Health Care Options for Foster Care, Adoptive and Kin-GAP Children

Policy

Medi-Cal MCP are OPTIONAL for FC, AAP and Kin-GAP recipients. Children in FC, AAP and Kin-GAP can be exempt from enrolling in managed care however, the decision to enroll is the responsibility of the child’s or youth’s LG, SW/PO, or the adoptive parent. While a child/youth is in a foster care home, the packet is mailed to the Foster Care Provider but the managed care option remains with the SW/PO or with the Non-Dependent NRLG. Managed Care information is sent to non-mandated recipients at various times since they have the option to enroll.

FC EW must clarify the available options if the child’s/youth caretaker/provider has questions.

Managed Care may be a better option for the child’s/youth’s medical care for various reasons such as but not limited to when the child/youth:

Is in a stable placement with a relative or guardian,
Easier access to medical care,
Other children in the home have managed care, and
To meet the child’s medical needs.

Upon removal from the home and placed in FC, there are some occasions when the child/youth is in or has been enrolled in a MCP. The most common instances are when:

The child/youth is on CalWORKs and MC and the is family enrolled in a health plan,
The child is an ICT in from another county and is still enrolled in that county’s health plan, or
The child has a residence address in a county with a COHS.

Managed Care and Two-Plan Models

Medi-Cal MCP provide health services to patients within a specific geographic area. Medi-Cal beneficiaries (clients) who enroll in a Medi-Cal MCP must seek medical care from a participating physician and cannot go outside the plan for medical care.

The DHCS has contracted with two MCPs to provide the County of Santa Clara’s Medi-Cal services with the Two-Plan Model. One contract is with a local initiative - a publicly sponsored health plan cooperatively developed by local government, clinics, hospitals, physicians and other providers that historically have served the Medi-Cal population in the county. The other contract, awarded through competitive bidding, is with a commercial plan.

Santa Clara County’s two managed care plans are:

Santa Clara Family Health Plan - Local Initiative.
Anthem Blue Cross of California - Commercial Plan.

Note: For more information regarding Managed Care Option for enrollment and changes refer to [“Managed Care, Health Care Options, and OHC,” page 13-1.]

Adding FC Providers, Kin-GAP Guardians and AAP parents to MEDS

Due to privacy rules, FC providers (including AAP and Kin-GAP) may not be able to enroll or disenroll a child in managed care. Managed Care may tell the provider that they cannot assist them because their name is not on the MEDS screen. The FC EW must update the Maintain Address Window in CalWIN with the provider’s name by adding either the Foster Parent, AAP parent/s or Kin-GAP legal guardian.

FC EW must follow the steps listed below:

Go to the Display Individual Demographic Summary window for the child or youth
From the Collect Individual Demographics Detail window select the “Individual Address” tab and the Collect Individual Address Detail window will display.
From the Collect Individual Address Detail window select the “Address”.
On the Maintain Address windowMaintain Address window enter the FC provider, Kin-GAP guardian or AAP parent(s) name in the Care of (c/o) field. Save and close

The FC EW must check MEDS in two working days to ensure the update is transmitted. When the information does not transmit a “Request for Online Transaction” (SCD 1296) must be completed and forwarded to the FC MTO for a manual transmission.

When completing the SCD 1296 the FC MTO must enter either the FC provider, Kin-GAP guardian’s or AAP parent/s name into MEDS on the 2nd field below the child's name as “C/O” on the [INQR] screen. The FC EW must check MEDS in two working days to ensure the new information is properly recorded.

Enrollment/Disenrollment

All Two-Plan Model enrollment and disenrollment functions are handled by the California Department of Health Services HCO contractor. The current HCO contractor is Maximus.

When the child’s or youth’s provider needs assistance selecting, enrolling or disenrolling from a plan the FC EW, FC Provider, AAP parents or LGs may:

Contact the HCO contractor at 1-800-430-4263, weekdays from 8 a.m. - 5 p.m. Assistance is available in a variety of languages.
If difficulties arise when trying to disenroll a FC, AAP or Kin-GAP child or youth from managed care, contact the Ombudsman’s office at (888) 452-8609.
- Note: Enrollees can make changes to plans by telephone or by completing a California State form which is “Medi-Cal Choice Form” (SA_0MM3495). This form is available from the HCO contractor or online at http://www.healthcareoptions.dhcs.ca.gov/HCOCSP/Enrollment/content/en/forms/SC_0MM3452.pdf.

Emergency Disenrollments

Most children or youth placed in foster care require emergency disenrollments from MCPs. When an emergency disenrollment from a MCP is needed for FC, AAP or Kin-GAP it must be processed within two working dates. Prior to submission the FC EW must ensure the following:

MEDS reflects current information (i.e., residential address and county code), and
MEDS must show active coverage for the child/youth.
- Note: When the FC EW is advised the child or youth has used their Medi-Cal card in the month they are attempting to disenroll, the disenrollment may fail. The FC EW must contact the Ombudsman’s office at (888) 452-8609 or wait until the following month to disenroll the child or youth.

The FC EW will complete the DHCS fillable form as follows:

Go to the DHCS website located at http://dhcs.ca.gov/mcombudsman and select the “Request for Change” - Online Fillable form (COUNTY STAFF USE ONLY):
When the form displays, enter the “Security Code”“Security Code”. An example of the Security Code is displayed below. The Security Code changes each time the fillable form is accessed. The Ombudsman Unit will display after the Security Code is entered.

The FC EW must complete the following:

Under Section A Your Contact Information:
- Name and Worker ID,
- Select the “43 Santa Clara”,
- Submitter type is either “Eligibility Worker or Foster Care Worker”,
- Provide Phone number with area code, and
- Provide FC EW’s e-mail address.
Under Section B Medi-Cal Member Information:
- Provide the child’s/youth’s SSN or CIN,
- Provide the child’s/youth’s FNAME, LNAME, and Date of Birth,
- Residential County, and
- Residential Zip Code.
Under Section C Request Type:
- Select “Expedite Plan Disenrollment Form”,
- Select “Medical Plan”, and
- Select “Dental Plan (when applicable).
Section D Services Rendered:
- Has the Member received Services with the current month “Yes or No”
- (select “No”),
- Is this a Foster Care Case “Yes”, and
- Additional Comments, provide any additional information such as Child/Youth is receiving Kin-GAP, or AAP assistance.

Prior to submitting the on-line form the FC EW must do a “Screen Print” and print the request, then Submit the completed On-line Form.

To confirm that the request has been processed by the MC Disenrollment Ombudsman, a confirmation e-mail will be sent to the FC EW to state the request was processed or denied. The FC EW must check the MEDS record to confirm that their request was processed.

The FC EW must print the e-mail along with the “Screen Print” and send the documents to imaging.
All actions taken must be documented in the CalSAWS journal, including the submission date and the MEDS validation.