Update : Common Place Handbook Affordable Care Act (ACA) Workflows

Transcription

1 Santa Clara County Social Services Agency page 1 Date: 11/19/13 References: N/A Cross-References: Medi-Cal Update Clerical: Handbook Revision: Yes No Affordable Care Act (ACA) Workflows Background In September 2013, ACA (also referred to as Health Care Reform (HCR)) training was provided by Staff Development to all HCR Eligibility Workers (EWs) and designated eligibility staff. The HCR Workflow Committee comprised of various classifications was formed to create workflows that would assist staff with the administration of health care coverage requests. Changes After implementation of HCR on October 1, 2013, the workflows were revised to reflect the reccommendations of eligibility staff. These revised workflows are exhibited in this update. Process In the workflows it references Designated Eligibility Worker, which refers to the 40 Continuing Eligibility Workers trained in September In addition, it refers to all Continuing Eligibility Workers who have already received HCR training, which started October 21, Workflows Please see the following workflows: HCR General Call Handling (Intake Phone Support). Calls Coming to Continuing Office Phone Support. Walk-In Health Care Coverage Requests for Continuing Offices. HCR General Call Handling This workflow is for calls received through Intake Phone Support from the general public about health care coverage.

2 page 2 1. Intake PS Receives call from General Public inquiring about health care coverage. ID the client to determine if there is an existing case in CalWIN/CALHEERS/MEDS. Has an existing case Does not have an existing case Transfers to appropriate District Office. NOTE: If a CalHEERS only case, then warm transfers the call to (internal use only). Follows script: "To get us started, can you tell me if you need health coverage benefits now, or if you want to enroll in the new health care program available January 1st?" If applicant... Declares current MC need, Declares health coverage need for January 1, 2014, Asks about the difference between NOW & January 1, 2014, Follows current office business process. Warm transfers the call to NOTE: This phone number is for internal use only. Clients should be given Intake phone number ( ) as call back phone number. Follows script: "The Medi-Cal coverage available today uses the current regulations. There are more forms or verifications required, and information about property you own will be needed. If you or a family member needs medical help now, this is the way to go. If you are eligible now, you will stay eligible when the new regulations begin in January. You will not have to reapply. Starting in January, we will have new regulations and more people will be eligible. The process is shorter and easier, but the coverage does not start until January 1, Is undecided Offers the following options: Call us back at Website For coverage that starts in January 2014, please go to For coverage now, please go to

3 page 3 Calls Coming to Continuing Office Phone Support This workflow is for calls coming to the continuing office phone support and the process for adding health care coverage for January Cont. PS Recieves call from General Public/Current Clients. ID the client to determine if there is an existing case in CalWIN/ CALHEERS/ MEDS. If client... Then... Has an existing case at a different district office, Has an exisiting case at same district office, Does not have an exisiting case, Transfers to appropriate district office. Proceeds to Step 2. Warm transfers to Intake ( ). 2. Cont. PS Identifies reason for the call. Wants to apply for health coverage, Has general questions, Proceeds to Step 3. Answers questions to the fullest extent possible. 3. Cont. PS Determines which programs client would like to be screened for and if client wants coverage now or later (January 2014). Wants Medi-Cal NOW and there is potential eligibility, Wants Medi-Cal NOW and there is NO potential eligibility, Follows current office business prcoess. Determines if the clients meets the following criteria: Santa Clara County resident. Between the ages of 19 and 64 years old. A U.S. Citizen or Legal Permanent Resident for at least 5 years. Family income at or below 133% FPL. (One person - $1,274/monthly)

4 page 4 If... Yes, No, Refers client to Health and Hospital Systems (HHS) to apply for Low Income Health Program (LIHP). Refers client to HHS to apply for Ability-to-Pay. Wants health care coverage starting January 1, 2014, Wants CalFresh/ CalWORKs/GA, Offers the following options: Phone interview [Transfers call to Designated Eligibility Worker (DEW)]. Mail Request for Tax Household Information form (SCD 2350). Covered CA website ( Follows curent office business process. Process for Adding Health Coverage for January DEW Recieves request for health coverage starting January 1, NOTE: If request received is not a phone call, then call the client and continue to follow this workflow. If SCD 2350 is recieved, then complete an application in CalHEERS using information from CalWIN without contacting the client, if possible. Wants to complete an application, Wants to complete a pending CalHEERS application, Needs assistance selecting a health plan, Proceeds to Step 2. Proceeds to Step 2. Proceeds to Step 4.

5 page 5 2. DEW Informs client of the following: - If they want to check status/edit the application later, then he/she nees to create his/her own account in CalHEERS before we start processing an application. If client is not able to create an account, then he/she MUST call the county or Covered CA for any updates to his/her application. NOTE: After 11/25/2013, clients will be able to create an account and select their own plan through Covered CA website ( at any time. - In order to process an application, consent must be given to check other agencies' computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if you and other people on this application qualify for health insurance. NOTE: If consent is not given, application cannot be completed. However, if an application has been started, it does not need to be withdrawn and it can remain in CalHEERS. - Processing an application over the phone can take an average of an hour. Performs interactive interview in CalHEERS. Reviews and explains the CalHEERS consent page to obtain client consent. 3. Submits CalHEERS application for Federal Hub Data Match. If Eligibility Results page in CalHEERS states... Eligibility Pending, Reviews Personal Verification page in CalHEERS. Conducts Ex Parte Review. If... Verification is available (i.e. IDM, MEDS, client provides, etc.) Uploads documents directly into CalHEERS. Changes Pending to Pass. Clicks Save. Clicks Redetermine Eligibility. Proceeds to Step 4.

6 page 6 Verification is not available, Informs client of options to verify information: Conditionally Eligible, Proceeds to Step 4. Eligible, Proceeds to Step 4. - Upload directly into coveredca.com. - Mail to County of Santa Clara. - Fax to district office. Mails SCD 1121 with 10-day due date and pre-paid self-addressed envelope with EW worker number. Creates alert per office/unit business process to follow-up after 10 days. NOTE: Two (2) 10-day notices are required when requesting missing verifications. Proceeds to Step DEW Informs client of eligibility. If there is... APTC/CSR eligible individual(s) Informs client of health care plan options. Explains to client that he/she must select a plan within the next 30 days and pay his/her initial premium payment 4 business days before health coverage begins.

7 page 7 If client wants to... Make plan selection now, Make plan selection later, Enrolls client in his/her selected plan. Refers client to coveredca.com for detailed information on health plans. Offers client options: - Informs client that if he/she already has an account, then he/she can select a plan on his/her own. Proceeds to Step 5. OR - Informs client to call back district office with a plan selection. MAGI MC eligible individual(s), Informs client that they will receive information on Managed Care Plans via mail. Provides Health Care Options phone number ( ) for further information. Proceeds to Step DEW Documents actions taken in CalWIN and CalHEERS. NOTE: Documentation in CalWIN should include client's CalHEERS case and application number. Documentation in CalHEERS should include client's CalWIN case number. Updates TMT status per office business process. Health Coverage Requests for Continuing Offices (Walk-In) This workflow is for walk-in health care coverage requests for continuing offices and the process for adding health care coverage for January 2014.

8 page 8 1. CST ID the client to determine if there is an existing case in CalWIN/ CALHEERS/ MEDS. If client... Then... Has an existing case at a different district office, Has an exisiting case at same district office, Does not have an exisiting case, Refers to appropriate district office. Refers to appropriate unit using current office business process. Refers to Intake. 2. EW Identifies client s needs Wants to apply for health coverage, Has general questions, Proceeds to Step 3. Answers questions to the fullest extent possible.

9 page 9 3. EW Determines which programs client would like to be screened for and if client wants coverage now or later (January 2014). Wants Medi-Cal NOW and there is potential eligibility, Wants Medi-Cal NOW and there is NO potential eligibility, Follows current office business process. Determines if the client meets the following criteria: Santa Clara County resident. Between the ages of 19 and 64 years old. A U.S. Citizen or Legal Permanent Resident for at least 5 years. Family income at or below 133% FPL. (One person - $1,274/monthly) If... Yes, No, Refers client to Health and Hospital Systems (HHS) to apply for Low Income Health Program (LIHP). Refers client to HHS to apply for Ability-to-Pay. Wants health care coverage starting January 1, 2014, Offers interactive interview. If client wants now... Yes, Follows current office business process to have client assigned to Designated Eligibility Worker (DEW). No, Gives Request for Tax Household Information form (SCD 2350). OR Gives Covered CA website ( Wants CalFresh/ CalWORKs/GA, Follows curent office business process.

10 page 10 Process for Adding Health Coverage for January DEW Recieves request for health coverage starting January 1, Wants to complete an application, Wants to complete a pending CalHEERS application, Needs assistance selecting a health plan, Proceeds to Step 2. Proceeds to Step 2. Proceeds to Step DEW Informs client of the following: - If they want to check status/edit the application later, then he/she nees to create his/her own account in CalHEERS before we start processing an application. If client is not able to create an account, then he/she MUST call the county or Covered CA for any updates to his/her application. NOTE: After 11/25/2013, clients will be able to create an account and select their own plan through Covered CA website ( at any time. - In order to process an application, consent must be given to check other agencies' computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if you and other people on this application qualify for health insurance. NOTE: If consent is not given, application cannot be completed. However, if an application has been started, it does not need to be withdrawn and it can remain in CalHEERS. - Processing an application over the phone can take an average of an hour. Performs interactive interview in CalHEERS. Reviews and explains the CalHEERS consent page to obtain client consent. 3. Submits CalHEERS application for Federal Hub Data Match. If Eligibility Results page in CalHEERS states... Eligibility Pending, Reviews Personal Verification page in CalHEERS. Conducts Ex Parte Review.

11 page 11 If... Verification is available (i.e. IDM, MEDS, client provides, etc.) Verification is not available, Uploads documents directly into CalHEERS. Changes Pending to Pass. Clicks Save. Clicks Redetermine Eligibility. Proceeds to Step 4. Informs client of options to verify information: Conditionally Eligible, Proceeds to Step 4. Eligible, Proceeds to Step 4. - Upload directly into coveredca.com. - Mail to County of Santa Clara. - Fax to district office. Gives SCD 1121 with 10-day due date and pre-paid self-addressed envelope with EW worker number. Creates alert per office/unit business process to follow-up after 10 days. NOTE: Two (2) 10-day notices are required when requesting missing verifications. Proceeds to Step DEW Informs client of eligibility. If there is...

12 page 12 APTC/CSR eligible individual(s) Informs client of health care plan options. Explains to client that he/she must select a plan within the next 30 days and pay his/her initial premium payment 4 business days before health coverage begins. If client wants to... Make plan selection now, Make plan selection later, Enrolls client in his/her selected plan. Refers client to coveredca.com for detailed information on health plans. Offers client options: - Informs client that if he/she already has an account, then he/she can select a plan on his/her own. Proceeds to Step 5. OR - Informs client to call back district office with a plan selection. MAGI MC eligible individual(s), Informs client that they will receive information on Managed Care Plans via mail. Provides Health Care Options phone number ( ) for further information. Proceeds to Step DEW Documents actions taken in CalWIN and CalHEERS. NOTE: Documentation in CalWIN should include client's CalHEERS case and application number. Documentation in CalHEERS should include client's CalWIN case number. Updates TMT status per office business process. Implementation The workflows reflected in this update are effective immediately.

13 page 13 Clerical Office Management Coordinators (OMCs) must review this update with their respective staff at their next clerical meeting, and ensure that the correct procedures are being followed. EW Supervisors Eligibility Work Supervisors must review this update with their respective staff at their next unit meeting, and ensure that the correct procedures are being followed. Data Systems California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) is a new system that was created by the State to determine consumer eligibility for Modified Adjusted Gross Income (MAGI) Medi-Cal (MC) and Covered California Health Plans such as Advanced Premium Tax Credit (APTC), Cost-Sharing Reduction (CSR), or Unsubsidized Health Plans. Forms The following new form is now available on the DEBS Forms Library, Request for Tax Household Information (RFTHI) (SCD 2350). Kudos Special thanks to: Christa Starr, Robert Sacasa, Margareta Hodzic, Roseann Berthron-Arechiga, Olivia Cuevas, Angelica Diaz, Linda Farias, Mariela Perez, Marco Brambila, Chanteau Wilson, Welmín Militante, Leanne Lam, Tracey Medina, Diane Zertuche, Margaret Badal, Marjorie Raudez, and Johnny Saldivia. DENISE BOLAND, DIRECTOR, Department of Employment and Benefit Services Contact Person(s): Flavio Barbosa, Medi-Cal Program Coordinator, (408)