Medi Cal Eligibility and Procedures

my name is Mara delle Santos and I'm a medical program specialist with Alameda County social services I'm not an eligibility worker so what I'm going to do today is just present you with just a medical overview it's it appears that you know some of the speakers have already may address the issues in.

Regards to defining what medical is all about what affordable healthcare is all about what the Obama health care is all about Medicare in terms of the payment what Medicare pays why doesn't pay then we have legal aid here who also assist with the Appeals issues or hearing rights that you may have also and those hearing rights are also available in the.

Back of your notices of action when you apply for medical programs okay so I may may may go through just briefly or just skip the different sections that may already have been addressed additionally if nothing else I do have some good resource numbers that you can contact in regards to if you have any type of billing issues or questions as to.

Whether a procedure may be paid or not under the Medicare program Alameda County Social Services when you when you deal with our agency we don't deal with billing issues we do deal only with the medical aspect of eligibility okay so when you do speak to worker and you try to ask them questions about billing issues they are not in the position to.

Answer those questions because they are not they're not familiar with the billing codes or any billing eligibility aspect so they're okay so let me go through again this is what medi-cal is all about it's a free or low cost coverage for California residents as mentioned before in 2010 the federal government enacted the Patient.

Protection Affordable Health Care also noted also known as health care reform of bama care we work closely in conjunction with covered California which is the health care exchange the county's assist with person's eligibility for medical and any subsidies what is medical the medical expansion so California approved the.

Medicaid expansion which is medical in California for childless non-disabled adults between the ages of 19 to 64 years old there was a time when in order to qualify for the medical program you had to be aged blind or disabled or be over 65 now because of the expansion of the Medicaid program as long as your income is below 138 percent.

FPL which is the federal poverty level and you qualify for zero share of cosmetic health I've also attached a chart at the back of your handout that you have so if you need to know more about what is the 138 percent FPL see it also applies to the former foster care youth up to age 26 from any state now a lot of you may be from may not may have.

Heard the word Magi and trying to figure out what is Magi so Magi is that determined the definition for modified adjusted gross income okay and it's a way of doing budgeting in the Medicare program it's not a new Medicare program and there's no asset test under the Magi determination it's all based on income again 138 percent income okay so the.

Asset test is eliminated so under that program it doesn't matter what you have anymore it's what your income it's all based on income and and again these are the criteria liberal population 19 to 64 children under 19 and pregnant women so these are the household composition usually when when you apply for medical under the Magi household composition.

There are three categories that we look at we look at the tax filer if you're not claimed as a tax dependent tax dependents and knocking down tax file non tax filers in California we need to be able to provide proof of residency and the citizenship probably the recent legal immigrants is usually immigration.

Status usually verified through the federal data hub now this is non Magi medical when we refer to non Magi medical we're referring to if you're aged 65 and older it's a different criteria for determining eligibility under this program so this programs for the aged blind and disabled and for residents of a long-term care facility.

In terms of under this program there is an asset test in terms of unlike the not unlike the Magi program our site asset test is eliminated but with this there is a limit so for just an example for regular medical for a family budget of one your income your resources cannot exceed two thousand for a family budget of two it cannot exceed three thousand.

And any additional 150 for each additional member okay personal property referred to as cash bank accounts credit union stocks bonds cash or under life insurance policy for 1k and in terms of the life insurance policies if the policy is not in your name but you are the better and finisher beneficiary and someone else is the owner of that policy.

That's you don't have to disclose that to our agency because that's irrelevant it's only if the policy is also in your name as well as you're the owner your primary resident is exempt regardless of value as well as the your vehicle if you do have other properties it's exempt only if the value is six thousand or less and the net income received from it.

Is six percent or more from the net market value again for this if the eligibility worker will be the one to make that determination because they have a separate form that needs to be completed to make that assessment so that's a discussion we would have with your worker these are the in terms of income have listed we refer to as.

Wages for self-employment and in-kind under income we've listed social security benefits unemployment state disability veteran benefits child support alimony retirement pension income eating kind sheriff cause this is just a typical example of how a share of course is calculated for example if your gross income is $1,100 and you're.

Working we allow a $90 deduction it's a standard deduction so you're not near non-exempt income now becomes 1010 dollars okay the maintenance need for one person is only $600 at this time it has not changed in several years so then your share of cost will be four hundred and ten dollars okay but you're four hundred ten dollars is a monthly share.

Of costs however it's not something that you have to pay it's not a monthly premium as noted when there is a share of course the medical beneficiary has to pay at out-of-pocket expenses to me the share of cost before medical pays they share of course is to be met in the month in which services are provided it is not a monthly premium so as an.

Example if your bill is three hundred dollars for example and your share of cost is four hundred and ten dollars you do not pay the four hundred ten dollars because your bill is only three hundred dollars okay and just a note if you have any unpaid medical bills to do you can also use that to decrease your current or future share of cost its which is.

Referred to as hunt vs. Kaiser these are just additional deductions that's listed also in your handout that we allow for the aged blind or disabled twenty percent twenty dollars any income deduction sixty five and a half of earned income and health insurance premiums I just on the special programs just a.

Little background it's limited to coverage to life sustaining medical treatment you're of course you're required to pay a percentage of the treatment as indicated earlier and it's limited to individuals in need of kidney dialysis or our parental hyper elimination treatment also known as TPM we also it also targets our children.

Program the Quimby program qualified Medicare beneficiary which pays for your Medicare premium oftentimes if you are on receipt you have Medicare Part A and you're seeking to for assistance to pay for your Part B premium you would apply through our agency to see whether you qualify for the Part B and if you don't qualify for Part B through that way we.

Have the slim B program which is the specified low-income beneficiary so just because you're on SSI yourself should apply through our agency for the Quimby program the qualified Medicare beneficiary program to see if you qualify for us to be able to assist you to pay that premium okay we have also qualified working disabled individual.

Program and we have the two hundred fifty percent working disabled program again these are also again other the TPN programs we have the tuberculosis program for the special medical programs under dialysis or TPN as stated earlier you have to be able to meet all this criteria to be eligible for the program these are also supplement.

Under the eligibility requirement the first 40,000 of the fair market value of applicants or beneficiaries home is usually exempt so there are certain criterias also to qualify for through the medical program and for the Medicare application you must apply for Medicare within 10 days of applying for one of the special programs do we offer to our.

Agency resources you can apply for the Medicare program via covered California by mail or through social services my benefits Colwyn org you can go in person or by mail at Alameda County social services and I've also noted the the 800 number for covered California and these are the different offices that that's available we have the East Point.

Sufficiency Center the Livermore office even the Hayward office the North Oakland office the enterprise office and the Fremont office and they are now also open between the hours of 12:00 and 1:00 okay so it's open from 8 to 5 o'clock and this is a very important number that I think that you all should make sure that you have this handy this is the.

Billing department in Sacramento when you call this number it's nine one six six three six one nine eight zero what this number does is if you say you were to receive a rejection or from a provider saying that it's not your your prescription that you're seeking or the service that you're seeking is not being paid or their no medical program you.

Would need to call this number and they will explain to you why or if even the procedure code that's being used is the correct one make sure that when you do call that you provide the national drug code or procedure code obtained from your pharmacy or the provider okay so this is one of the very good numbers to make sure you have handy because.

Oftentimes we receive calls stating that it's not being paid for your bill healthcare option is another number to have handy when you're approved for the medical program you're usually given an option to select a healthcare plan on the whether it be Alameda Alliance Blue Cross Blue Shield that's a number you would have to call to make that plan.

Selection it's not done through our agency this is the federal poverty level chart that I was referring to it's also in your handout I know it's it's it's small but it's in it's in your handout and you can't read it there think okay if you need a bigger version I can also provide that to you okay and this is the explanation of the different categories.

Where do you find that just gross income when you're doing the Magi determination it's on line four on form 1040ez 1040 a 921 and form 1040 937 and again these are just common terms that we use federal poverty level legal permanent resident modified adjusted gross income the exchange when it is calheers retention center certified enrollment.

Entities and counselors and that's it you

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