Organ Transplant Anti-Rejection Medication Program

Assembly Bill (AB) 2352, Chapter 676, Statutes of 2010 added section 14132.70 to the Welfare and Institutions Code to allow MC recipients to remain eligible to receive coverage for anti-rejection medications for up to two years after a transplant, unless the he/she becomes eligible for Medicare or private health insurance that covers the anti-rejection medications.

Eligibility Requirements

In order to be eligible for this program, the client must meet at least one of the following criteria:

Had an organ transplant within two years and is losing MC and/or California Children’s Services (CCS) AND does not have Medicare or private health insurance that covers anti-rejection medications, OR
Had an organ transplant within two years and is only eligible for restricted scope MC, is not on CCS, AND does not have Medicare or private health insurance that covers anti-rejection medications.
- Note: No verification is required as to who paid for the organ transplant, as the payer is not relevant to eligibility for this program.
There are no income, property, or residency/citizenship requirements for this program regardless of their living arrangements or with whom they reside.
An annual redetermination and/or Midyear Status Report is not required. Clients will remain on this program for up to two years from the most recent organ transplant, unless they obtain Medicare or private health insurance that includes the anti-rejection medication.
- Note: A Redetermination due to change in circumstances (i.e., Medicare, private health insurance, move out of state, eligibility for another MC program or death) is still required.

Identifying Eligible Beneficiaries

The Department of Health Care Services (DHCS) will research the claims data and identify the beneficiaries who have had an organ transplant paid by MC and will send an informing notice to advise them of the new program.

DHCS will send a list of organ transplant beneficiaries to each county. These cases must be flagged to determine eligibility for this program before the client is discontinued by entering a Special Indicator.

If the client is not on the DHCS list, but indicates on the MC 210 RV or states verbally that he/she received an organ transplant, the EW must request a note from the treating physician on letterhead with the National Provider Identifier (NPI) stating that the individual had an organ transplant and the date of the transplant.

Eligibility Determination

When a client is no longer eligible for MC, the SB 87 process must be completed to determine if eligibility exists for another MC program. If the individual is not eligible and has had an organ transplant, he/she must be placed in this program. A ten-day NOA is required.
Undocumented children who are eligible for the California Childrens Services (CCS) program may be eligible for the anti-rejection medications program if they meet all the criteria (within two years of transplant). CCS only pays for the organ transplant and anti-rejection medication until the child ages out of CCS.
There may be other exceptions where a individual on restricted MC has received a transplant and MC does not pay for the anti-rejection medication. These beneficiaries should be placed in this program.
If the client has private health insurance, the EW must determine whether the insurance covers the medication. If the client states that the medication is not covered, verification must be provided. Verification can include the following:
- Summary of benefits showing anti-rejection medications are not covered.
- Letter from the insurance company stating the medications are not covered.
- Documentation that the transplant and/or related benefits are in a period of exclusion.
- Documentation showing the client has exhausted his/her lifetime limit on all benefits under the plan.
- Documentation showing the client’s coverage or his/her annual benefits for treatment of the organ transplant have been exhausted.
- Any other documentation that states anti-rejections medications are not covered.

Notices of Action

The Following Notices of Action (NOAs) are used for this program:

“Approval For Organ Transplant Anti-Rejection Medication Program” (MC 378). The NOA must include the time period for which the individual is eligible.
“Discontinuance For Organ Transplant Anti-Rejection Medication Program” (MC 379).

MEDS Transactions

Aid Code 77 provides State-only restricted scope MC coverage with no share of cost (SOC) for organ transplant anti-rejection medications, for up to two years following an organ transplant, to individuals who have lost regular full scope MC or are on restricted scope MC. Aid Code 77 does not cover physicians’ office visits.

An online MEDS Transaction is required to place the individual in Aid Code 77. A termination date is required. The termination date will be two years from the most recent transplant date, regardless of when they become eligible for the program.

Example Example individual had an organ transplant on April 1, 2010 and found eligible for Aid Code 77 on March 1, 2011. The termination date is March 31, 2012.

Note: An EW 20 transaction with an ESAC for closed eligibility must be sent to limit the services up to 24 months. If the transaction covers more than 24 months, a MED Alert 1094 [Displayed Data Elements Contain Conflicting Information Pre-Rej*] will be generated.

MEDS Alerts

There are two MEDS alerts that will be generated when Medicare or other health insurance is obtained by the individual:

ALERT 9061 - MEDICARE ELIGIBLE – COUNTY AID CODE TERMINATION NEEDED - URGENT
1. The criteria for generating this alert will be any establishment of pending eligibility in the Medicare status Part A/B and any pending eligibility in the Medicare Status – Part D.
ALERT 9062 - POSITIVE OHC REPORTED – COUNTY AID REEVALUATION NEEDED - URGENT
1. The criteria for generating this alert will be the establishment of other health coverage on the MEDS record in the current OHC field.