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DHCS implements period of “deemed eligibility” for Cal MediConnect plans



September 02, 2015
Area(s) of Interest: Payor Issues and Reimbursement Public Payors 

Effective September 1, 2015, Cal MediConnect will have the option to offer a one- or two-month period of “deemed eligibility,” defined as a grace period, to beneficiaries that lose Medi-Cal eligibility due to a change in circumstance. Cal MediConnect plans have the option to, but are not required to, offer this “grace period." 

According to the 2013 Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, a Cal MediConnect plan may choose to provide a one- or two-month period of deemed continued eligibility for individuals who lose Medicaid eligibility, if the individual is reasonably expected to regain Medicaid eligibility within one or two months. Plans that choose to offer this grace period must continue to offer the full continuum of benefits.

 

Effective with September enrollment, if the plan is offering this grace period and the beneficiary is deemed eligible, the eligibility verification through Medi-Cal’s automated eligibility verification system (AEVS) will reflect a new status under the “Eligibility Message” at the very end:

 

SUBSCRIBER LIMITED TO SERVICES COVERED BY HEALTH PLAN: (HCP Name) (HCP Telephone): (HCP) XXX, (HCP phone number) 1-800-XXX-XXXX.

 

If the beneficiary does not re-qualify within the plan’s period of deemed eligibility, their enrollment will be terminated.

 

To better understand which Cal MediConnect plans are offering the grace period, the California Medical Association asked the plans about their timeframe for potential deeming of Cal MediConnect beneficiaries:

 

 

Plan Name

 

Offering Deemed Eligibility (Yes/No)

 

Number of Months

 

Anthem Blue Cross

 

Yes

 

1

 

CalOptima

 

Yes

 

1

 

Care 1st

 

Yes

 

1

 

Community Health Group

 

Yes

 

1

 

Health Net

 

Yes

 

1

 

Health Plan of San Mateo

 

Yes

 

2

 

Inland Empire Health Plan

 

Yes

 

1

 

LA Care

 

Yes

 

1

 

Molina

 

Yes

 

1

 

Santa Clara Family Health Plan   

 

Yes

 

2, beginning Oct. 1, 2015

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If a plan opts to offer the grace period and the patient does not regain eligibility, the plan is responsible for payment for services incurred during the grace period. However, best practice is to always verify eligibility as close to, if not on, the date of service as possible and keep the AEVS confirmation in the patient’s medical record.

 

For additional information, click here.

 

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