Adult Systems of Care

1. Adult Systems of Care

2. General Healthcare for Adults • There are fewer healthcare programs for adults than for children • Most are for • adults with disabilities or • Pregnant women

3. Medicaid (Medi-Cal) • California’s Medicaid program • Health insurance for some low-income individuals

4. Fee for Service Medi-Cal • Go to any doctor who accepts Medi-Cal • Don’t need a referral to see a specialist

5. Eligibility for Fee for Service Medi-Cal • People who receive SSI • Most adults aren’t eligible for this

6. 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

7. Medi-Cal Managed Care • Different Plans • Los Angeles • LA Care • HealthNet • Orange County • Cal Optima • All Medi-Cal programs are managed care

8. 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).

9. 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 MAYBE

10. 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

11. Eligibility for Medi-Cal • Income • Few resources • United States Citizen or documented resident

12. 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.

13. 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

14. Denti-Cal • Program for dental care. • Provides • regular cleaning and check-ups • needed dental work • Full dentures

15. Eligibility for Denti-Cal • Eligible for Medi-Cal

16. 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

17. 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)

18. 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

19. 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)

20. 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

21. Eligibility • People under age 65 who • Are disabled • eligible for Social Security Disability Income (SSDI)

22. Adult Programs for Special Populations

23. 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

24. 250% Working Disabled Medi-Cal Program • Special Medi-Cal program for adults with disabilities who are working but still need health coverage • Monthly premium

25. 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 +

26. 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

27. 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.

28. Mental Health Programs • Care can include • therapy, • medication, • hospitalization and • other services

29. Mental Health Programs • Mental Health services who don’t have a SMI • Medi-Cal, • Private pay

30. 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.

31. Other Related Programs

32. IHSS • An alternative to out-of-home care, • nursing homes or board and care facilities • Two Types • Residual program • Personal Care Services Program (PCSP)

33. 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

34. 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

35. Personal Care Services Program (PCSP) • An alternative to out-of-home care, • nursing homes or board and care facilities • Covers similar services • Provides personal care and/or • Paramedical services • Doesn’t fund protective services • Must receive SSI to qualify

36. IHSS • Services can be provided by • A hired care provider • A parent or spouse

37. 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

38. 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

39. 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

40. Supplemental Security Income (SSI) • not a healthcare system provider • federal program that gives a monthly payment • automatically eligible for fee for service Medi-Cal

41. SSI • Adult programs • List of eligible diagnoses. • If not on the list, you may not be eligible.

42. 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

43. 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

44. Regional Center & Health Care Services • Serves people with developmental disabilities • Not ahealthcare provider • Can help their clients get some of the healthcare services they need.

45. Important Points about Regional Center & Health Care Services • May fund healthcare services related to the developmental disability • They are the payer of last resort