January 10, 1995CMSP LETTER 95-1

ALL CMSP COUNTY WELFARE DIRECTORSALL EXPEDITED ELIGIBILITY CONTACT PERSONS

To=

EXPEDITED ELIGIBILITY PROCESS REQUIREMENTSSubject:

In a recent letter (CMSP LETTER 94-6, dated November 4, 1994), weprovided a basic overview of the County Medical Services Program(CMSP) Medical Case Management Pilot Project which includes anexpedited eligibility component. Medical Case Management is aprocess which coordinates quality care and assures continuity ofcare for certain hospitalized CMSP beneficiaries suffering fromchronic/catastrophic illness or injury, and/or requiring medicallyextensive services. As an extension of the California Departmentof Health Services' utilization review function, case managementactivities link the beneficiary with medically necessary outpatientservices to facilitate discharge from the hospital. In addition tothe direct benefits to those being case managed, it is anticipatedthat there will be significant program cost savings as a result ofthe activity. For these reasons the Small County AdvisoryCommittee approved the pilot project. This letter provides youwith detailed information concerning the process, the specifictasks which the "home" County needs to complete as a part of thatprocess, and the forms which will be used. It should be noted thatvolume of cases to be processed through the expedited process willvary from county to county. The total number of anticipated casesstatewide to be evaluated within a full year is 600.

EXPEDITED ELIGIBILITY PROCESS

The process will commence when either staff at one of the targetedhospitals or the Medi-Cal Case Manager (MCCM) identifies a case asa candidate for Medical Case Management. If the MCCM after aninitial evaluation considers case management appropriate, the MCCM

All CMSP County Welfare DirectorsPage 2

will contact the Expedited Eligibility Clearinghouse Unit (EECU),located in Sonoma County, which will determine if the individual iscurrently a CMSP eligible. If the individual is currentlyeligible, the MCCM and the hospital will be notified and casemanagement activities will commence. If the individual is notcurrentlyeligible, the EECU will contact the hospital (contactperson) and direct them to assist the individual in the completionof the required forms. Once completed, the forms will be FAXEDfrom the hospital to the EECU which will determine if theindividual is eligible. When a decision is reached, the EECU willFAX its decision to the appropriate Home County Contact Person(HCCP) .If the individual was determined eligible, the HCCP will

be responsible for insuring that a CMSP case is established. Onceestablished, the HCCP will FAX the case number to the EECU (whichwill pass the information on to the MCCM and the hospital), flagthe case for tracking purposes, and schedule a redetermination ofCMSP eligibility within 3 months. If the individual is noteligible, the HCCP will insure that the appropriate actions aretaken. The entire eligibility process will be completed within 48hours.

SPECIFIC TASKS FOR THE "HOME" COUNTY

Your County has identified an individual to be the Home CountyContact Person (HCCP) for this process. This is the person whowill be responsible for accepting information and direction fromand responding to the EECU. If your County has not designated anHCCP, the County Welfare Director will be considered the HCCP.Beyond the HCCP, the County should determine which individual(s)will actually perform the required tasks listed below in order toinsure that the 48 hour completion deadline is met. The HCCP isresponsible for insuring that the "HOME" County:

Assists the EECU in determining if an active Medi-Cal or CMSPcase exists or if a pending CMSP case is being processed incounties where such information is not readily available in atelephone accessible central file index.

1.

Receives the FAXED expedited eligibility information from theEECU.

2.

Takes the appropriate steps to process an EECU based expeditedeligibility denial decision.

3.

approvalbased expedited eligibilityEECU4. Evaluatesdecision.

an

All CMSP County Welfare DirectorsPage 3

For all EECU based approvals which are considered correct,within 1 working day of notification: establish a CMSP case;assign a case number; create a case file folder; create a MEDSrecord; process the appropriate Notice of Action; flag thecase created for tracking purposes; notify the EECU via FAXthe full CMSP case number assigned; insure that aredetermination of eligibility will occur within 3 months ofthe case establishment; any other actions required by thelocal County Welfare Department.

6. For EECU based approvals which are considered incorrect,within 1 working day of notification: FAX to the EECU thereason why the approval decision was incorrect; take theappropriate actions to deny the case including issuance ofNotice of Action. Please note that override decisions must bebased on one of the following where the Home County identifiesthat: a. a regular CMSP application is in process; b. theindividual is not eligible for the full scope of CMSP benefitswith no Share of Cost; c. the individual is ineligible basedon excess property; d. the individual is currently ineligibledue to a previous transfer of assets where there wasinadequate consideration received; e. the individual is not aresident of the county.

7 For all cases added through the expedited process: monitorthe continuing eligibility status of individual's being casemanaged; report changes in the eligibility status of theseindividuals to the EECU; initiate the process for performinga redetermination within 3 months of the case beingestablished. The redetermination is to be completed under thelocal County Welfare Department procedures with theexpectation that each case managed individual will apply forMedi-Cal and be evaluated for that eligibility based ondisability (DED referral) .The results of the redeterminationmust be reported to the EECU.

EXPEDITED ELIGIBILITY FORMS

The forms used in the expedited process include:

SAWS 12 PAGE SHORT FORM CMSP APPLICATIONCMSP 216CMSP 217CMSP 1153CMSP 13DECLARATORY AFFIDAVIT

All CMSP County Welfare DirectorsPage 4

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Attached to this letter you will find several items. Attachment 1provides you with approval and denial notice of action language foruse in this pilot project. Attachment 2 contains a copy of theforms which will be used. Attachment 3 is a question and answersummary about the project. Attachment 4 is a flowchart of theentire process.

Sonoma County has designated Ms. Carol Shirrell and Mr. SteveRussell as the staff assigned to the EECU and Ms. Judy MadMaster astheir supervisor. The EECU contact phone numbers are intendedintended solely for the use of the HCCP and must not be madegenerallyavailable. These numbers are:

(707)(707)

527-2420527-2666 (FAX)

By assuming the liability for the decisions reached by the EECU,the SCAC has confirmed its commitment to the pilot project. As akey player in the pilot system, your timely, active participationis critical. If you should have any questions regarding thisletter or the project, please contact the Project Coordinator,Mr. Albert Cooper at (916) 322-1615 or via FAX at (916) 322-1533.~

Sincerely,

C' ~ -7}f 1'~ frv ~/ " /J--

// f/,f~rit Martinez, Chief /

County Medical Services Program

Attachments

CMSP County Contact Personcc:

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ATTACHMENT 4

EXPEDITED ELIGIBILITY PROCESS FLOWCHART

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ATTACHMENT 3

EXPEDITED ELIGIBILITY QUESTIONS AND ANSWERS

CMSP EXPEDITED ELIGIBILITYQUESTIONS AND ANSWERS

1. Q. How many people will be case managed? In which hospitalswill the case managers work?

A. Current estimates indicate about 300 per year in thetargeted hospitals. Hospitals include: Mt.Diablo (ContraCosta) ; El Centro community, Calexico, and pioneer (Imperial) ;UCLA Med Center (Los Angeles) ; Queen of the Valley and st. Helena(Napa) ; UCD Med Center (Sacramento) ; Loma Linda (San Bernardino) ;Donald Sharp,Scripps, UCSD Med Center, Mercy (San Diego) ; UCSFMed Center and st. Francis Memorial (San Francisco) .

Q. How many workers will be in the clearinghouse unit?A. Initially, 2 eligibility workers.

2.

3. Q. Who is liable for eligibility determination decisionsreached by the clearinghouse unit?

A. The SCAC Governing Board will assume liability on behalfof all participating counties.

4. Q. Can a home county override a clearinghouse uniteligibility determination (assuming the home county has morecomplete information)?

A. The Home County may override the clearinghouse unitdecision that an individual is eligible in cases where: aregular CMSP application is in process; the individual is noteligible for full scope benefits with no Share of Cost; theindividual is ineligible based on excess property; the individualis currently ineligible due to a previous transfer of assetswhere there was not adequate consideration; the individual is nota resident of the county. THE HOME COUNTY MAY OVERRIDE THECLEARINGHOUSE UNIT DECISION THAT AN INDIVIDUAL IS INELIGIBLEBASED ON THE EXPEDITED ELIGIBILITY INFORMATION.

5. Q. will case management continue regardless of the residenceof the individual involved or will it continue only if theindividual is in their HOME county?

A. Case management should continue as long as the individualremains a CMSP eligible, regardless of where he/she is physicallylocated. The HOME county in these instances would maintain thecase UNTIL notified by either the new HOME county or theclearinghouse unit that a new case had been opened. The originaland new HOME counties would be responsible for notifying theclearinghouse unit of any such changes.

6. Q. Is their a hierarchy of precedence in situations where ahome county has a regular CMSP application in process, and theclearinghouse unit directs the home county to establisheligibility?

A. In situations where a "regular" CMSP application isactive, there will be no expedited process. The home county

should immediately notify the clearinghouse unit if a regularapplication is in process. This policy will be reevaluated oncethe project has run for 6 months.

7. Q. Who completes the basic application forms for the expeditedprocess?

A. The hospital contact person will assist the patient in theapplication process if no relatives were available to do so.

8. Q. will an individual determined eligible under the expeditedeligibility process receive a CMSP card?

A. Yes, the card will be mailed to the home address of thisindividual.

9. Q. If an individual is placed on the CMSP through theexpedited process, and then experiences a fatal eligibilitycondition (i.e. loses citizenship, declares residency in an MISPcounty, converts to Medi-cal, etc.) who is responsible for changenotification and or case processing? How is this accomplished?

A. The HOME county would bear this responsibility and woulduse the "regular" CMSP case termination process.

10. Q. What happens if the client in the home countyredetermination process fails to cooperate in the DED process?

A. For this pilot, CMSP eligibility will be terminated forfailure to cooperate.

11. Q. Who will assist the client in completing the DED paperworknecessary to complete the referral process? How will this bedone if the client is in one county and the information is in thehome county?

A. Relatives, friends. The contact person and/or the casemanger could help facilitate the retrieval of necessary medicalinformation with the proper authorization documents.

12. Q. will the case managers be aware of the Medi-CalPresumptive Disability criteria? will they alert theclearinghouse unit when they encounter them?

A. YES. YES.

13. Q. will an individual's CMSP eligibility status (i.e.eligible for full scope of benefits vs limited scope of benefits)affect the case management process? If so will this informationbe passed to the case manager?

A. Yes. Only those individuals eligible for full scope ofbenefits will be case managed. The Home County Contact Personwill pass this information to the clearinghouse unit.

14. Q. If an individual who was first on CMSP based on theexpedited eligibility process, then later placed on Medi-Cal, butwho then loses Medi-Cal eligibility STILL case managed? How willnotification of these changes occur?

A. In this situation case management will cease when Medi-Caleligibility terminates. The individual must reapply for CMSP via

the regular application process.

15. Q. Are individuals determined eligible with a Share of Costcase managed? Individual's with other health coverage?

A. Persons with a Share of Cost are not case managed whilepersons with other health coverage will be.

16. Q. What is required of the HOME county when redeterminingeligibility for an expedited eligible?

A. All activities which are required for regular CMSPredeterminations AND the processing of a companion disabilitybased MEDI-CAL application (including a DED referral) .Thesecases are not to singled out for any "special" handling beyondthe 3 month window and the DED process.

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ATTACHMENT 1

NOTICE OF ACTION LANGUAGE

1""""

,-

EXPEDITED ELIGIBILITY PROCESSSUGGESTED NOA LANGUAGE

(TO BE USED IN NOAS PRODUCED BY COUNTIES)

GRANTING

WE HAVE REVIEWED THE INFORMATION ABOUT YOUR CIRCUMSTANCES WHICHYOU HAVE PROVIDED AND FOUND THAT YOU ARE ENTITLED TO RECEIVECOUNTY MEDICAL SERVICES PROGRAM (CMSP) BENEFITS BEGINNING THEFIRST DAY OF ENTER MONTH/YEAR .SINCE YOU APPLIED FOR THECMSP UNDER THE EXPEDITED ELIGIBILITY PROCESS, YOUR CONTINUINGELIGIBILITY WILL BE RE-EVALUATED WITHIN 3 MONTHS BY THE COUNTY.

INITIAL DENIAL..

WE HAVE REVIEWED THE INFORMATION ABOUT YOUR CIRCUMSTANCES WHICHYOU HAVE PROVIDED AND FOUND THAT YOU ARE NOT ELIGIBLE FOR THECOUNTY MEDICAL SERVICES PROGRAM UNDER THE EXPEDITED ELIGIBILITYPROCESS. WE HAVE REACHED THIS CONCLUSION BECAUSE:

( ) YOUR INCOME EXCEEDS THE AMOUNT ALLOWED FOR LIVING EXPENSES.

( YOU ARE NOT A RESIDENT OF THIS COUNTY.

( YOU HAVE AN ACTIVE REGULAR APPLICATION FOR CMSP.

( YOu ARE NOT ELIGIBLE FOR THE FULL SCOPE OF CMSP BENEFITS.

( YOU HAVE TRANSFERRED PROPERTY WITHOUT RECEIVING ADEQUATECONSIDERATION IN RETURN .

YOU APPLIED FOR THE CMSP UNDER THE EXPEDITED ELIGIBILITY PROCESSIN ORDER TO PARTICIPATE IN THE MEDICAL CASE MANAGEMENT PILOTPROJECT. THIS DENIAL MEANS THAT YOU WILL NOT BE CASE MANAGED ASA PART OF THE CASE MANAGEMENT PILOT PROJECT.

THIS DENIAL IN NO WAY LIMITS YOUR ABILITY TO APPLY FOR THEREGULAR CMSP PROGRAM, AND HAVE YOU CIRCUMSTANCES EVALUATED.PLEASE CONTACT YOUR LOCAL COUNTY WELFARE DEPARTMENT IF YOU WISHTO APPLY.

ATTACHMENT 2

EXPEDITED ELIGIBILITY FORMS

COUNTY OF SONOMA HUMAN SERVICES OEPARTMEN

APPliCA TJON FOR COUNTY MEDICAL SERVICES PROGRAM (CMSP)

1. HAMI

RISSI C... '.

I Alien'

3. Marital Status: r J Married ( ] Single !4. list other family members with whom you live

Name I Bil1hdale r

J Divorced SeparatedI OL '.

SocjaJ Secu~uJ!1~ 1- Rela~onshiE Circle SexI P"otO ID

I O.ol.,.tion

5 Date of hospital admittanceIOthor

J CMSP '3

6. Name of Hos.pital

7 Medical need

8. County of residence

OTHER HEAL THCOVERAGE

VI& ( J No9Do vou nev. eny h..lth ineuranoa which is currently in effect?

.availaole througn a parent. employer. or .be.nt p8rent which vou h.ve not applIed tor?

.It vour enlWer II y.8 to .ny of the .bove. pl.88e oompl8te ttle 1ollowing:

Neme of He8lth Insu'.ence ~".on(,) Insured-

Premium/How Often Peid

M...t~Y I J

Ouart.tly IIE.0/..t.an 0...,

A. Are you working or expecting to work in the next 2 month.?If yes. pl&e" complete the intorm.tion b.low:.

Yes } No10,

SOURCE AMOUNT I FAeQUENCY(W88kly,Mont"ly)

B. If not currently working: Date last worked Date last pay received

Do you receive any of the following items free or in exchange for work?rent or housing --utilities food clothing

2 How much do YOu pay each month for rent $ Utilities $

Have you applied for, do you receive or do you expect to receive any of the followingbenefits or payments? (check if ye$i)

-Social Security Disability or Workman's Compensationretirement benefits Money from an Insurance

-SSl/sSP settlement or a lawsuit-Unemployment Insurance Payment from another County-State Disability Insurance Generif Assistance/General Relief

Veterans Benefits OtherIf yes, how much have you already recelvedliiTi"" month?How much do you expect to receive in the next 2 months?Do you pay child or spousal support? [ ] Yes ( } No8. Have you ever been in the U.S. Military service? ( ] Yes ( J No

.Are you the spouse, parent, or child of a person who has been in the U.S. Military service?( J Yes [ J No

':l.. o \sso

14. Do you have life Insurance? If SO, company name and address.COUNTY USE ONl

Is your policy whole life or term ?

what is the face value ? cash surrender value ?List all liquid resources you have. such as cash, checking and savings accounts. Stocks,

retirement accounts. etc.

Tvoe of Account

5

Bank Account Number Balance

Do you have/own a carl sI or other motor vehicle(sl ? If so. list year and make:16.

Are you purchasing a home or do YOu own a home or any other real propertY?If so, please list:

17

Do you own a boat, jewelry or any other personal property, other than household items 7If so please list:1 a.

'9 Has anyone given away, transferred. sold or traded any money, vehicles, propertyor other resources like those listed above in the last 30 months ? If yes, completethe following:

OateItem

.1 J Transferred [ ) SoldI 1 ] Traded [ ] Closed

..I] Given A way

aE SURE YOU HA VE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONSREAD THE FOLLOWING CAREFULL Y

-I ~olere under penelty of per,ury thet the en.wers I heve glv~n ere correct end true to the beet of my knowledge

..I agree to tall the Counry Department within 10 d8VI if there are 8nv change. in my (or the perlon on W"O8e be"8tf I em 8ctingl income,

poBses.ion.. or sxpsn..1 or In t"e number of per.onl In the houlo"old or of Inv ohanQe of Iddr..I. end I -oree to meet ell other reBponaibilitisB&xplelned In the "County Medico! Service. Progrem(CMSPI Reepon..bllltie. Checklist" I hive recelveo

-I under.ta"d that t may be asked to prove my Btetement and thet my eligibility m-y be &ubj-ct to a Quality contro! review--I under&tend that the COU"ty i& required by lew to keep ell informetion I provide confidentiel.

I REAlIZE THAT IF I DELIBERATELY MAKE FALSE STATEMENTS OR WITHHOLD INFORMATION. I (OR THE PERSONON WHOSE BEHALF I AM ACTING' MA Y LOSE MY CMSP CARD ANO/OR I CAN BE PROSECUTED FOR FRAUD

SIGNATURE OF APPLICANT OR PERSON ACTING FOR APPLICANT OATE:

SiGNATURE OF WITNES511F APPLICANT SIGNED WITH MARK) DATE:

ADORESSSIGNA TUAE OF PERSON HELPING APPLICANT COMPLETE FOAM OATE

COUNTY USE ONL y

E.W. SIQNATUAE/ DAn

DA TE OF BIRTH:

TELEPHONE #:HOSPIT AL DA TE:

TIME:

TO: COUNTY

FROM: SONOMA COUNTY CMSP CLEARINGHOUSEP.O. Box 1539

Santa Rosa, CA 95402

T eJephone #FAX #

A TTENTION:

n The above person has been approved for full scope no share of cost expeditedeligibility effective , if you are in agreement with the determination,approval must be within 1 working day and CMSP # supplied to clearinghouse.

D The above person has applied for full scope, no share of cost expedited eligibilityand we are unable to determine eligibility because:

Please proceed with determination through regular process

0 Case management has ceased.

TO SONOMA COUNTY ClEARINGHOUSE

1. The above case has been processed for full scope, no share of cost expeditedeligibility. The CMSP # is

2. The above case has been denied full scope, no share of cost eligibility because:

0 information is known that other persons have linkage to patient

u case has been discontinued

0 case is share of cost

0 case has converted to Medi-Cal the new # is

0 client has moved out of county

stateffo.rm

DATE:

I"""TIME:

HOSPIT ALTO:

SONOMA COUNTY CMSP CLEARINGHOUSEFROM:

iS an inpatient inWe have received notification that

your facility and may benefit from CMSP medical case management.

If you wish that an expedited CMSP eligibility determination be completed, please

contact the case manager .

stateffo.rm