Directs counties how to reinstate eligibility for Qualified Medicare Beneficiary Program (QMB) cases that are erroneously discontinued through no fault of the beneficiary. Eligibility can be reinstated for months when the beneficiary should have been receiving benefits. Medi-Cal must retroactively pay for all past-due Medicare premiums. [Download]
Summaries of select CalWORKs, CalFresh, Health and Housing Regulations
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]
Block Transfer Filings, 28 C.C.R. § 1300.67.1.3
This regulation, which became effective in August of 2005, establishes standards for redirecting enrollees to one or more contracting providers when their health plan terminates or does not renew the contract with their provider group or hospital. The regulation applies to transfers of 2,000 or more enrollees. Among other provisions, it requires health plans to file with the Department of Managed Health Care, no later than 75 days before the termination, a detailed transition plan to ensure continuity of care for enrollees. It also requires plans to mail notices of the transfer to affected enrollees at least 60 days prior to the proposed termination date. [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]
ACIN I-04-06 Quality Assurance (QA) Initiative Fraud Detection And Prevention Activities (January 23, 2006)
This ACIN provides information on how counties can/should be implementing the anti-fraud provisions in SB 1104 and existing rules to prevent and pursue IHSS fraud. Just so you know what the counties will be up to. … Includes ability to collect non-fraudulent overpayments against the chore provider. [Download]
HUD PIH Notice 2006-5(HA) – Implementation of the 2006 HUD Appropriations Act (Public Law 109-115); Funding Provisions for the Housing Choice Voucher Program (January 13, 2006)
“This Notice implements the Housing Choice Voucher (HCV) program funding provisions resulting from enactment of the Federal Fiscal Year (FFY) 2006 HUD Appropriations Act … signed into law on November 30, 2005.” Among other things, this Notice describes the method by which HUD will allocate funds for FFY 2006 to public housing authorities (PHAs) consistent with the HUD Appropriations Act. Most important for housing advocates and PHA directors and staff is the provision permitting a PHA to apply to HUD for funds to adjust (increase) its baseline funding allocation. Congress has appropriated $45 million dollars for such adjustments. The adjustments are available only to (1) adjust allocations for Calendar Year 2005 renewal funding that was based on leasing and cost data averaged for the months of May, June and July of 2004 which, due to temporarily low leasing levels during these months did not accurately reflect actual leasing levels and costs for such period; and (2) adjust allocations for PHAs that experienced a significant increase in renewal costs from unforeseen circumstances or portability.
Is that crystal clear? The bottom line is that the application deadline for adjustment funds is close of business (5:00 p.m. EST) January 31, 2006. So, advocates and PHAs in jurisdictions that may be eligible should take note and act quickly. Surprisingly, the application form which is attached to this Notice is short and simple. [Download]