2.0 Alliance Membership top

Alliance members can be enrolled in one of the following plans:

· Medi-Cal;

· Healthy Families Program;

· Santa Cruz County Healthy Kids Health Plan; or

· Alliance Care IHSS Health Plan.

2.1 Eligibility by Plan top

Medi-Cal Plan

Medi-Cal is California’s version of the federal Medicaid program, which provides coverage for low-income families, pregnant women, children, the elderly and persons with disabilities who meet certain criteria. The program receives both federal and state funding, and, at the state level, is administered by the Department of Health Care Services.

Eligibility for Medi-Cal is determined by each county, usually through the county’s Department of Social Services. Individuals and families may apply by mail or over the phone. The exception to this are those individuals who receive Medi-Cal because they qualify for Supplemental Security Income (SSI) through the Social Security Administration.

There are different levels of coverage under Medi-Cal, with some individuals and families qualifying for full-scope Medi-Cal and others qualifying for restricted Medi-Cal, with only certain services being covered such as emergency and pregnancy care only. In addition, some individuals have what is called a Share of Cost, which is a set amount they must pay each month to a provider/providers in order be covered by Medi-Cal for that month.

Healthy Families Program

The Healthy Families Program is California’s version of the federal State Child Health Insurance Program or S-CHIP. It provides low-cost health, dental, mental health and vision coverage for children from birth to age 19 whose families earn at or below 250% of the federal poverty level and who do not qualify for no Share of Cost Medi-Cal, have other health coverage or have been covered by employer provided health insurance within the three months prior to application. Children must be legal residents of California, citizens, or qualified legal aliens or be in a satisfactory immigration status in order to be eligible.

Under the Healthy Families Program, enrollees are eligible for a twelve-month period upon enrollment. This allows families whose income rises above eligibility limits to maintain coverage during that period. Applications can be done through the mail or electronically by visiting a Certified Application Assistor (CAA). CAAs are also available through the Alliance. Once enrolled, individuals will remain eligible for a year, unless they fail to pay their monthly premiums for 2 or more months, move out of the area or reach age 19.

Families pay low monthly premiums to the program, depending on the family income and family size. In addition, some services require a $5 co-payment, with a $250 co-payment maximum per benefit year per family for medical services. When they apply, families select a health, dental and vision plan from among the choices serving their county. All Alliance Healthy Families members are linked to a Primary Care Provider.

Santa Cruz County Healthy Kids Health Plan

The Healthy Kids Health Plan is a local, Santa Cruz County program which is part of Healthy Kids of Santa Cruz County. It provides low-cost health, dental, mental health and vision coverage for children who are residents of Santa Cruz County, under 19 years of age, are in families with incomes at or below 300% of the federal poverty level, do not already have health insurance, have not been covered by employer paid insurance within the three months prior to application and are not eligible for no Share of Cost Medi-Cal or the Healthy Families Program. Immigration/citizenship status is not a factor in determining eligibility for the Healthy Kids Program.

The Alliance is the health plan for the Healthy Kids Health Plan. Families apply through a Certified Application Assistor (CAA) in the community. The applications are then sent to the Alliance, which determines eligibility. Once enrolled, a child will have 12 months of eligibility, as long as he/she continues to meet the eligibility criteria and there is sufficient funding for the program. Healthy Kids is a locally funded program, it is not funded by the state or federal government.

Families are responsible for paying quarterly premiums, based on family income and family size. There are $5 co-payments for some services, with a $250 co-payment maximum per family per benefit year for medical services. The benefits are very similar to those of the Healthy Families Program, and all members are linked to a Primary Care Provider.

Alliance Care IHSS Health Plan

The Alliance Care IHSS Health Plan provides health coverage to Monterey County In Home Support Service (IHSS) workers. These IHSS caregivers are employed by the Monterey County Public Authority, and their salaries are paid from a mix of County, State and Federal funds. These are individuals who are employed to provide personal care and support services in the home, (such as housecleaning, transportation, personal care services, and respite care) to eligible, low-income seniors and persons with disabilities. These services allow recipients to remain safely in their homes and help to prevent premature institutionalization.

The Alliance Care IHSS Health Plan was developed by the Monterey County Public Authority in partnership with Central Coast Alliance for Health. There is a distinct benefit package, which includes co-payments for some services ($10 for outpatient services, $25 for emergency room unless admitted, $5/generic prescription and $15/brand prescription). Under the Alliance Care IHSS Health Plan, only the IHSS caregiver will be covered, dependent coverage is not available. There are no dental or vision benefits associated with this plan. Alliance Care IHSS members pay monthly premiums to the Public Authority and are required to maintain a minimum number of hours worked per month in order to remain eligible for coverage.

2.2 The Member Services Department top

The Member Services department staff provides information to members about how to make the best use of the health plan. Members may request a one-on-one or a group orientation to the Alliance. Individual orientations may be done via telephone or in person and all new members are encouraged to contact a Member Services Representative (MSR). During the orientation, Alliance staff help members understand what the Alliance is, how it works and what their rights and responsibilities are as Alliance members. They will talk to members about choosing a Primary Care Provider, explain what managed care is and how it works, explain how members can access care and discuss which services are covered by the Alliance and which are not. The Alliance has a short member orientation DVD in English and Spanish, which can be sent to members. Members can request one by calling Member Services.

Alliance members who are required to be linked to a PCP (approximately 90% of Medi-Cal members, and 100% of Healthy Families, Healthy Kids, and Alliance Care IHSS members), choose a Primary Care Provider. MSRs help members to choose by letting them know which providers are taking new patients. MSRs also help members change their provider.

In order to change a member’s PCP, the request must come from the member or the member’s authorized representative, parent (for minor children) or legal guardian. We cannot change a member’s PCP at the request of a provider. PCP changes are effective the first of the following month, except in certain special circumstances. These exceptions are done on a case-by-case basis.

MSRs assist members on a daily basis with answering questions and problem solving. This ranges from the simple replacement of a lost Alliance ID card to the more complex areas of members having trouble accessing care, member complaints and quality of care issues.

MSRs also attend community group meetings, give presentations about the Alliance, and network with the larger community and other agencies that service Medi-Cal, Healthy Families, Healthy Kids, and Alliance Care IHSS enrollees.

If you are seeing a member that you feel is in need of our help, please direct him/her to call a Member Services Representative. Our hours are Monday-Friday, 8am-5pm. There is also information available to members on the Alliance web site, at www.ccah-alliance.org. Members can see a list of frequently asked questions and answers, view a Member Handbook/Evidence of Coverage, Provider Directory, Alliance Drug Formulary, the latest member newsletter and/or file a complaint on our web site.

Member Services Staff

To reach the staff of the Member Services Department, call the appropriate number or extension listed below:

Jan Wolf, Member Services Director 430-5520

Pat O’Brien, Member Services Manager 430-5521

Angie Baltazar, MS Supervisor Scotts Valley Ofc 430-5522

Veronica Olivaria, MS Supervisor Salinas Ofc 430-6766

Eligibility Clerks 430-5502

Automated Eligibility System (available 24/7) 430-5501

or 800-700-3874, ext. 5501

Member Services Representatives

Member Services Representatives can be reached Monday-Friday, 8 am - 5 pm:

The Alliance Main Office: 430-5505 (English)

430-5508 (Spanish)

The Alliance Watsonville Office:

119 W. Beach St., Watsonville 430-5500 ext. 7038 or

800-700-3874 ext. 7038

The Alliance Salinas Office: 755-8220 ext. 5505 (English)

755-8220 ext. 5508 (Spanish)

2.3 Primary Care Provider (PCP) Assignment top

Under the Alliance Medi-Cal plan, most members are assigned to a Primary Care Provider (PCP). A small percentage of Medi-Cal members have medical or other issues that make successful PCP case management difficult. These are referred to as administrative members.

All Alliance Healthy Families, Healthy Kids and Alliance Care IHSS members are linked to a PCP from their first day of eligibility. There are no administrative members in the Healthy Families Program, Healthy Kids or Alliance Care IHSS plans. If the member or applicant has not chosen a PCP upon enrollment, the member will be assigned to an open PCP, based on zip code, age, gender, language, provider type, provider capacity and family linkage.

Members with a Primary Care Provider (Linked Members)

The majority of Alliance Medi-Cal members, approximately 90%, are linked to a PCP, who is responsible for providing primary care and for acting as the member’s case manager. When a member becomes an Alliance Medi-Cal member for the first time, he or she is “newly eligible” and can see any Medi-Cal provider during the first 30 days of eligibility. During this time, the member must select a PCP to be linked to for the following month. If the member doesn’t select a PCP by the end of his/her first 30 days as an Alliance member, he or she is automatically assigned to an open PCP, based on zip code, age, gender, language, provider type, provider capacity and family linkage.

Linked members are case managed by one of the Alliance’s contracting PCPs. The name of the PCP appears on the Alliance Identification Card or this information may be accessed via the Alliance’s Automated Telephone Eligibility Verification system, or by calling the Alliance’s Eligibility Clerks. Authorization for most services must be obtained from the PCP.

Linked members are able to change their Primary Care Provider by calling an Alliance Member Services Representative, who will talk to them about the reason for the change and let them know which PCPs are taking new patients. The change will be effective the first of the following month. If a linked Medi-Cal member goes off of Medi-Cal and then comes back on within 12 months, he or she is automatically relinked to his/her previous PCP unless the previous PCP is at maximum capacity. In this case, member is reassigned to an open PCP.

Medi-Cal Members Without a Primary Care Provider (Administrative Members)

The remaining 10-15% of Alliance Medi-Cal members are referred to as administrative members and have “Central Coast Alliance for Health” shown on their identification cards rather than a particular PCP. Administrative member designation is determined by an individual’s Medi-Cal eligibility category, an individual’s medical condition or when other circumstances exist which result in the member not being a good candidate for case management. Administrative members will not have a specific PCP listed on their cards.

Administrative members may access care from any willing Medi-Cal provider, without a Referral Authorization Form (RAF). Many administrative members primarily see specialists for their care, and don’t fit into the primary care case management model. Others are case managed, or co-case managed by another agency, such as California Children’s Services (CCS). Although they do not require RAFs, prior authorization requests are required when applicable.

Categories of administrative members include the following:

· Out of area members

Members who reside outside of the service area, but whose eligibility remains in Santa Cruz or Monterey County. An example is a foster child placed out of area.

· Inter-county transfers

An individual moving out of Monterey or Santa Cruz County whose eligibility has not yet been transferred to their new county of residence.

· New Members

New Alliance members are administrative members for their first month of eligibility.

· Retroactive Medi-Cal Eligibility

When an individual becomes eligible for Medi-Cal retroactively and becomes an Alliance member, the member is an administrative member for the retroactive eligibility period only. This reduces the need for retroactive RAFs and Authorization requests.

· Share-of-Cost (SOC)

Individuals who are eligible for Medi-Cal with a Share-of-Cost do not become Alliance members in any given month until they have satisfied the SOC requirement. (See further description on page 7.)

· Geographic Access

Members who live more that 10 miles or 30 minutes from a contracted Primary Care Provider.

· HIPP Members

Members who are approved for the HIPP (Health Insurance Premium Payment) program by the Alliance.

· Member Deletes

When a member has been deleted by his/her PCP, the member is made an administrative member for the month the delete becomes effective, to give him/her time to select a new PCP. If the member does not select a new PCP within that month, he/she will be assigned to an open PCP for the first of the following month.

If one of your members meets that following medical criteria, please contact the Health Services Department at the Alliance at 430-5567 (Santa Cruz County members) or 755-8220 ext. 6771 (Monterey County members).

· Breast and Cervical Cancer Treatment Program (BCCTP)

Member who qualifies for limited Medi-Cal benefits because of a Breast or Cervical cancer diagnosis.

· California Children’s Services (CCS) eligibles

Children who are covered for CCS eligible services must see a CCS panel provider for the CCS diagnosis. For Alliance covered services, they become administrative members

· End Stage Renal Disease

· Hospice Patients

· Long Term Care/Institutional Care

When a member goes into a Skilled Nursing, Intermediate Care, or Long Term Care Facility and the stay is expected to last for at least one full calendar month after the month of admission.

· Major Organ Transplant

· Persons with HIV or AIDS

The change of a member’s status to administrative is not automatic. The Alliance needs to be informed by the provider or the member in order to make the change in status. For medical reasons, please contact the Health Services Department at the Alliance at 430-5567 (Santa Cruz County members) or 755-8220 ext. 6771 (Monterey County members) if you feel a member’s status should be changed to administrative. For non-medical reasons, please contact the Member Services Dept., 831-430-5505.

Claims for services rendered to administrative members must be sent to the Alliance unless the member is CCS, in which case the claim should first be forwarded to the CCS office. All covered services provided to administrative members are reimbursed on a Medi-Cal fee-for-service basis.

There are no administrative members under the Healthy Families, Healthy Kids, or Alliance Care IHSS Plans.

Not all Medi-Cal Beneficiaries are Alliance Members

Medi-Cal beneficiaries who become eligible in counties other than Santa Cruz and Monterey are not the responsibility of the Alliance. However, any Medi-Cal provider may render services to these members and bill EDS or the appropriate Medi-Cal Managed Health Care Plan.

When a member moves out of the area, it is his/her responsibility to notify his/her Medi-Cal eligibility worker or the Social Security Administration (for those individuals receiving SSI). If you, as a Primary Care Provider become aware of Alliance members who have moved, or may be planning a permanent move out of our service area, please provide the Member Services Department with the out of area address. This will allow the Alliance to confirm that the member has reported the move. The member will be dropped from your case management list by the first of the following month and will remain in an administrative capacity until the member’s case is transferred to his/her new county.

The majority of Alliance members who leave the service area will eventually become the financial responsibility of the new county of residence and cease to be Alliance members. The time frame to effect this change depends on several factors, including the timeliness of notification which program the member is enrolled in and how long that program takes to transfer a member’s case. It can take from two weeks to three months.

There are several circumstances when a person residing or relocating out of county does not result in a change of responsible county. They are:

1. Placement of foster/adoptive children out-of-area; and

2. Placement of children, adults or Long Term Care residents where responsibility for the individual remains in Santa Cruz or Monterey County through guardianship, conservatorship, parent or probation.

The Alliance routinely receives notification from the Human Resources Agency/County Social Services Department and Social Security Administration staff regarding members change of county residence, and has developed materials to inform members how to access health care services while outside the Alliance service area.

Non-Medi-Cal Alliance Members

Healthy Families, Healthy Kids and IHSS Member Eligibility are not governed by Medi-Cal regulations but are under the Department of Managed Health Care and should be considered a commercial benefit plan with different fee schedules and procedures.

Who Determines Eligibility?

ü Eligibility for Healthy Families is determined by the Healthy Families Plan.

ü Eligibility for Healthy Kids is determined by the Healthy Kids Coordinator at the Alliance.

ü Eligibility for Alliance Care IHSS is determined by the Public Authority.

Primary Care Provider (PCP) Assignment

All members enrolled in one of these plans will be linked to a PCP on the Effective Date of their eligibility. There are no administrative members in these plans. Members must access care from their PCP or obtain a RAF (Referral Authorization Request) to see another provider or specialist. If the member or applicant has not chosen a PCP upon enrollment, the member will be assigned to an open PCP.

The name of the PCP appears on the Alliance Identification Card. Eligibility information can be accessed via the Alliance’s Automated Telephone Eligibility Verification system, or by calling the Alliance’s Eligibility Clerks. Authorization for most services must be obtained from the PCP.

Linked members are able to change their Primary Care Provider by calling an Alliance Member Services Representative, who can make the change effective the first of the following month.

Co-pays (not Share Of Cost)

Members enrolled in these plans have varying co-payments. Co-pay amounts depend on what service the member is accessing. There are generally no co-payments for preventive services such as immunizations and well-child care.

Out of Area

Members enrolled in these plans cannot access non-emergency/non-urgent services outside the service area. Members who have moved outside the service area will have their benefits either transferred to a health plan in their new area (Healthy Families) or will be terminated at the end of the month (Healthy Kids, IHSS).

2.4 Identification of Members top

Eligibility must be verified prior to delivery of services. The Alliance identification card alone does not verify eligibility.

· For PCPs - check your monthly Alliance Member List, your Mid Month Capitation List, or follow procedures in the next paragraph

· For All Providers - Check member eligibility on-line at www.ccah-alliance.org. If you have not already used this feature, you will need to request a PIN from the Provider Services Department. The web site will walk you through the process. There is also a link to the state Medi-Cal web site, in case you need to see if a patient is eligible for fee-for-service Medi-Cal.

· Call (831) 430-5501 for the 24 hour eligibility verification line OR

· Call the Alliance Eligibility Clerks, (831) 430-5502, Monday through Friday, 8 am to 5 pm.

· Fax the Alliance using an eligibility fax form. You must provide the member’s name, and date of birth, or the member’s Alliance ID or Social Security Number (Please note that the SSN can only be used to verify eligibility for Alliance Medi-Cal or Alliance Care IHSS members only), the date of service that you are checking eligibility for. The Alliance will fax you back the form indicating whether or not the member is/was eligible, what plan the member is/was enrolled in and who the PCP is/was. To get a form for your office, please contact the Provider Services Coordinator at (831) 430-5540.

If you cannot verify eligibility for a Medi-Cal member through the Alliance, please swipe the BIC card. This can tell you if your patient is eligible for Medi-Cal but not covered under the Alliance.

To determine eligibility for a Healthy Families enrollee, you must contact the specific health, dental or vision plan the individual is enrolled in or call the Healthy Families Program at (800) 880-5305. To determine eligibility for a Healthy Kids enrollee, you must check your member list or verify eligibility through the Alliance using one of the options listed above. To determine eligibility for an IHSS enrollee, you must check your member list or verify eligibility through the Alliance using one of the options listed above.

When you call or fax, you will need to provide the clerks with the following information:

ü The member’s full name

ü The member’s Alliance ID # or Social Security Number (SSN can only be used for Medi-Cal or Alliance Care IHSS members)

ü If you do not have the member’s Alliance ID and/or Social Security Number, you will need to provide the clerk with the member’s date of birth, along with the member’s full name

ü Date(s) of service you want to check eligibility for.

The on-line and automated eligibility systems and the Eligibility Clerks will provide you with the following pieces of information:

ü Eligibility status for the date(s) of service requested. (Please note, our eligibility information is most accurate for the current month and the preceding 11 months. The electronic systems cannot check eligibility for Dates of Service older than one year.

ü Name of the member’s PCP or identification of the member as an administrative member.

ü Whether or not the member has other health coverage.

ü CCS eligibility, if applicable, for the member.

In addition, the on-line and automated eligibility systems will provide you with a confirmation number. You will not receive a confirmation number from the Eligibility Clerks.

2.5 Medi-Cal Members with a Share-of-Cost (SOC) top

Medi-Cal recipients with a Share-of-Cost do not become Alliance members until they have met their monthly Share-of-Cost. Providers can post monies paid for services toward a member’s SOC either via the DHCS website, the POS device, or by calling DHCS. Contact the POS and Internet Help Desk at 1-800-427-1295. Please post SOC amounts on the date the member paid. If you cannot post SOC amounts, please provide the member with a receipt which the member can present to his/her Eligibility Worker for posting.

2.6 Member Identification Cards top

Medi-Cal recipients are issued a plastic Medi-Cal identification card by the state, known as the Benefits Identification Card, or BIC. The BIC shows the member’s:

ü name,

ü date of birth,

ü Medi-Cal identification number (or CIN) and

ü the card issue date.

Use this information to verify eligibility with the state or with the Alliance. The County Social Services Department may issue a temporary, emergency “paper card” when the member cannot wait for the state to issue the plastic BIC.

The Alliance also issues an identification card to members. The Alliance ID card for Medi-Cal members is a black and white, laminated card that identifies Medi-Cal recipients as Alliance members, but is not a guarantee of eligibility and payment for services. Providers are still responsible verifying eligibility and linkage prior to the date of service.

The Alliance ID cards for Healthy Families are purple and white paper cards and has the Healthy Families Program logo as well as the Alliance logo in black on the front of the card.

The Alliance Healthy Kids member ID card is a white and red violet paper card and has the Healthy Kids logo in red violet as well as the Alliance logo in black on the front of the card.

The Alliance Care IHSS member ID card is a white and red paper card and has the Alliance logo in black on the front of the card.

All Alliance ID cards have the following member information:

ü Member name

ü Alliance ID number

ü Member’s effective date with the Alliance

ü Member’s date of birth

ü Name, address and phone number of the member’s PCP.

Alliance ID cards are reissued only when there is a PCP change or a card is lost. Cards are not sent annually.

Alliance Medi-Cal members who have a Share of Cost will not receive an Alliance ID card until they have met their share of cost for the first time. Once members meet their share of cost for the first time, they will be sent an Alliance ID card, which the member will use for current and future identification. Members are not reissued a new card each month in which they meet their share of cost.

The Alliance cards are intended only to be a means of identification; they are not proof of eligibility. Providers must access eligibility information through one of the options made available by the Alliance. (See section 2.4)

2.7 Medi-Cal Aid Codes top

The Medi-Cal aid code is the two-digit number that tells the specific program category under which the individual qualifies. The State Department of Health Services, not the Alliance, establishes aid codes. Medi-Cal aid codes are assigned by county Medi-Cal eligibility staff, based on federal and state guidelines for eligibility. The list of aid codes is revised regularly.

There are some aid codes that are not covered by the Alliance. These aid codes are reimbursed by Electronic Data System (EDS), the state Medi-Cal fiscal intermediary. A listing of the excluded aid codes is on the following page.

Services provided to members with an aid code not covered by the Alliance must be billed to EDS. It is important that providers be able to identify this for correct billing. Any necessary prior authorization for elective services (Treatment Authorization Requests) for members with excluded aid codes should be submitted to the Medi-Cal field office, not the Alliance.

Aid Codes Not Included in Alliance’s Contract with the State

Percent of p