There are three separate processes. The first is the original application. Second is the annual redetermination and the last is the recovery questionnaire.
The goal with the original application is to get approval in the shortest time frame possible. The annual redetermination goal is to maintain eligibility and with recovery, it is to avoid recovery against the beneficiary’s estate for benefits paid out.
With the goal of getting approval as quickly as possible, we submit the application via UPS Overnight. This provides evidence of when the office received the application. This is important because they have 45 days to either approve or deny benefits.
Applications can be submitted in a variety of ways. One way is to do it online. For this, a Covered California application can be completed. This is a very short basic initial application that goes to Sacramento. Sacramento then forwards it to a local office for further processing.
This actually delays the process by as much as a week.
One could also apply in person or submit an application via the mail. Based on our many years of experience, submitting an application via UPS Overnight is the best choice.
We have seen online applications for LA County long-term care go to a local general Medi-Cal office then get transferred to the LTC office. This took weeks to happen.
Once the case is assigned to an eligibility worker (EW), they will do a quick review of the application then send out a request for additional information. By this time in the process, a couple of weeks has already passed. This is the problem with doing it online, delay in processing.
This is why we like to send the application in via UPS. We already know what documentation the EW needs so we send in as complete an application as we can. This helps to speed up processing.
Imagine that you’re an EW and you have a stack of files on your desk to process. Which one is going to get faster, the most complete and organized, or the one with the least amount of documentation?
We want our file to stay on top of the stack not at the bottom.
Once the request for more information is received, we have 5 days to respond. There is an automatic 5 day extension given if response hasn’t been received by the EW.
Back in the pre-Obamacare days in LA, we were able to call the EW directly once the case was assigned. This helped to clarify any issues the EW had or to have them tell us what the latest requirements were that had come down the pipe. This helped to speed processing.
After Obamacare was implemented in California, processing became more difficult. Instead of being able to contact the EW directly, a “Customer Service” number was created. Now, in order to contact the EW, a message had to be left with the customer service person which was then forwarded to the EW. The standard line was “they’ll get back to you in 24 hours (We have a number now that is not published which bypasses the customer service number and allows us to get in touch with someone quicker).
For the most part, EW’s responded but sometimes there was no response even after multiple calls. In the old days the EW’s phone number was on all of the forms but that stopped. So when the EW called us and left their number for us to call back, we created our own directory of EW’s numbers. Once again, a time saver.
LA County also recently put in a new computer system to help streamline the application process. With the old way, our entire paper application packet was given to the EW. They had everything in one place. This was a good thing.
With the new computer system, upon arrival at the office, everything is now scanned in. But it’s not all in one place. So, the EW’s using their psychic powers, have to go to different places to get all of the information they need. This often means that they end up requesting information that we have already sent to them (a bad thing).
Ideally, we receive a Notice of Action (NOA) of Medi-Cal approval. But occasionally we would get one for a denial. The most common reason was the EW (and supervisor) were not familiar with the exemption for Japanese American redress payments of $20,000 for internment during WWII.
Decades ago we were the first in LA County to use this exemption and had to fight to educate LA County EW’s and supervisors. Even today, we encounter new EW’s and supervisors who deny applications because of this.
If an application is denied, one can apply for a Fair Hearing which is an administrative hearing. I can’t remember ever having to file for one in LA because of the many other options they have to correct an error in processing. Knowing how to appeal a denial without having to go to a fair hearing saves months off of the approval process.
Recently the worst situation in LA that we ran into was an initial denial because the applicant was over assets due to the EW and supervisor counting a spouse’s retirement account as a countable asset. Spouse’s retirement accounts are non-countable and a periodic income doesn’t have to be taken. That’s the rule.
The supervisor was vocally adamant that she was right even after I sent her all of Medi-Cal’s own available information as proof. We were unsuccessful in appealing to her boss. In this situation, because of a contact, we went directly to Sacramento and the error was straightened out.
We’ve also run into major problems with Orange County where EW’s routinely reject our applications. Both they and their supervisors fail to respond to phone calls or written requests. In these cases, we’ve had no choice but to file for a fair hearing.
Fortunately, about a week before the hearing date, I will get a call from the appeals officer. In fact, the last time this happened, she opened the phone call with “Mr. Kim, before we get started let me just say that we are wrong.” So we spent the rest of the call figuring out how to correct the mess of the OC office and never went to the fair hearing.
Once the approval is received, we notify the facility. Business offices appreciate us keeping them in the loop as to the application status. Upon approval they can go to the Medi-Cal website and get all of the information including the Share of Cost.
In the case of married couples, once the spouse is approved, our work doesn’t end there. We now have to separate accounts and provide proof within 90 days to the EW that this was done.
With Obamacare, another layer of bureaucracy was created with the formation of the Healthcare Options (HCO) department. HCO is supposed to make sure that Medi-Cal recipients are enrolled in a managed care plan (HMO).
The difficulty here is that the incorrect Authorized Representative was often listed on their computer system. Their system and Medi-Cal’s didn’t line up correctly.
In the old days, health care came directly from Medi-Cal. But now it has to go through a managed care provider. If the plan was set up wrong in LA County, we then have to go to another agency called LA Cares to get it straight.
The reps there are not knowledgeable and we would go around and around between these two agencies.
This is important to the facilities because now, instead of Medi-Cal paying them, the managed care provider pays them.
NEXT TIME: Redeterminations and Recovery