Reminds counties that, pursuant to the Lynch v. Rank lawsuit, every potentially eligible Pickle person must receive a Pickle Medi-Cal notice for three consecutive years. The letter also announces that individuals listed during years previous to the most recent three will be dropped from the Pickle Tickler report and a year’s worth of ineligibles will be purged each year. Lynch also requires that each person on the Pickle Tickler listing who has an active Medi-Cal case or who brings the Tickler notice into the county welfare department to apply under the Pickle Amendment shall have an eligibility determination completed.[Download]
Summaries of select CalWORKs, CalFresh, Health and Housing Regulations
ACWDL 05-28: Medi-Cal Changes Due to a Property Change in the SSI program (8/29/05)
Effective April 1, 2005, all Medi-Cal programs that use SSI property rules (Pickle, Disabled Adult Child, Disabled Widow(er), and 250% Working Disabled) are to adopt the following changes:
· The definitions of “Household goods” and “personal effects” have been broadened and, regardless of their dollar value, no longer count as resources.
· The $500 limit for items of unusual value has been eliminated. [Download]
ACWDL 05-24: Processing Qualified Medicare Beneficiary Cases When Eligibility Has been Erroneously Discontinued (8/5/05)
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]
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]