ARTICLE 14

 

                                                              SECTION 1

 


                                                              CARD USE

 

1.        GENERAL

 

This section provides staff with information about how beneficiaries use Medi-Cal/PHP cards to obtain medical services.

 

2.        DELIVERY SYSTEM OPTIONS

 

There are two benefit delivery systems available to Medi-Cal eligible persons in San Diego County.

 

A.       Health Care Plans (HCP)

 

HCP is also called PHP (Prepaid Health Plan) and HMO (Health Maintenance Organization).

 

1)      HCP enrollment is currently available only to AFDC RECIPI­ENTS in San Diego County.  It is known as Health Care Options.  An explanation of the option and information on the individual HCPs are presented to AFDC applicants at ORIENTATION.  See APG 44-415 for detailed information about HCO.

 

 

 

 

 

2)      Enrollment in specific HCPs is determined by a recipient's ZIP code.  HCPs only serve specific geographical areas.  See APG 44-400, Appendix G.

 

3)      HCP enrollees are issued HCP identification cards by the HCP.  To obtain medical services, the enrollee will:

 

a)        Present the card to a provider in that HCP.

 

b)        In emergency circumstances, present the card to non-HCP providers who will use the card to bill the HCP.

 

4)      HCP enrollees may also be entitled to a restricted Medi-Cal card if they are enrolled in a non-comprehensive HCP.  For example, in San Diego County, HCPs do not provide dental service so all HCP enrollees receive a monthly restricted Medi-Cal card for dental services.

 

 

 

 

 

B.      Medi-Cal Card

 

1)      Medi-Cal only beneficiaries must receive a Medi-Cal card, as they cannot enroll in an HCP.

 

 

2)      AFDC recipients may choose to receive a Medi-Cal card instead of enrolling in an HCP.

 

 

 

 

 

 

3)      Medi-Cal cards are issued monthly by the state or county.

 

4)      To obtain medical services, the recipient presents the card to medical providers of their choice who accept Medi-Cal.  It is authorization for payment of claims for covered Medi-Cal services which are all of the following:

 

a)        Incurred during the month in which the Medi-Cal card is valid; and

 

b)        Not paid or obligated by the beneficiary to meet the share of cost requirement; and

 

c)        Not provided by any HCP of which the beneficiary is a member; and

 

d)        Not payable by a third party under a contractual or other legal entitlement; and

 

e)        Not prohibited due to the limited service status of the beneficiary.

 

 

 

 

 

 

 

5)      Locations where the Medi-Cal card can be used include:

 

a)        Any California county; or

 

b)        Any state outside California for emergency services.

 

6)      Signature Requirement - Each Medi-Cal beneficiary is required to sign and date his/her own Medi-Cal card in the space provided upon receipt of the card and before it is presented to a provider.  Beneficiaries who can only make a mark (X) in place of a signature must make the mark on their card.  This requirement does not apply to:

 

a)        Beneficiaries who are under 18 years of age; or,

 

b)        Beneficiaries who are in Long Term Care; or,

 

c)        Beneficiaries who are determined by the provider to be unable to sign the card because of disability.

 

 

 

 

 

 

7)      A mother's Medi-Cal card can be used as authorization for services for her newborn child, during the month of birth and the month following the month of birth.

 

8)      It is a misdemeanor for a beneficiary to sell, furnish, give or lend the beneficiary's Medi-Cal card to any other person or persons for their use.

 

 

 

 

 

 

 

 

 

 



3.        New footer 2/94 ltr # 237LIMITED SERVICE DELIVERY SYSTEM

 

Certain beneficiaries have limits placed on their use of Medi-Cal services.  They receive Medi-Cal cards printed with special coding which indicates any restrictions on the use of the cards.

 

A.       Limited Service Medi-Cal Cards may be used as authorization of payment of claims only for Medi-Cal services that are not restricted to the beneficiary.

 

B.       Examples of limited service status:

 

1)      Minor consent services - the card can only be used for services connected to the minor consent situation.

 

2)      Non-comprehensive HCP enrollee - the card can only be used for services not covered by the HCP.

 

 

 

 

 


 

3)      Program abuse - this type of card is issued to beneficiaries identified as having a high drug utilization pat­tern or a high Medi-Cal visits pattern.  Limits are placed on the amount of services available with this card.

 

4)      Postpartum Medi-Cal - the card only covers postpartum and pregnancy related services.

 

5)      Special treatment programs such as dialysis and TPN have cards that only cover services in the special programs.

 

6)      Hospice Services - the card is used to treat the symptoms of terminal illness in lieu of curative or life-extending care.  Hospice care is oriented towards meeting the needs of patients and their families who are coping with the later stages of terminal illness.  The card may be used for all other non-terminal diagnosis related health care.

 

 

 

 

 

 

 

 

 

 

ACWD

88-42

 

7)      Restricted Benefits - the card is issued to otherwise eligible OBRA aliens and covers only emergency and pregnan­cy-related services.

 

8)      Income Disregard/Asset Waiver Program - the card covers only pregnancy-related services for pregnant women eligible under either program.  Under either program, OBRA alien infants under one year of age are issued a card which covers only emergency services.

 

9)      Qualified Medicare Beneficiary (QMB)

 

a)        QMB-only recipients will receive restricted Medi-Cal cards which will only cover Medicare deductibles and co-insurance.

 

 

 

 

ACWD

94-07

 



b)        New footer 11/89 ltr # 76Beneficiaries with both Medi-Cal and QMB eligibility (dual-eligibles) will receive only one regular Medi-Cal card.

 

10)    Limited Services for Medically Indigent

 

                        Adults in LTC (Aid Code 53) - This card can only be used for services received while the client is residing in an LTC facility.  The Medi-Cal identification card contains the following message:  "Services to acute hospital inpatients are not covered."

ACWD 89-80

 

 

 

MEM Proc. 19c