagnosed with Autism spectrum disorder.  Under Federal law, states are required to provide coverage to EPDST eligible individuals for any covered service determined to be medically necessary to correct or ameliorate any physical or behavioral conditions.  DHCS intends to include BHT services, including Applied Behavioral Analysis (ABA), as a covered benefit for individuals under 21 with ASD.

The letter defines BHT and provides 12 months of continuity of care for those with ASD getting services outside a Regional Center.  Medi-Cal beneficiaries who spent out of pocket for BHT services from licensed providers between 7/7/14 and 9/14/14 are eligible for reimbursement under Conlan.  The letter also sets out eligibility criteria for BHT services, covered services, limitations, treatment plans and exclusions

Finally, the letter includes a beneficiary notice from DHCS as well as guidance from CMS dated 7/7/14.

DHCS ACWDL 14-31: 2014 Alternate Renewal Policy Letter (9/11/14)

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DHCS issued this letter about implementing Medi-Cal annual redeterminations in 2014, a process meant to convert some beneficiaries from pre-ACA Medi-Cal to MAGI Medi-Cal.

At the 2014 annual redetermination, counties will try to convert beneficiaries to MAGI by sending a RFTHI form at least 60 days prior to the redetermination date.  If a beneficiary reports certain changes (e.g., size of household, categorical eligibility), counties will complete the annual redetermination process per previous guidance.  If there are no such cases, the county will just renew without a CalHEERS transaction.  Counties must also review Share of Cost cases for MAGI Medi-Cal.  Those ineligible will be granted APTC eligibility per Covered California requirements for special enrollment periods.

For MAGI populations, RFTHI information must be provided but not necessarily in paper form.  The information will be entered into SAWS for the next renewal.  If a beneficiary fails to respond to the RFTHI, counties must try to contact the beneficiary to get this information.  If after these attempts the beneficiary still does not respond, and if the information is not available ex parte, then the county shall send a timely NOA to discontinue benefits.  There is a 90 day cure period.

ACWDL 14-29: Interim Non-Payment of Premium (NPP) Processes for the Optional Targeted Low-Income Children Program (August 8, 2014)

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DHCS issued guidelines for counties to proceed on discontinuing Optional Targeted Low-Income Children Program cases on the basis of non-payment of premiums (NPP).  The counties have experienced a backlog of NPPs that should have been terminated.  DHCS has determined that premium payment status is an eligibility condition, so there are no redetermination requirements unless there’s a reported change in circumstances.

For those on aid codes H3 and H5, NPPs will be sent a timely NOA and terminated accordingly.  Beneficiaries must pay past-due premiums before termination to preserve eligibility.  If a beneficiary pays past-due premiums after discontinuance but within 30 days, coverage can be reinstated without a break in coverage.  After 30 days, the beneficiary will need to reapply.  Those on aid code 5D will proceed similarly.

The letter includes sample discontinuance language for NOAs.

DHCS MEDIL I 14-45: Clarification of Medi-Cal Eligibility for Deferred Action for Childhood Arrivals (DACA) (August 6, 2014)

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DHCS has issued this letter to explain that those individuals granted deferred action status through DACA are eligible for full-scope state-funded Medi-Cal as PRUCOLs.  Individuals must meet all other Medi-Cal eligibility requirements.  DACA status will be verified through the federal data hub, SAVE, or by the applicant.  Counties will need to grant full scope through an eligibility workaround.

DHCS MEDIL I 14-44: Processing State Residency Verifications on Pending and Current Applications in the California Health Care Eligibility, Enrollment, and Retention System (CalHEERS) and the Statewide Automated Welfare System (SAWS) (8/1/14)

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DHCS provided this updated information on processing state residency verifications for pending and current applications through SAWS and CalHEERS.  Previously, the paper verification of state residency status had been suspended until 8/1/14.  That suspension is now extended until further notice.  Attestation by verbal contact or listing of California address is sufficient.