Medi-Care & Medi-CAL Health Insurance Programs & Prescription Drug Coverage

HOW CAN I CHANGE DOCTORS?

If you are in a Medi-Cal Health Plan, normally you must go to your Primary Care Physician (PCP) for your medical needs. If you want to change your PCP, you should:

• Call the Customer Service number for your Plan and ask to change your PCP.

• Change your PCP before you want an appointment. If you try to change without notifying your Plan, you may be denied service or charged for the service cost.

Why Do I Need More Than One Health Card?

If you are in a Medi-Cal Health Plan, you will need at least 2 health care cards. Some people need more. Health Plan Card: This card has the name of your Medi-Cal Health Plan. You should take it to all of your medical appointments. If the card is lost or destroyed, contact your Plan for replacement. Medi-Cal Card (Blue & White). You will need this card to pay for health services that are not provided by your health plan, such as dental or vision services.

Medicare Card (Red, White & Blue): Beginning January 1, 2006, people who receive Medi-Cal and Medicare may have to pay for prescription medicines with Medicare. If you have Medicare, take your Medi-Cal and Medicare cards with you to the pharmacy.

WHAT IF I MOVE TO A DIFFERENT COUNTY?

If you move to a different county, you will need to transfer to a Medi-Cal Health Plan in that county. Your current county should make sure your Medi-Cal is transferred to the new county. To make sure your Medi-Cal is transferred:

• Tell the county where you currently live that you are moving to another county before you are ready to move;

• As soon as you move, contact the Medi-Cal office in your new county to make sure you are enrolled in a Plan before you need a service or prescription medicine;

• Contact your local legal aid office if you have problems getting enrolled into a Plan in your new county or getting health care services.

HAS YOUR MEDI-CAL HEALTH PLAN REFUSED OR CUT-OFF A MEDICINE OR SERVICE?

• Sometimes your Medi-Cal Health Plan may refuse or stop a service or medicine you need.

• The Plan should give you a written notice of why it will not approve what you need.

• You have the right to appeal the cut-off or denial in a:

Grievance Hearing: You can ask your Medi-Cal Health Plan to reconsider its decision in a Grievance Hearing. Your Member Handbook explains how to request a Grievance Hearing or call the Health Plan customer service for information about how to file a grievance.

State Administrative Hearing: You can also appeal the Plan’s decision to the State. A judge will hear both sides of the story and decide if you are right. Information on how to ask for a State Administrative Hearing should be on the written notice you get from your Plan or call 1-800-952-5253 to ask for a state hearing.

PRESCRIPTION DRUGS: THREE WAYS TO GET MEDICARE TO HELP PAY FOR YOUR DRUGS THROUGH MEDICARE’S LOW INCOME SUBSIDY (LIS) PROGRAM

Medicare’s Low-Income Subsidy (LIS) Program helps people who have No Share of Cost Medi-Cal, Medicare Savings Program, or Sliding Scale Program.

No Share of Cost Medi-Cal:

What Is No Share of Cost Medi-Cal? Most people use Medi-Cal without paying any cost. Others who have a higher income must pay a monthly charge or “share of cost” before using Medi-Cal. If you don't have this monthly charge, you have Medi-Cal “with no share of cost.”

People who have Medicare and “Medi-Cal With No Share of Cost” automatically receive LIS extra help to pay for Medicare Part D drugs. People who have Medicare & Medi-Cal “with no share of cost” should pay:

• No Yearly Deductible
• No Monthly Premiums &
• A Co-Payment of $1-$3 per drug.


Medicare Savings Program

People in a Medicare Savings Program (MSP) automatically get LIS extra help from Medicare to pay for their drugs. People who are in a MSP should pay:

• No Yearly Deductible
• No Monthly Premiums &
• A Co-Payment of $1-$5 per drug.


Who Can Be In A MSP? Low-income people who do not normally get Medi-Cal, may get their Medicare drug (and Medicare A & B) costs paid by Medi-Cal through a MSP. They are called:

Qualified Medicare Beneficiary (QMB / ”Quimby”); or Specified Low-Income Medicare Beneficiary (SLMB / “Slimby”); or Qualified Individual (Q1).

To find out if you qualify for a MSP, contact your Medi-Cal office.


Sliding Scale Program

People who have income below 150% of poverty (about $1,300 per month for one person) may qualify for LIS Sliding Scale extra help.

Sliding Scale monthly premiums (depending on your People who get Sliding Scale should pay:

• Sliding Scale monthly premiums (depending on your income)
• No Yearly deductible &
• 15% coinsurance charge

Apply For LIS Sliding Scale At SSA. To get LIS Sliding Scale extra help, you must file an application at the Social Security Administration office. You will have to provide information about your income & financial assets.

If you cannot Get Your Medicines From Medicare

If you do not qualify for Medicare Part D and do not have any other way to get them, you may be able to get free or low-cost medicines from your county.
To qualify for county help, you should:

• Be low income
• Have no way to pay for medicines after you pay for living expenses
• Be willing to get your medicines from the county public health department.



MEDICARE ADVANTAGE PLANS: An ADVANTAGE OR DISADVANTAGE FOR YOU?

What is a Medicare Advantage Plan?

Medicare provides health care services to eligible recipients. There are different ways that you can get your Medicare services. One way to get Medicare is to join a Medicare Advantage Plan.

There are different kinds of Medicare Advantage Plans, such as:

• HMOs (Health Maintenance Organizations)
• PPOs (Preferred Provider Organizations)
• PFFS (Private Fee For Service) &
• SNPs (Special Needs Plans)

The rules for getting services are different depending upon which kind of plan you join.

Should I Join a Medicare Advantage Plan?

It depends. Before you join, make sure that you understand the plan’s rules and that you will be able to get the services you want from the health care providers you want.

• Find Out If Your Health Care Providers Are Included In The Plan: Some Advantage Plans only let you go to health care providers that are members of their “network” - except for emergencies. Get a list in writing of all plan providers and make sure that the ones you want are nearby and speak your language.

• Find Out What You Will Have To Pay Out Of Your Own Pocket: Some plans charge monthly premiums and co-payments. Get a list in writing of all charges which you may have to pay.

• Find Out How To Un-Enroll: Even if the plan seems like a good idea, make sure you know how to get out (un-enroll) if you need to and how long it will take, or if you can only un-enroll at certain times of the year.

What if I Can’t Get a Service From My Plan?

1. Talk To Your Doctor/Health Care Provider: Find out why the plan is denying your service. Is there any additional information that you or the doctor can supply that might make a difference?

2. Read Your Plan Member Handbook: When you join a Medicare Advantage Plan, you should receive a Member Handbook that explains how to appeal a service denial. Make sure that your appeal is submitted within the time required by your plan.

3. If You Want Help With A Medicare Advantage Plan Appeal: Bay Area Legal Aid provides legal advice and representation to low-income individuals who have been wrongly denied health care services. To find out if BayLegal can help, contact the Legal Advice Line or the office near you.

If you live in Alameda, San Francisco, Contra Costa, Santa Clara, Marin, or Napa counties in California For more information on the topics addressed above, you can contact:

Bay Area Legal Aid:
(510) 250-5270 (925) 219-3325
(707) 320-6348 (415) 354-6360
(650) 472-2666 (408) 850-7066

or
The California Department of Managed Health Care - HMO Help Center
1-866-HMO-2219 or http://www.hmohelp.ca.gov


Sponsored by funding from The State of California, Office of the Patient Advocate