California Health Reform Low Income Eligibility, Benefits

1
California Health Reform Low Income Eligibility,
Benefits Cost Sharing
Families USA Conference 2008 January 25, 2008

• Presented By Angela Gilliard, JD
• Legislative Advocate

1107 Ninth Street, Suite 801 Sacramento, CA
95814 [phone] ext 15 Agilliard_at_wclp.org
2
Childrens Coverage Effective July 1, 2009

• Expands Medi-Cal for all children up to 300
  Federal Poverty Level, (FPL) regardless of
  immigration status.
• Expands Healthy Families Program (HFP) from 250
  to 300 FPL.
• Maintains Current levels of cost sharing for
  families with incomes 250 FPL and below.
• Establishes HFP premiums for children with family
  incomes 250 to 300 FPL at 22-25 per month per
  child, with a maximum of 66-75 per month per
  family.
• Current budget proposal if adopted by the
  Legislature could require increase cost sharing
  for HFP enrollees.

3
Childrens Coverage Benefits and Delivery
Systems

• Medi-Cal children receive existing full-scope
  coverage through managed care, county organized
  health care system, or fee for services delivery
  systems
• Healthy Families Program children receive the
  existing comprehensive benefit package including
  dental and vision through a managed care delivery
  system

4
Adult Coverage Expansion CategoriesEffective
July 1, 2010

• Medicaid Expansion19 and 20 year olds with
  incomes 100 - 250 FPL.
• Medicaid Expansion Parents and Caretaker
  relatives 100 250 FPL.
• 1115 Waiver Expansion Childless adults under
  100 FPL.
• Employed adults with incomes 100 - 250 FPL,
  whose employer elected to pay a fee into the
  purchasing pool.

5
Medi-Cal Adult Expansion - Eligibility19 20 yr
olds and Parents Caretaker Relatives

• Net family income at or below 250 FPL.
• Utilizes FPL income deductions but not income
  disregards.
• They are not otherwise eligible for Medi-Cal.
• They would be eligible for full-scope Medi-Cal
  w/out a share of cost if they had a categorical
  linkage.
• They are citizens, nationals, or qualified aliens
  without regard to date of entry.
• Eligibility determination does not include an
  assets test.
• State will seek federal approval to waive the
  deprivation standard.

6
Medi-Cal Adult Benchmark Benefits 19 20 yr
olds and Parents and Caretaker Relatives

• Benefits will be provided through the California
  Cooperative Health Insurance Purchasing Program"
  or "Cal-CHIPP" the newly established statewide
  purchasing pool.
• Medi-Cal beneficiary with a net family income
  above 100 percent FPL will receive his or her
  benefits by means of a Cal-CHIPP Healthy Families
  Plan, a new benchmark package.
• Benchmark Package consist of covered services and
  benefits required under the Knox-Keene Health
  Care Service Plan Act of 1975 plus prescription
  drugs outpatient generic prescription drugs and
  brand name, as specified.
• Dental or vision benefits are not part of the
  benchmark package but may be made available
  through the purchasing pool

7
Childless Adults Expansion - Eligibility1115
Waiver

• California residents 21 years and older.
• Family income at or below 100 FPL
• Not otherwise eligible for the Medi-Cal Program
• They would be eligible for full-scope Medi-Cal
  without a share of cost if they had a categorical
  linkage.
• They are citizens, nationals, or qualified aliens
  without regard to date of entry.
• They are not offered employer-sponsored health
  care coverage.

8
Childless Adults1115 Waiver (contd)

• Utilizes the application requirements and the
  income methodology of the FPL programs for
  pregnant women and children, but not income
  disregards.
• Creates no right of entitlement.
• The individual shall be required to meet all of
  the minimum federal requirements necessary for
  federal claiming by furnishing all necessary
  information and providing all documentation.
• Except to the extent required by the terms of any
  applicable federal waiver, federal Medicaid
  rights, including the right to retroactive
  eligibility, do not apply to persons or services
  under this section.

9
Childless Adults Benefits1115 Waiver

• Adults with incomes below 100 FPL receive the
  benefit package equivalent to the purchasing
  pool, Knox Keene plus prescription drugs
  (generic), as specified.
• Specific services are excluded long-term care
  services, nursing home care, personal care
  services, in-home supportive services, and home-
  and community-based or other waiver services.
• No Dental or Vision.

10
Childless Adults Delivery Systems1115 Waiver -
Local Coverage Option (LCO)

• Establishes the LCO, a new delivery system in
  counties where public hospitals operate,
  approximately 15 counties.
• For three years, the LCO will be the exclusive
  delivery system for the childless adults waiver
  population.
• In year four individuals can opt out of the LCO
  system and in year five individuals will have the
  choice of LCO or other delivery systems available
  in the county.
• In counties without an LCO the delivery system
  will be either managed care or fee for services,
  depending upon the county.

11
Unemployed Childless AdultsEligibility

• Is a resident of California
• Is a citizen or national of the United States or
  a qualified alien without regard to date of
  entry.
• Is 19 years of age or older/not eligible for
  Medicare Parts A B .
• Has family income, less applicable deductions,
  greater than 100 of the FPL but less than or
  equal to 250 FPL.
• Is ineligible for the Medi-Cal program.
• Is not offered employer-sponsored health care
  coverage

12
Unemployed Childless AdultsBenefits

• Benefits will be provided through the California
  Cooperative Health Insurance Purchasing Program"
  or "Cal-CHIPP" the newly established statewide
  purchasing pool.
• Benchmark Package consist of covered services and
  benefits required under the Knox-Keene Health
  Care Service Plan Act of 1975 plus prescription
  drugs outpatient generic prescription drugs and
  brand name, as specified.
• Dental or vision benefits are not part of the
  benchmark package but may be made available
  through the purchasing pool.

13
Cost Sharing250 Percent FPL and Below

• 150 FPL and below Zero premium and out of pocket
  cost.
• 150 FPL 250 premiums shall not exceed 5
  percent of the family income net of applicable
  deductions.
• No cap on out-of-pocket.
• State to seek waiver of federal cost sharing
  requirements.

14
Individual MandateExemptions Affordability

• On and after July 1, 2010, every California
  resident is required to be enrolled in and
  maintain at least minimum creditable coverage,
  unless exempt as determined by the Managed Risk
  Medical Insurance Board (MRMIB).
• An individual may be exempt if the purchase of
  minimum creditable coverage would constitute an
  undue hardship for that individual.
• An individual may be exempt if the person or
  family has an income at or below 250 FPL, and
  the persons or familys share of the premium for
  minimum creditable coverage exceeds 5 percent of
  his or her familys income.

15
Medi-Cal Program Changes

• Eliminates the Assets Test.
• Replaces the Mid-Year Status Reporting
  Requirement with a Semiannual Address
  Verification Requirement.
• Increase in Provider Rates.

16
Premium Assistance

• Legislature to establish mechanisms by which the
  state may defray the costs of an enrollee's
  public program participation. The state's efforts
  may include, but shall not be limited to,
  creating mechanisms to take advantage of other
  opportunities for coverage available to that
  enrollee, to access nonstate resources available
  to fund care for that enrollee, or other
  mechanisms to minimize state costs.
• The Department of Health Care Services is
  required to assess the fiscal ramifications and
  administrative feasibility of potential options,
  and determine the requirements that best
  effectuate and implement this section.

17
Western Center on Law and PovertyA voice for
the disadvantaged

• Contact Angela M. Gilliard, JD
• 1107 Ninth Street, Suite 801
• Sacramento, CA 95814
• [phone] ext 15
• [phone] fax
• [phone] cell
• E-mail Agilliard_at_wclp.org
• Website www.wclp.org