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
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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]
Medi-Cal Emergency Regulation R-32-00E – Estate Recovery (March 23, 2005).
Have a low-income client who is an heir on the receiving end of the estate of a deceased Medi-Cal beneficiary, but the estate is subject to repayment for the deceased person’s Medi-Cal costs? That client, my friend, may qualify for a “substantial hardship” waiver of repayment due from the estate because of the surviving heir’s own financial hardship. How so? Read all about it in the new CDHS emergency regulation (see, generally, 22 C.C.R. § 50963. (The emergency reg is open for comment through May 27, 2005). To make it even easier, download a copy of the hardship waiver form itself.
DHS ACL 04-31 – Questions and Answers on SB 87 Medi-Cal Redetermination Process for Discontinued SSI/SSP Beneficiaries as Ordered in Craig v. Bonta (October 22, 2004)
Clarifies the policy directives in ACL 03-24. Clarifies that if the SSA discontinuance reason is “no longer disabled” the beneficiary can still allege a disability but it must be a disability different from the disability under which the SSI/SSP was granted. Discusses ongoing eligibility for Personal Care Services (PCS) and In Home Supportive Services (IHSS) during redetermination. [Download]