Table of Contents
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A.
Overview
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Limited Medi-Cal coverage is available to persons who need
special types of life-sustaining medical treatment. These individuals must
pay a percentage of their treatment costs, based on their net worth, which is
a combination of property and income. This special coverage is limited to persons in need of
kidney dialysis or parenteral hyper-alimentation treatment, also known as
total parenteral nutrition or TPN. TPN provides total nutrient replacement
for persons who are unable to eat and digest food. There are two categories of Special Treatment benefits:
Special Treatment Only and Special Treatment Supplement. |
A.
Special Treatment Only
Benefits
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Persons who need dialysis or TPN treatment, and are not
eligible for regular Medi-Cal solely because of excess property, may be
eligible for Medi-Cal Special Treatment Only benefits. To be eligible for these benefits, a person must be all of
the following in a month:
The Special Treatment Only category uses the following two
aid codes.
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B.
Special Treatment
Supplement Benefits
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Employed persons who need dialysis or TPN treatment and who
are eligible for regular Medi-Cal with a SOC are also eligible for Medi- Cal
Special Treatment Supplement benefits. To be eligible for these benefits, a person must be all of
the following in a month:
Medicare eligibility does not affect eligibility for
Special Treatment Supplement benefits. NOTE: If a Medi-Cal
Special Treatment Supplement beneficiary loses Supplement eligibility solely
because of excess property, eligibility for Medi-Cal Special Treatment Only
benefits must be determined. The Special Treatment Supplement category uses the
following aid codes.
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C.
Medicare Referrals
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All applicants for Dialysis Special Treatment benefits must
apply for Medicare Hospital coverage within ten days of applying for Special
Treatment benefits. They must also supply the worker with a copy of the
Medicare status within ten days of its receipt. Applicants who fail to apply
for Medicare without good cause will have their application for Dialysis
Special Treatment benefits denied. Applicants for TPN Special Treatment benefits must follow
the requirements of MPG Article 15, Section 4 in applying for
regular Medicare, since there is no special Medicare assistance for this
group. |
A.
Application Process
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Applications are received and processed
according to the procedures addressed in MPG
Article 4, Section 2 with the following addition. · All Medi-Cal Special Treatment
Supplement applicants must sign and date a Medi-Cal Special Treatment
Supplement benefits client information statement at initial application and
at redetermination interviews. The form numbers are: -
14-30
DSS - Dialysis Medi-Cal Special Treatment Supplement benefits. (Appendix A) -
14-31
DSS - TPN Medi-Cal Special Treatment Supplement benefits. (Appendix B) NOTE: There is no
retroactive eligibility to Medi-Cal Special Treatment benefits. MPG Letter 755 (05/2012) |
B.
Verifications
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All Special Treatment benefit applicants or beneficiaries
must provide the verifications required in MPG Article 4, Section 7. Additionally, all Dialysis Special Treatment benefit
applicants or beneficiaries must provide verification of Medicare status as a
condition of eligibility. Receipt of Medicare affects Dialysis beneficiaries
in the following ways:
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C.
Beginning Date of
Eligibility
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The beginning date of eligibility is the first day of the
month of application, or the first of the month during which eligibility
exists, whichever is later. Examples:
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D.
Card Issuance
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A MEDS on-line transaction must be completed to establish
the Medi-Cal Special Treatment case on the MEDS record. The worker will
complete a form 14-28 and forward the form to the MEDS operator. The worker
must be sure to include the beneficiary's percentage obligation on the form. |
E.
Change in Circumstances
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Special Treatment cases require a MEDS on-line transaction
whenever there is a change in case circumstances. Changes of address,
percentage obligation, OHC and worker number all require an on-line
transaction. The worker will complete a form 14-28 to request the MEDS record
change and forward the form to the MEDS operator. |
F.
Reporting Changes
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The beneficiary is responsible for reporting changes. The worker must evaluate information
received from any source to determine if benefit eligibility and/or the
percentage obligation is affected and take appropriate action on reported
changes. |
A.
Determining Annual Net
Worth
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To calculate the percentage of cost the beneficiary pays,
the annual net worth must be determined first, using form MC 176D. This is done by
combining: · The net
market value of all available property; and · The gross
income reasonably expected to be received in a 12-month period by the
person(s) whose property and income are considered. The 12-month period
begins on the first of the month of initial eligibility. |
B.
Included Property and
Income
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The available property and income of the following persons
will be considered when determining annual net worth: · The
beneficiary · The
beneficiary's spouse · The
beneficiary's parents, if the beneficiary is all of the following: - Under
21 years of age - Unmarried - Living with his/her parents |
C.
Excluded Property
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The following real and personal
property is excluded in determining annual net worth:
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B.
Other Health Coverage and
the Billing Process
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If the patient has Medicare, private health insurance, or
any other non Medi-Cal coverage, that coverage must be billed first for the
cost of a dialysis or TPN service. The patient's percentage obligation
applies to the balance remaining after payment by the other coverage. For
example, if Medicare covers $80 of a $100 charge, the patient's percentage
obligation will be applied to the remaining $20. The provider subtracts the
beneficiary's obligation from the $20 and bills Medi-Cal for the rest. |
C.
Determining and
Application of Percentage Obligation
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The percentage obligation is based on the annual net worth
of the beneficiary as determined in MPG 17.1.5a. The percentage
obligation is applied to the cost of allowable services that remain unpaid
after all other benefits or entitlements have been utilized. Form MC 176D is used for this
calculation. The amount of the percentage obligation cannot be: · Claimed
against any Medi-Cal Special Treatment benefit. · Reimbursed
by a third party. |
D.
Medi-Cal Special Treatment
Only Beneficiaries Computation
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The percentage obligations for
Medi-Cal Special Treatment Only beneficiaries is determined as follows: · Who have
an annual net worth of less than $5,000 will be assigned a
zero percentage obligation. · Who have
an annual net worth of $5,000 or more will be assigned a
percentage obligation of two percent for each $5,000 of net worth, including
the first $5,000. Round down to the nearest increment of $5,000. Special Treatment
Only beneficiary: · The amount
of annual net worth is determined to be $4,500. The percentage
obligation is 0. ·
The
amount of annual net worth is determined to be $42,500. Divide 42,500 by
5,000 = 8. 8 x 2% is 16%. The percentage obligation is 16%. (Round down to
the nearest increment of 5,000.) |
E.
Medi-Cal Special Treatment
Supplement Beneficiaries Computation
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The percentage obligations for
Medi-Cal Special Treatment Supplement beneficiaries is determined as follows: · Who have
an annual net worth of less than $5,000 will be assigned a
zero percentage obligation. · Who have
an annual net worth of $5,000 or more will be assigned a percentage
obligation of one percent for each $5,000 of net worth, including the first
$5,000. Round down to the nearest increment of $5,000. Special
Treatment Supplement beneficiary: · The amount
of annual net worth is determined to be $4,500. The percentage
obligation is 0. · The amount
of annual net worth is determined to be $42,500. Divide
42,500 by 5,000 = 8. 8 x 1% = 8%. The percentage obligation is 8%. (Round
down to the nearest increment of 5,000.) |
F.
MC176D
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Form MC 176D is used to compute
the amount of annual net worth and the percentage obligation. The form is
filed on top of the right-hand side of the financial folder. Form MC 176D is required at
application, re-application, restoration, change in net worth affecting
percentage obligation, and at redetermination. Appendix
C
gives instructions on completion of the form. |
G.
Special Treatment
Supplement Beneficiary Share of Cost
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Medical services other than those covered under Special
Treatment benefits are subject to a share of cost as found in MPG Article 12, Section 1, instead of a
percentage obligation. Costs paid by the beneficiary under Special Treatment
Supplement benefits in any month are applied to the share of cost for that
month. A beneficiary of an MFBU which has met its share of cost
will be issued a regular Medi-Cal card according to the instructions in MPG Article 12, Section 2. The regular
Medi-Cal card will be received in about six weeks. All Medi-Cal services received by the beneficiary during
that month will be covered under the provisions of the full Medi-Cal program
rather than Special Treatment Supplement benefits once full coverage has been
certified |
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DIALYSIS MEDI-CAL SPECIAL
TREATMENT SUPPLEMENT CLIENT
INFORMATION SAN DIEGO
COUNTY – DEPT.
OF SOCIAL SERVICES If you
need kidney dialysis and qualify for the Medi-Cal Dialysis Supplement Special Treatment Program,
that program could
reduce your out-of-pocket
dialysis costs. Here are key facts and rules about
the program. I. Dialysis Supplement Eligibility Requirements You
must be all of these
things in a month: § In need of dialysis. § Eligible
for regular Medi-Cal with a personal or family share
of cost. §
Employed, or self
employed, with gross
earnings which are greater than the individual Medi-Cal maintenance need
for one person. §
Receiving either
home dialysis or self-care
clinic dialysis. II. Information for
Dialysis Supplement Eligibles A. Advantages of Dialysis Supplement Program This
program provides you
medical cost relief
for dialysis and related services. Under the regular Medi-Cal program, you must pay all your surplus income
toward meeting your share of cost for medical care. Under this
program, you need
pay only a percentage of the cost
for dialysis services after any
other health coverage payment is subtracted from the cost
of those services. B. Using Your
Other Health Coverage If you have Medicare, private health insurance, or any other non-Medi-Cal coverage, that coverage
must be billed
first for the cost of a dialysis
service. Your percentage
obligation applies to the
balance remaining after payment by such other coverage. For example, if Medicare covers $80 of a $100 charge, your percentage obligation will be applied only to the remaining $20. The provider
subtracts what you owe from the $20, and bills Medi-Cal for the rest. C. What You Pay Toward the Cost of Your Dialysis Care The amount
you pay toward
each dialysis
service depends on the annual
net worth of you and
your spouse, or you and your
parents if you
are under 18.
Annual net worth
is annual income
plus property holdings. The
following are not counted as part of your property holdings: The first $40,000 of your home’s
taxable value, one
vehicle, $1,000 for burial expenses, burial plots or vaults,
wedding and engagement rings, heirlooms, clothing, household furnishings, and household equipment. If your
annual net worth
is less than
$5,000, you pay
nothing. If it is more than
$5,000, you pay one percent
of the net cost of each dialysis service for each $5,000 of annual net worth you
have. For example, if your annual
net worth is $15,000, you
pay three percent
of the net cost of each
dialysis service. The percent you pay is called your
“percentage obligation.” D. How Your Dialysis Supplement Eligibility Fits into Your Regular Medi-Cal Eligibility Dialysis Supplement covers dialysis and related services only. If you or your family
need other types of medical care, you must meet your regular Medi-Cal share of cost before you can receive a regular
Medi-Cal card.
The amount you pay for dialysis and related services as part of your Dialysis
Supplement eligibility will be a credit
against your share
of cost, just the same as any other medical
bill you pay. Be sure and have your dialysis provider or supplier fill out your “Record of Health
Care Costs,” form (MC 177).
Once you receive a regular
Medi-Cal card for any month, you must
use
it for all medical
services, including dialysis, for the remainder of that month. E. What Happens
if You Lose Regular Medi-Cal Eligibility Eligibility for Dialysis Supplement depends on eligibility for the regular
Medi-Cal program. If you lose
eligibility for regular Medi-Cal for any reason, including accumulation of excess
resources, you will
no longer be eligible for Dialysis Supplement. In this case,
the county welfare department will
determine your eligibility under the Dialysis Only program. III. Services Covered
by the Medi-Cal Dialysis Supplement Program B. Dialysis
Supplement Benefits The Medi-Cal Dialysis Supplement program covers
the full range
of dialysis services except routine full-care dialysis. Routine full-care dialysis is not a Dialysis Supplement benefit. This exclusion does not preclude provision of full-care dialysis treatment in cases
of a physician certified medical emergency. Dialysis Supplement coverage ends when you meet your regular
Medi-Cal share of cost, since
for the rest
of the month
you are entitled to free Medi-Cal services, including routine
full-care dialysis. C. Definition of Dialysis and Related Services Dialysis and related services are defined in Title 22,
California Administrative Code,
Section 51157: “Renal Dialysis, Renal Homotransplantation, and
Related Services”
as follows: (a) ‘Renal
dialysis’ means removal by artificial means of waste products normally excreted by
the kidneys. Such
removal may be accomplished by the use of an artificial kidney or
peritoneal dialysis on a continuing basis.* (b) ‘Renal
homotransplantation’ means
the implantation of a kidney
from one person to another
for the treatment of renal disease. (c) ‘Related services’ means hospital inpatient and physician’s services related to the treatment
of renal failure, stabilization of renal
failure, treatment of complications of dialysis, and
dialysis related laboratory tests, medical supplies, and drugs.” *(Note: “Renal dialysis” means full-care,
self-care, or home-care dialysis.) D. Definitions of Types of Dialysis 1. Full-care dialysis is provided in a dialysis
clinic or a hospital
outpatient clinic. Treatment is fully
managed by staff; the patient takes no part in managing his or her own care. 2. Self-care dialysis takes place in a “self-care dialysis unit” of a dialysis
clinic or hospital
outpatient clinic. The patient manages his or her own treatment with less staff supervision
required. 3. Home dialysis takes
place in the home. The
patient has a home dialysis unit and dialyzes at home. Usually a dialysis clinic
or outpatient hospital clinic will supervise the patient’s home care
and will provide needed supportive services, including the services of qualified home dialysis aides on a selective basis. IV. Your Responsibilities A. Medicare Application 1. You must apply for Medicare coverage within
ten days of making application for this program
unless you already
have Medicare coverage or have a statement from Social Security showing
you are currently not eligible for Medicare. 2. You must provide the county welfare department a copy of the Social
Security Medicare
status, or any evidence of eligibility such as a card or letter,
within ten days of receipt. 3. If you are not currently eligible for Medicare, you must request a statement of quarters of coverage from Social Security (Social Security Benefit Estimate Form). You should
determine, with
the aid of a Social
Security representative, how many more quarters of coverage
you need to become eligible for Medicare. This information must be given to the county
welfare department or your eligibility will have to be redetermined every quarter. It is
to your direct advantage to apply for Medicare as soon as you believe you are eligible. The cost
you must pay is based on the balance left after Medicare or any other insurance has paid.
Medicare coverage can reduce your cost up to 80 percent. B. General Reporting Responsibilities You must report any change in status that could affect your dialysis program eligibility or your percentage obligation. These include, but are not limited to: ·
Loss of employment ·
Change in marital status ·
Increase/decrease in earnings · Change in other health coverage I have
reviewed the above
information with the county representative. I understand my responsibilities in regard to Medicare and
general reporting requirements.
I have explained the Medi-Cal Dialysis Supplement requirements listed above
to the applicant.
14-30 DSS (4/88) |
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TPN MEDI-CAL SPECIAL TREATMENT
SUPPLEMENT CLIENT INFORMATION SAN DIEGO COUNTY
– DEPT. OF SOCIAL SERVICES If you
require parenteral hyperalimentation treatment, also known as total parenteral nutrition (TPN), and qualify for the Medi-Cal TPN Supplement program, that program could
reduce your out-of-pocket
TPN costs. Here are key facts and rules about
the program. I. TPN Supplement Eligibility Requirements You must be all of these things
in a month: ·
In need of TPN. ·
Performing home TPN treatment. ·
Eligible for regular Medi-Cal with a personal or family SOC. · Employed, or self-employed, with gross monthly earnings, which are greater than the individual Medi-Cal maintenance need for one person. II. Information for TPN Supplement Eligibles A. Advantages of TPN Supplement Program This program provides you medical cost
relief for home TPN treatment. Under the regular
Medi- Cal program, you
must pay all your surplus
income toward meeting
your share of cost for medical care. Under this
program, you need
pay only a percentage of the cost for home TPN treatment after any
other health coverage payment is subtracted from the cost
of those services. B. Using Your Other Health Coverage If you have Medicare, private health
insurance, or any other non-Medi-Cal coverage, that coverage
must be utilized or billed first for the cost of home TPN treatment. Your percentage obligation
applies to the balance remaining
after payment by such other coverage.
For example, if Medicare
covers $80 of a $100 charge, your percentage obligation will be applied
only to the remaining $20. The provider
subtracts what you owe from
the $20 and bills Medi-Cal for the rest. C. What You Pay Toward the Cost of Your Home TPN Treatment The amount
you pay toward
your home TPN treatment depends
on the annual
net worth of you and
your spouse, or you and
your parents if you are under 18.
Annual net worth
is annual income plus property holdings. The
following are not counted as part of your property holdings: The first
$40,000 of your home’s taxable
value, one vehicle, $1,000 for burial
expenses, burial plots or vaults, wedding and engagement rings,
heirlooms, clothing, household furnishings, and
household equipment. If your
annual net worth
is less than
$5,000, you pay
nothing. If it is $5,000
or more, you
pay one percent of the net cost
of your home TPN treatment costs for each $5,000 of annual net worth
you have. For example, if your annual
net worth is $15,000, you
pay three percent
of the net costs of your home TPN treatment costs. The percent you pay is called your
“percentage obligation.” D. How Your TPN Supplement Eligibility Fits Into Your Regular
Medi-Cal Eligibility TPN Supplement covers home TPN supplies and related
services only. If you or your family need
other types of medical
care, you must meet your regular
Medi-Cal share of cost before
you can receive a regular
Medi-Cal
card. The amount you pay for home TPN supplies and related services
as part of your TPN Supplement eligibility will also be a credit
against your share of cost, just the
same as any other medical bill you pay. Be sure and have your
medical provider or supplier fill out
your “Record of Health Care Costs,” form MC 177.
Once you
receive a regular Medi-Cal
card for
any month, you must
use it for all medical services, including TPN, for the remainder of that month. E. What Happens if You Lose Regular Medi-Cal Eligibility Eligibility for TPN Supplement depends on eligibility for the regular Medi-Cal program. If you lose
eligibility for regular Medi-Cal for any reason,
including accumulation of excess resources, you will
no longer be eligible for TPN Supplement.
In this case, the county welfare department will
determine whether
you are eligible under the TPN Only program. III. Services Covered by the Medi-Cal TPN
Supplement Special Treatment Program A.
The
TPN Supplement Special Treatment Program covers only a limited range of outpatient
benefits. You may use your TPN Supplement Medi-Cal card for approved nutrient solutions and
related supplies, related laboratory services, and outpatient physician visits. If you
require treatment for an underlying condition, acute hospital care, or other
forms of medical care,
you must meet your regular
Medi-Cal share of cost before
Medi-Cal will
pay for these services. IV. Your Responsibilities A.
Medicare Application You must apply
for Medicare coverage after you apply for
this program if you are
receiving Social Security Title II Disability benefits. You must
provide the county
welfare department with
a copy of the Social
Security Medicare status statement, or any evidence of eligibility such as a card or letter, within
60 days of your
Medicare application. If Social Security does not provide you with a Medicare status
statement within 60 days,
you must provide
a copy to the county
welfare department as soon as you do receive it. B.
General Reporting Responsibilities You must report any change in status that could affect your TPN Supplement Special Treatment
Program eligibility or your percentage obligation. Such changes include, but are not limited
to: § Loss of employment. § Change in marital status. § Increase/decrease in earnings. § Change in other health
coverage. I have
reviewed the above
information with the county representative. I understand my responsibilities in regard to Medicare and general reporting requirements.
I have explained the
Medi-Cal TPN Supplement requirements listed above to the applicant.
14-31 DSS (4/88) |
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