94 adult systems of care. 95 general healthcare for adults there are fewer healthcare programs for...
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Adult Systems of Care
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General Healthcare for Adults
There are fewer healthcare programs for adults than for children
Most are for adults with disabilities or Pregnant women
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Medicaid (Medi-Cal)
California’s Medicaid program
Health insurance for some low-income individuals
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Fee for Service Medi-Cal
Go to any doctor who accepts Medi-Cal Don’t need a referral to see
a specialist
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Eligibility for Fee for Service Medi-Cal
People who receive SSI Most adults aren’t eligible for
this
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Medi-Cal Managed Care
Most common kind of Medi-Cal
For most adults this is your only choice
Primary care provider • gatekeeper
• need referral to see a specialist
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Medi-Cal Managed Care
Different Plans Los Angeles
• LA Care• HealthNet
Orange County• Cal Optima
• All Medi-Cal programs are managed care
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Automatically Qualify for Medi-Cal if …
You receive cash benefits from Supplemental Security Income /
State Supplementary Program (SSI/SSP).
California Work Opportunity and Responsibility to Kids Program (CalWORKs).
Refugee Cash Assistance (RCA).
In-Home Supportive Services (IHSS).
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You may also be eligible if you are
65 years of age or older. Blind or disabled, even if you are working receiving care in a skilled or intermediate
care facility. Pregnant have certain chronic conditions such as
tuberculosis or kidney dialysis. And other exceptions
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Share of Cost Medi-Cal
For people with disabilities who make too much money for regular Medi-Cal
pay a certain amount (share of cost) each month that you receive medical care before Medi-Cal begins to pay
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Eligibility for Medi-Cal
Income
Few resources
United States Citizen or documented resident
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Important Points about Medi-Cal
There are many ways to qualify for Medi-Cal An adult with a disability may qualify
even if the rest of the family doesn’t It can be very confusing to figure
out if you qualify.
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Important Points about Medi-Cal
You can get help with things like finding out if you are eligible, filling out applications or problems
at places like the Consumer Health Center of Los Angeles
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Denti-Cal
Program for dental care. Provides
regular cleaning and check-ups
needed dental work Full dentures
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Eligibility for Denti-Cal
Eligible for Medi-Cal
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Important points about Denti-Cal
California provides Denti-Cal services for adults
You can receive a list of dentists who accept Denti-Cal from CHDP
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Medicare
A federal health insurance program for: Seniors over age 65 People under age 65 who
• Are disabled and eligible for Social Security Disability Income (SSDI)
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Medicare
Not a comprehensive program Doesn’t pay for
• routine physicals, • hearing aids, • eyeglasses, • prescription drugs (limited
payment), or • long-term care at home or in a
nursing home
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Medicare
Medicare is not free You get Part A
(Hospital Insurance) when you enroll
But you must pay extra to get Part B (Medical Insurance)
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Eligibility United States Citizen or
documented resident and Seniors over age 65, or
Has worked at least 10 years at a job that pays into Medicare
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Eligibility People under age 65
who Are disabled eligible for Social
Security Disability Income (SSDI)
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Adult Programs for Special Populations
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Aged, Blind & Disabled (ABD) Program Only for people
who are Seniors - Over 65
or Blind or Disabled
And make too much money to qualify for SSI
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250% Working Disabled Medi-Cal Program Special Medi-Cal
program for adults with disabilities who are working but still need health coverage
Monthly premium
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Medi-Cal and Medicare (dual eligibility)
Can qualify for both Medi-Cal and Medicare
Medi-Cal may pay Medicare HMO fees
May have a share of cost before Medi-Cal pays
+
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Genetic Health Prevention Program? (GHPP)
State program for people 21 and older some genetic diseases
medical case management and pays the medical and dental costs
Some people under age 21
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County Department of Mental Health (DMH)
care for adults with Serious Mental Illness (SMI).
Examples of these are severe depression or bi-polar disorder.
not for people with developmental disabilities or substance abuse
unless they also have a SMI.
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Mental Health Programs
Care can include • therapy, • medication, • hospitalization
and • other services
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Mental Health Programs
Mental Health services who don’t have a SMIMedi-Cal, Private pay
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Access for Infants and Mothers (AIM) Program
AIM provides low-cost health coverage for pregnant women and their newborns (ages 0-2). Woman – to 60 days after the
pregnancy has ended. The newborn- up to second
birthday.
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Other Related Programs
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IHSS
An alternative to out-of-home care, nursing homes or
board and care facilities
Two Types Residual program Personal Care
Services Program (PCSP)
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IHSS
An alternative to out-of-home care,nursing homes or board and care
facilities Services can be provided by
a spouse or someone who isn’t related to you
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Residual Program
An alternative to out-of-home care,nursing homes or board and care
facilities For people
with disabilities (including blindness)Who don’t need personal care or
paramedical services Must meet SSI/SSP disability criteria
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Personal Care Services Program (PCSP)
An alternative to out-of-home care,nursing homes or board and care
facilitiesCovers similar services
• Provides personal care and/or• Paramedical services• Doesn’t fund protective services
Must receive SSI to qualify
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IHSS
Services can be provided by A hired care provider A parent or spouse
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IHSS Services include
housecleaning, preparing meals, laundry, grocery shopping, personal care services taking people to medical
appointments, and protective supervision for
people with cognitive disabilities
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Eligibility for IHSS
United States citizens or qualified aliens; and California residents.
Live at home Current recipients of SSI/SSP (PCSP) or Current recipients of SSI/SSP (Residual)
• Are eligible for SSI/SSP but their family income is too high
• May have share of cost• are eligible for SSI/SSP, including income,
but don’t get SSI• Get Medi-Cal and meet SSI/SSP disability
criteria.
Limited resources
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Important Points About IHSS
You can qualify for both Residual and PSCP If service is covered by both
programs, it will be funded by PSCP
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Supplemental Security Income (SSI)
not a healthcare system provider
federal program that gives a monthly payment
automatically eligible for fee for service Medi-Cal
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SSI
Adult programs• List of eligible
diagnoses. • If not on the list,
you may not be eligible.
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Important Points about SSI
Diagnosis on the list Different requirements for
children and adults Financial eligibility Provides a cash payment
you eligible for fee for service Medi-Cal
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The Health Insurance Premium Payment Program (HIPP)
may pay premiums for private health insurance for people who are on Medi-Cal a high-cost medical condition covered by private health
insurance
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Regional Center & Health Care Services
Serves people with developmental disabilities
Not a healthcare provider
Can help their clients get some of the healthcare services they need.
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Important Points about Regional Center & Health Care Services
May fund healthcare services related to the developmental disability
They are the payer of last resort