Transcript Adult Systems of Care

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 lowincome 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 …
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You receive cash benefits from

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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
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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
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Eligible for MediCal
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

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You get Part A
(Hospital
Insurance) when
you enroll
But you must pay
extra to get Part B
(Medical
Insurance)
Eligibility


United States Citizen or
documented resident and
Seniors over age 65, or
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Has worked at least 10
years at a job that pays
into Medicare
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Eligibility
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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
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Only for people
who are
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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

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Special Medi-Cal
program for adults
with disabilities who
are working but still
need health
coverage
Monthly premium
Medi-Cal and Medicare
(dual eligibility)
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Can qualify for both MediCal 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
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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).
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Examples of these are
severe depression or bi-polar
disorder.
not for people with
developmental disabilities or
substance abuse
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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 SMI
Medi-Cal,
 Private pay

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Access for Infants and
Mothers (AIM) Program
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AIM provides low-cost
health coverage for
pregnant women and their
newborns (ages 0-2).
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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
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An alternative to
out-of-home care,
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Two Types
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nursing homes or
board and care
facilities
Residual program
Personal Care
Services Program
(PCSP)
IHSS
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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
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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


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Must meet SSI/SSP disability criteria
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

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Must receive SSI to qualify
IHSS
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Services can be provided by
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A hired care provider
A parent or spouse
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IHSS
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Services include
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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
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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

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If service is covered by both
programs, it will be funded by
PSCP
Supplemental Security
Income (SSI)
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not a healthcare
system provider
federal program
that gives a
monthly payment
automatically
eligible for fee for
service Medi-Cal
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
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Diagnosis on the list
Different requirements for
children and adults
Financial eligibility
Provides a cash payment

you eligible for fee for service MediCal
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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
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Can help their clients get some of
the healthcare services they need.
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Important Points about
Regional Center & Health
Care Services
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May fund healthcare
services related to the
developmental
disability
They are the payer of
last resort
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