SECTION 5


                                               IMMEDIATE MEDICAL NEED


1.        GENERAL


This section provides instructions for identification of Medi-Cal immediate need situations and requirements for expediting the immediate need applicant’s eligibility determination at preapp and intake.


Procedures for issuance of immediate need Medi-Cal ID cards are included in MPG Article 14, Section 2.




2.        BACKGROUND


State DHS policy requires that when an applicant has an immediate medical need, the County must expedite the applicant’s eligibility determination. The SDHS policy further states that women who are pregnant are automatically considered to have an immediate medical need, whether or not they plan to carry their pregnancy to term.


If a beneficiary has a need for medical services prior to the anticipated receipt of a state issued Medi-Cal card, the County must issue a current month card.


These policies are applied equally to all applicants and beneficiaries who have an immediate medical need, including those with other health insurance coverage or coverage through the County Medical Services (CMS) Program.



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An IMN exists when an applicant, or any family member for whom application is made, indicates any of the following conditions or circumstances at any time during the preapplication or intake process:


A.      Pregnancy; or


B.      A hospital or nursing home admission is planned within the next ten working days; or


C.      A doctor, dentist, clinic, or other medical appointment is scheduled or necessary within the next ten working days and the provider refuses treatment without the Medi-Cal ID cards; or


D.      A prescription must be filled within the next ten working days; or


E.      A referral (HHSA:CMS-5) from a CMS Program Case Manager or from CMS medical staff indicates an immediate need.

The applicant’s statement of any of the above conditions or circumstances, verbally or otherwise, is to be accepted for purposes of determining that an IMN exists.





ETs and staff assigned to the rescheduling of appointments must be alert to any indication that an IMN exists and reschedule the new appointment within IMN timeframe. Applicants with an IMN are not required to specifically request that their eligibility determination be expedited. Immediate need procedures, as stated below, are followed whenever an IMN is identified.


A.       Preapplication


When an IMN is identified at preapplication, and potential eligibility exists, the applicant must be scheduled for an immediate need intake appointment. Every effort should be made to schedule the immediate need intake appointment as soon as possible within ten working days to permit completion of the eligibility determination in time to meet the specific requirements of the IMN situation.


The ET should remind the applicant that all required verifications, information, and completed forms must be provided at the intake interview so that an eligibility determination can be made at that time. Cards will be issued the same day for any eligible person with an immediate medical need. If the applicant indicates that any of the required verifications are not available, or that additional assistance with completion of the forms is required due to illiteracy or for other reasons, the applicant will be advised to do the best he/she can and that additional assistance will be provided by a contract SW, CMS Case Manager, the Intake ET or other available staff based on FRC procedures.





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B.       IMN Identified Between Preapp and Intake


If an applicant with a scheduled intake appointment contacts the Preapp ET or reschedule clerk to request an earlier appointment due to an IMN, every effort should be made to provide an earlier appointment.



C.       Intake


1)      Eligibility Requirements Not Met


If an IMN was identified at preapplication or during the intake, and the ET is unable to certify eligibility because of missing information/verifications, the ET will review the remaining requirements with the applicant and offer assistance, as necessary, to expedite completion of the eligibility determination.






2)      Eligibility Requirements Met


Once all Medi-Cal eligibility conditions are met, including presumptive factors as appropriate, the ET submits a 14-1 DSS or 16-17 DSS to the MEDS operator for issuance of a Paper ID Card. This includes beneficiaries with a share of cost. If the beneficiary already has a valid Benefits Identification Card (BIC), the ET will note on the 14-1/16-17 DSS form “No Card Needed” or “NCN” to alert the MEDS operator to only establish immediate eligibility and not issue a Paper ID Card.


















D.       Granted Cases with IMN


Granted beneficiaries who have requested a replacement BIC and have an immediate medical need, which will occur prior to receipt of the state issued replacement BIC, are issued a Paper ID Card.








An immediate need for a prior eligible month is to be processed for any beneficiary when:


A.       The provider refuses to see the beneficiary until eligibility for a past month’s service is made available; or


B.       It has been at least ten months since the month of service and eligibility is needed so that the provider can submit a claim to Medi-Cal within one year of the date of service.