 Alright, welcome to the San Francisco Public Library Government Information Center. Today we are proud to bring you Bay Area Legal Aids presentation, Know Your Rights, MediCal, Medicare, and Covered California. I will begin with the land acknowledgement. Welcome to the unceded land of the Ohlone Tribal people. We acknowledge the many Raimutush Ohlone Tribal groups and families as the rightful stewards of the lands on which we reside. San Francisco Public Library is committed to uplifting the name of these lands and community members from these nations with whom we live together. SFPL encourages you to learn more about first person culture and land rights and are committed to hosting events and providing educational resources on these topics. A little bit of housekeeping for you. Audio, video and chat will be monitored and recorded for quality assurance and record keeping. By default, all participants will be muted and video turned off to avoid distractions during the presentation. To submit a question or comment, you may select the chat button at the bottom of your screen and type in your message and alternatively you may save your questions until the end of the program. At that time you may utilize the raise hand function and the presenters will call on you. Again, welcome to the San Francisco Public Library. I am pleased to hand it over to Amy Freeland from Bay Area Legal Rights, Bay Area Legal Aid. Excuse me, Amy, the floor is yours. Okay, thank you. Okay, I am Amy Freeland from Bay Area Legal Aid Health Consumers Center. And the Health Consumer Center is an advice hotline. We provide freely assistance on health care coverage and health care access issues. Most of what we provide is legal advice tailored to the situation for who is calling us. But we also occasionally do brief services or even extended representation, including representing people at state fair hearings. We provide services to people in any languages. If it's not a language that we have a staff person who speaks, then we get an interpreter on the line. And we serve residents of the seven main Bay Area counties and our services are free and we don't have any kind of income cap like a lot of other legal services program has. So we serve people at all income levels. And down here we put some, the actual hotline number and our hours were open Monday through Thursday, nine to five, Friday, nine to one, and all of the people who answer the phone were all attorneys. So some people wonder about that, but we all are all our attorneys who answer the phone. And some of the things that we do that we advise or help people with our eligibility enrollment and enrollment and disenrollment issues, access to the medically medically necessary services claims denials gender for me care in home supportive services, which is IHS S, among other issues with medical and dental Cal cover California Medicare and private health insurance programs. We do advise on medical debt. And some of these other issues as well. So we're going to talk about the Affordable Care Act briefly, generally, because the Affordable Care Act kind of gives a framework for a lot of the other programs and how they're offered at this point in time. And we'll also talk about Medi-Cal cover California and Medicare. So the Affordable, the patient protection and Affordable Care Act, which is also known as Obamacare was passed into law in March of 2010, and expanded Medi-Cal to a much greater, a greater group of people and it created a health benefit exchange which in California that would be that would be covered California and it created a system where people get subsidies for their private health insurance. Okay, and yeah, it created more consumer protections than were previously available for consumers of, you know, of health health insurance in the past. So all marketplace and Medi-Cal plans must have must offer these 10 essential benefits. So those are things that that's kind of the benchmark for for a plan that's that is offered on the marketplace through cover California or through, you know, public health programs. The Affordable Care Act, it created a mandate that individuals can't be denied insurance coverage because of pre-existing conditions, which has been a huge benefit to a lot of people in the community. And yeah, there are lots of lots of rules that have been added about, you know, how how much they're allowed to charge people for insurance premiums, including based on age, and it ended annual lifetime caps on a lot of benefits, and it allowed adults up to 26 to be included on their parents private insurance and there's several other other parts of the Affordable Care Act that expanded health care access to people. So the Affordable Care Act covered spectrum. What this is what this map is kind of showing is that so for people who are up to 138% of the federal poverty level, those people qualify for generally qualify for Medi-Cal. In the past Medi-Cal was really or Medicaid programs in general were more limited to people with disabilities and children. And so now this is kind of the Affordable Care Act expanded Medi-Cal access, Medicaid access, Medi-Cal access to to anyone under this this threshold as long as they they meet all of the other non non income requirements as well. And so for people whose incomes are above 138% of the poverty level but below 600% of the poverty level. Those folks are able to get some premium assistance with a health insurance a private health insurance plan that you can get off of the covered California marketplace. Medi-Cal is California's Medicaid program so I you know I use those interchangeably a bit in this presentation but Medi-Cal is Medicaid in California. It's a federal and state funded health insurance program for low income people it's a combination federal and state program and it's administered by California's Department of Health Care Services and eligibility is determined at the county level, except when some people have Medi-Cal that's based on their SSI if they receive SSI benefits, then that would be determined by the Social Security Administration instead. There are certain programs that so there are many many different Medi-Cal programs. Some Medi-Cal eligibility is linked to people's eligibility for other public benefits programs like SSI like I just mentioned cow works. Medi-Cal is a health medical program for adults under 26 who have aged out of the foster care system and adoption assistance or some Medi-Cal programs that are kind of just linked to that. And so that for this for Medi-Cal essentially yeah essentially most people as long as they are income qualified would qualify for you know for some Medi-Cal program although we'll talk about some of the immigration restrictions in the future in this program as well but yeah there are lots and lots of people can qualify for a Medi-Cal program but they do need to be a California resident or have the you know intent to reside in California. So so immigration Medi-Cal immigration criteria. Most people as long as their income qualified can receive some form of Medi-Cal benefits full scope Medi-Cal benefits are available to qualified immigrants. And that is a federal definition which includes citizens, legal permit residents, refugees and asylees, people with a UVSR or TVSA, everyone up to 26 and other qualified immigrants. And restricted scope is available to people who don't have a qualifying immigration status, but restricted scope is going to have a lot a lot fewer benefits it's generally meant to, to, to kind of work in an emergency type setting. So if someone to deal with issues that are are urgent like emergency room or that kind of thing. So permanently residing under color of law those people who have pro call status are eligible for full scope Medi-Cal pro call is not an immigration status it's a public benefit eligibility category, but what it basically means is immigration authorities know you're here and they're not going to begin deportation proceedings. And DACA recipients qualify under pro call. So there are several main types of Medi-Cal coverage there's free full scope free full scope Medi-Cal. That involves no cost sharing or no responsibility to pay for services, which means there's no premium you don't have to pay anything to the doctor. And it pays for medically necessary healthcare treatment when you're using a Medi-Cal cover provider. Sometimes, sometimes people there are a couple programs that require a monthly premium, and that's for generally higher earners that still fit to the qualifications for programs other than the free full scope Medi-Cal. It's usually people who are working with a disability or people when there's a child below 19, but the monthly premiums are usually very low, much lower than anyone would probably be able to find in a on a private marketplace. And share of cost Medi-Cal is for people who would qualify for Medi-Cal. This is specifically for people who have, who have either are over age 60, 64, or over age 64 or have a disability determination. And so what for share of cost Medi-Cal is for people whose incomes are a little bit too high or a lot too high for free full scope Medi-Cal. And then there's a set amount that they must pay out of pocket each month before Medi-Cal coverage starts. And it's, it kind of acts as like a deductible that resets every month. Most of the time people use it when they are in maybe some kind of residential setting because usually the share of cost is pretty high. And so for most people it's just, it still makes healthcare inaccessible because the share of cost compared to income is still is still really high. So a lot of the work that we do is is looking to see if there's any way that we can help people avoid a share of cost because we know that if you have a share of cost, your income is probably pretty low but not low enough to qualify for for free full scope Medi-Cal. And restrict restricted scope Medi-Cal is free. But it like again it's it's restricted to emergency services and pregnancy related services and it's for undocumented adults who don't qualify under some other category for for immigrants. This table right here is the Medi-Cal income limits for a household of one. The income limits increase the more people that you have in your household. So, you know, you add people in an incoming limits will go up. But in general for 2021. The Medi-Cal the limit for free full scope Medi-Cal is $1,482 a month for one person. And the amount generally you may qualify for cover California plan. Okay, so this, this kind of gets a little, a little complicated but there are two main types of Medi-Cal programs and this is directly because of the Affordable Care Act. The Affordable Care Act expanded Medi-Cal. They created like that the newish type of Medi-Cal was called Magi Medi-Cal which stands for modified adjusted gross income. And so that just means generally it means that the income determination is going to be made based on how you file your taxes so your household is going to be determined on who you know who is a household for tax purposes who's a dependent for tax purposes. And income is generally defined as how it is in the tax code, except for the modified part which we're going to get to I think in the next slide but traditional Medi-Cal which is non-Magi Medi-Cal programs. These are for people with disabilities who are or who are over 65. And those under the age line disabled those are some 250% working disabled program, the share of cost program and long term care Medi-Cal are just types of other types of non-Magi Medi-Cal programs. And for everyone else which is non-disabled people, non-disabled adults between 1964 and pregnant women and children up to 19 and parent caretaker relatives. Those are all Medi-Cal programs that fit under the Magi definition and Magi income counting system. So, yeah, this is the formula for determining Magi Modified Adjusted Gross Income for these programs it's your adjusted gross income, which is pretty much what the income you report on your taxes, plus non-taxable social security benefits. So a lot of social security benefits are not counted as income for IRS purposes, but they are counted as income for Magi Medi-Cal programs or for all Medi-Cal programs, social security benefits are counted. So your income would be your adjusted gross income so you just your regular income plus your non-taxable social security benefits and taxes of interest and foreign earned income so things that may not count on on your IRS taxes may count for Magi Medi-Cal. And there is this Magi Medi-Cal programs have no asset test. That means that someone could have, you know, could live in a multi-million dollar mansion and if they as long as they make as long as their income is below 138% of the poverty level, they would still qualify for Magi Medi-Cal so there's no asset test at all for this type of Medi-Cal. For non-Magi Medi-Cal, this program is still using pre-affordable care act rules for counting income and so that these programs have rules about what kind of income is deducted and it kind of differs depending on what particular Medi-Cal program it is. For example, for age and disabled Medi-Cal, you can deduct, you know, premiums that you would pay for a supplemental health insurance plan. So let's say you have Medicare and you pay, but you also pay, so you pay your Part B premium and you also pay $75 a month for a supplemental dental plan. You can, you know, subtract that from your income for eligibility purposes. And these programs unfortunately have an asset test and that is very low, $2,000 a month for a single person and $3,000 for a couple. There are a lot of excluded assets, so the house that you live in is an excluded asset, a car that you use for transportation is excluded, but in general their assets have to be less than $2,000 or $3,000 a month. Although I will note that I believe that within the next few years the California legislature has voted to eliminate the asset test but for now they still are there so that can be a barrier for people. So yeah, the house is exempt, one car. Yeah, the retirement accounts, there are specific rules about retirement accounts and life insurance policies, I won't get too much into that. And yeah, this is age blind and disabled Medi-Cal, they used to, this Medi-Cal non-Magi age blinded disabled Medi-Cal and the regular adult Magi Medi-Cal programs used to have different income limits but within this last year they have made it so that for both, for most adults the income limit is going to be $1,482 a month for a single person. If that's your house told as a single person with a caveat that it could be a little higher depending if they meet some kind of exception to get into some other Medi-Cal program that might have a higher asset limit or a higher income limit. Okay, and yeah for non-Magi Medi-Cal, they kind of differentiate between earned and un-earned income and there's a formula, there's an automatic deduction for all income and then there's a $65 deduction for employment income and then you can subtract impairment-related expenses and that are related to your work or income-related expenses including transportation and uniforms if you're blind. So yeah, and you divide, yeah, so down here is an example. So if you earn $3,000 in employment then first they subtract the $65 which is the un-earned income exclusion or deduction and then you divide it in two and so that would end up being your countable income. So your countable income is your earned income divided in half after you minus the $65 earned income. So that's how you calculate earned income and then un-earned income is just the amount minus a $20 deduction. So I know that that's kind of complicated and we are always happy if you don't get anything else from this presentation that the Health Consumer Center we're always happy to give people more thorough advice and information about how these programs work. The 250% working-disabled program provides full scope Medi-Cal to people with a higher income limit than the normal income limit for Medi-Cal programs and to qualify for the 250% working-disabled program you have to have a Medi-Cal or Social Security determination of disability and you have to be engaging in minimal employment but the state has purposefully made the definition of employment for the working-disabled program be very flexible and pretty much anything can count as work at any amount or any frequency. So we've got we advise people who may have a little bit who have let's say disability income that's a little bit too high to qualify for free full scope Medi-Cal. We try to help people get into this program because it allows you to have a higher income limit. And even if people are disabled a lot of times people say well I'm disabled I can't work and that very well may be true but the definition of work is so flexible that sometimes it might be babysitting your grandchildren that you may be already do that but that someone is willing to pay you to do it. Or filling out forms pretty much anything collecting cans watering your neighbor's plants giving someone a ride to the store anything that someone you know is willing to pay you to do. As long as you can get them the person who's paying you to do it to you know write a little statement that says what it is and how much they're paying you and how often then that would count generally as work under the working disabled program. And as I said earlier the general income limit for Medi-Cal is 1482 for per month. But for the working disabled program that shoots up to $2,684 for this year, which is a huge there's a lot of people who are in that income level that's higher than 1482 dollars but less than this 2684 number just because of the average amount of social security benefits that people get is often in between those numbers so there are a lot of people who qualified for this program. It provides full scope Medi-Cal benefits. It usually it has a monthly premiums but they're usually very very low I mean they're essentially always less than the share of costs that they would have otherwise and any kind of disability based income is exempt for eligibility purposes so that's not used to calculate the premium amount or that the income limits for those programs. And you can also save the earned income that you get from this employment is qualifying employment put it in a separate bank account and they won't count it towards your asset limit so if you want to kind of if you know if you're disabled and you want to build up a little bit of nest a little bit of a nest egg then you can put that in a separate account and save up a little bit without it impacting your benefits. And this is just a chart for what the what the premiums are so for a lot of the people that we work with are in that one to six hundred dollars limit because they're they're kind of just doing this program they're only working in order to qualify for this full scope Medi-Cal for twenty dollars a month. But yeah you can make more in these premiums are way for the amount of services that you get. It's it's way cheaper than the share of cost would be okay. Okay. Yeah so for for a share of cost is a sign when the countable income is over the maximum countable income for the other non Magi Medi-Cal programs. But your assets in order to qualify for non Magi program you have to have assets below the asset limit. A share of cost is not an insurance premium. And like I said earlier it functions like a monthly deductible which is the a cap on the amount that you have to pay out of pocket per month. And then after that Medi-Cal will step in and pay the rest. But if you don't you don't have to pay your share of costs every month like let's say you don't use very much of your benefits in one month. You don't have to pay your share of costs every month it's only it's just a cap on what you have to pay out of pocket. But for a lot of people who I mean non Magi Medi-Cal programs are are are for people who are either are either on disability or are over 64. So a lot of times people have enough monthly expenses that it gets up to the share of costs are close to it. And the share of cost restarts every month. So I'm not going to go through too much of the meeting share of cost. Okay I'll do this example. Joseph is 67 a single person and receives $1,800 in Social Security retirement each month. His insurance is Medicare and he pays $150 a month in Medicare Part B premiums and $60 in vision insurance. He wants to know if he can qualify for full scope Medi-Cal and so $1,800 he would be able to subtract the $150 for the Medicare Part B premium which would get him to $650 and then he could then deduct also the $60 in in vision insurance and that would put him at oh plus the $20 automatic deduction would put him at $1,000 a month in Medicare Part B premium which would get him to $650 and then $1,000 in vision insurance and that would put him at oh plus the $20 automatic deduction would put him at $1,570 in countable income and the limit for free Medi-Cal is $1,482 so he would be $88 above the limit. So the county will run a calculation to assess the share of costs and it will be it will be high. The share of costs just it doesn't it doesn't really they they they calculate the share of costs based on a formula that they developed like in the 80s or 90s and they haven't adjusted it at all so they assume that people's cost of living is much lower than it actually is. Yeah, so the 600 maintenance lead need level. So his share of costs would be $970. So in this case, his income puts him $88 above the age blinded disabled the Medi-Cal limit, but his share of cost would then be $970. So that that means he would have to pay $970 before Medi-Cal would pay anything. And that would be every single month. But well in this situation what we advise people to do is to purchase a supplemental health insurance plan. You know he's already paying for vision but now we could pay for dental and as long as you've found a plan that was valued at $88 or more a month. Another another option is like a supplement Medicare has supplemental plans that make your out of pockets expenses a little bit less and so you can get one of those instead. But that you're able to then subtract that from your accountable income. So if he got a premium at some kind of supplemental insurance that costs $88 or more than it would get him free Medi-Cal as opposed to a $970 a month share of cost that he would have to meet before he would be eligible to have Medi-Cal pay for any of it. So under the Medi-Cal program, folks are entitled to dental benefits. It's it's quote equally called dental Cal. I think they actually now call it Medi-Cal dental, but you'll hear dental Cal used all the time. And it includes major major dental work like root canals and dentures. There are lots of, you know, there are limits about how often you can get dentures and when, you know, when they'll do allow you to do a root canal. And there's a soft cap of $1800 in covered services a year. That doesn't apply to children and it doesn't apply to pregnant to to pregnant members. And there are also some ways to to really get around that $1800 cap in services. So it's not it's kind of just this it's a soft cap we call it. And a lot of times providers dental Cal providers will sometimes try to bill patients for like maybe a portion of the bill that that Medi-Cal didn't pay and that's illegal when when a provider a dental provider is accepts Medi-Cal for a service, then they can't bill the patient for any amount for that service. So they're accepting Medi-Cal is payment in full and that goes for every provider who provides a service to a Medi-Cal patient. If they're taking Medi-Cal is payment, they cannot build the patient directly for any kind of, you know, contribution toward the the cost of the service. And it provides supportive services is a benefit under Medi-Cal. It's administered by the California Department of Social Services, and it provides income in home assistance for individuals who are aged blind disabled and would would be unable to remain safely in their home without IHS care and it really it provides says it provides care but it really provides hours it provides you a number of hours that you can find maybe someone who know a friend a family member, a neighbor. You can find your own provider in any way or you can also go to the county and have them provide you a list of potential providers. But it's people who people who need a lot of assistance to perform daily activities and the number of hours and the eligibility is determined by the county. They do an assessment to kind of determine how much help you need at home. And you, if you're given a number of hours and you are unhappy with it, you think you needed more than that's an appealable issue that you can take to a state for hearing. So, you can apply for Medi-Cal at cover california.com or on my benefits calwin.org or in person or by phone. I do want to really highlight this last section which talks about accelerated enrollment. And this isn't kind of hasn't been talked about a whole lot, because it's it's very new, but for people who apply for Medi-Cal through cover california.com or through the cover California telephone service center. They have a program called accelerated enrollment, which grants people immediate Medi-Cal benefits, as long as it looks from the application like they will qualify for Medi-Cal. And so that prevents people from having to wait to get care while the county is still determining whether they really do qualify for Medi-Cal. So that's a really a very new it started January, or January, it started July 1, 2020. It's going to be expanded to applications that are done in other ways other than California cover california.com in 2023. But the the state just says it's going to take them longer to do it that way. So if it's if if you or someone you know it needs Medi-Cal benefits. Quickly, then applying on cover california.com is probably the best way to do it because they they they could have access to this immediate Medi-Cal benefit. Okay, Medicare. Medicare is a federal health insurance program that is for people who are 65 or older or younger people with with disabilities who have received SSDI or Social Security Disability insurance income for 24 months. And there are also people who have in-state renal disease. And there are no income assets limits. It's a it's an entitlement program. It's based on the your work history and your work credits. Medicare has it has three main parts. Part A is the hospital care, which includes skilled nursing facility after you have an inpatient hospital care. It doesn't cover a whole lot of other long term care. If for, you know, care that's right after a hospital inpatient hospital care, it does cover that and hospice care and home health care it pays for. In part B is like the regular the regular care that you get in the course, you know, of your health care like going to the doctor test preventative services outpatient care ambulances are covered in a part B. In part D is prescription drugs. Okay, and you have two options with Medicare you can go with original Medicare, which is part part A and part B and part D. And then you if you want to you can also add a Medicare plan, which is supplemental that kind of just makes it all a little bit less expensive. Or you can go with option two and you can get a Medicare Advantage program and people call those Medicare Part C plans and that's it's kind of you go with the health insurance company you have. You know, there's a health insurance company not not actually Medicare that's paying the bills is the health insurance company and it combines Part A and Part B and Part D into one plan. So that's another option. Excuse me. Most people get premium three part a once once they turn 65 or if they're eligible through through after their waiting period for Social Security disability. But some people if you just really haven't don't have a work history or work credits for a job that pays into the Medicare system, you may not qualify for part A, and you can buy into it. But it's expensive $471 a month just for part A. And then for Part B, everyone has to pay a premium for it. So the standard premium for Medicare is 100 or for this year is $148 and 50 cents. So with Part D, with Part D prescription drug plans you they're they're all through private, not private but they're through like health like you go with a health insurance company and you pick a plan. And so the price of the premium depends on what plan you choose. So, you know, United offers a lot of there are lots of companies that offer party plans and Kaiser offers them to if you're a Kaiser member. If you cross the board with Medicare, Medicare pays 80% and you pay 20% coinsurance for most covered services. So there, there stands to be a lot of out of pocket costs with Medicare is your only insurance. And so if you're if you're on Medicare, you, you, you may be either disabled or, or an older person in which case your, your Medicare medical care may be pretty expensive and having to pay 20% of that can be a lot of money. So in Part A B and D, you get when you first enroll in Medicare, there's a seven month window where when you can sign up, and it starts the three months before you turn 65, and ends three months after you turn 65. And if you qualify for disability, seven month period around the 25th month of your, your SSD qualifications. Okay, Medicare savings programs. These are, these offer assistance to lower income people that help them pay for Medicare premiums and cost sharing, like co pays and coinsurance. And there are several different Medicare savings programs that which one you might qualify for depends on on your income. And you can apply for these with with your local county office, like Medi-Cal office, wherever you would apply for Medi-Cal, you could also apply for these Medicare savings programs. They don't have, well they have a much higher asset limit than, than would be the case for a Medi-Cal program. The income caps are pretty low, lower than for at least qualified Medicare Q and B program, which pays Part A and B and all other cost sharing. So it's a pretty comprehensive program. The income limit for that is less than Medi-Cal. So the people who might want this coverage or people maybe who have, still have a low income but have a little bit higher asset amount. So they might not qualify for Medi-Cal as well because you can, you can have both Medicare and Medi-Cal at the same time we call those dual eligible. The way it works if you're eligible for both Medicare and Medi-Cal is that Medicare pays first and Medi-Cal is secondary. So Medicare will pay 80, like 80% of covered services and Medi-Cal will pay the remaining 20. That is the, the remainder that would normally be the beneficiaries responsibility up to the Medi-Cal rates. And it pays, Medi-Cal pays the Medicare Part B premium. And it may cover, it may cover the Part A premium too, it just depends. If you have Medicare and Medi-Cal you automatically qualify for Part D extra help, which is a low income subsidy that covers premiums and deductibles for Part D prescription drug plans. Okay, so balance billing. I alluded to this a little bit earlier, but it is illegal for a provider to balance bill. People who are, who are dual-eligible enrolled in both Medicare and Medi-Cal. So you can't, if they, if someone is eligible for both Medicare and Medi-Cal, the provider cannot then go after the patient directly to try to get some of the costs of service back from them. They must bill Medicare first and Medi-Cal first, Medi-Cal second. But not all providers, most providers take Medicare because the reimbursement rates are higher. Not every provider is going to take Medi-Cal. So it's important if you're a dual to find providers that take both Medicare and Medi-Cal. Okay, so does anyone have any questions about Medi-Cal or the Affordable Care Act before I move on? I know I went through that really fast. Amy, there were several questions in the chat, which some of them might have been answered already, but I can go ahead and go through those. So one of the participants asked, what is the actual dollar amount of income for the threshold? And I believe you answered that, that there was the general threshold, and then there was the WDP threshold. Did you want to quickly just clarify that? Yeah, so for the most part, the income threshold, so it depends on the number of people in your household, and it depends on what specific Medi-Cal program you're in. So for a single person, for 2021, generally the Medi-Cal limit is $1,482 a month. If a person is able to get into the working-disabled program, the 250% working-disabled program, it's around $2,600 a month, and that's not including the disability-related income, which would count under other Medi-Cal programs. But there are also some Medi-Cal programs that, for example, Medi-Cal for former foster youth up to 26 doesn't have any income limits at all. So there are some caveats to that, that a person may qualify for a program that has a different income limit or no income limit. I think that's the only one with no income limit, but there are other niche programs that someone might qualify for that has a little bit higher income limit. There may be ways that we can try to finagle things to get someone eligible for Medi-Cal, no guarantees, but we help people kind of try to figure that out. So if you have specific questions, we would be happy if you called our hotline to help you with that. And then a lot of people are asking about the slides for the presentation and the link, and so I just wanted to assure everyone that these slides would be available. I think we discussed that too. Yeah, they are eligible. Just keep in mind that these programs change all the time. So if you're looking at the slides next year, there could be, the income limit, the numbers will definitely be different. Other things may be different too, because these programs just constantly change, but I'd be happy to share it with you as like a reference point. Okay, great. And then another question was, can a dental provider decline to take an individual with Denti-Cal? That's a tough question. So a Denti-Cal provider, so lots and most, it can be tricky to find a Denti-Cal provider. There aren't enough of them for the number of people that are on Medi-Cal. Technically, it gets a little bit hairy about whether a Denti-Cal dentist can turn away a Denti-Cal patient. They do. I know that they do. I'm not sure how legal that is. A lot of times what happens, like Medi-Cal dental reimbursement rates are really, really low for dentists, which is why a lot of dentists don't want to participate. But a lot of dentists think it's worth it to just do, you know, if it's just a teeth cleaning or maybe filling a couple cavities, they want to participate, but they don't want to participate if it involves heavier duty dental work because they're going to get just pennies on the dollar for that. So a lot of times people will, dentists will say, will accept a Denti-Cal patient and then say, well, I can't do that because it's out of my area of expertise, and then they'll kind of push them out to someone else to try to do this specific work. And that happens all the time. And it's kind of hard to push to push back on it. But it definitely does happen. Okay. So then another question was about whether seniors can qualify for Medicaid and Medicare, I'm assuming simultaneously. Yep, absolutely. And a lot of people do. It's, it's, it's really, really beneficial for someone to have Medi-Cal in addition to the Medicare because just because the out of pocket costs for Medicare can be very high. So, yeah. And then just one more, and I'll let you keep going to the covered California piece. There was a question about a California program that's ending tomorrow for new applications. Um, do you know what it's called? I don't know. Um, for the participant who put that in the chat, if you could elaborate on that, we'll try to get to that in the end. And there was also another participant who's an RN case manager and wants to learn a little bit more about helping someone who's hospitalized. And it might be that there's, if we don't have time at the end, maybe calling the hotline and giving more specifics around, you know, specifics around the situation might be helpful. So that hotline, I'll, I'll put it in the chat a couple more times. Okay, sure. Okay, great. Lauren P said it was on the radio today. It's a program that was started for COVID coverage. So that might be coming up in the upcoming part of the presentation. Yeah, yeah. Okay, yeah. Let us go onward. Okay. So Cover California, I said a little bit about this before, but it was created directly as, as part of the Affordable Care Act. And on the Cover California exchange, this is for people who whose incomes are a little bit higher. Well, I mean, and you can apply for it for just health insurance in general on the marketplace. And first they check to see if you qualify for Medi-Cal, which would be 138% of the poverty level. That's the $1,482 for this year. And if you don't qualify for that, then a lot of times they qualify for tax credits to make the premiums more affordable. And also possibly cost sharing subsidies, which make the like copays and stuff and deductible more affordable. And it helps you. The CoverCalifornia.com marketplace has a shopping compare tool where you can kind of, you can plug in your income. And if you're not eligible for Medi-Cal, it will kind of give you a sense of what options, health care, what health plan options you have and what your net premium would be. That means after the assistance to pay for the premium would be so you can kind of pick out based on whether you think you need a lot of medical care or you don't use it very often. And it can kind of help you figure out what what kind of plan would work best for you. Premium tax credits are fundable tax credit to help low and moderate income people under 600% of the poverty level. So you may hear nationally it's 400% of the poverty level but California specifically expanded this program to people between 400 and 600% of the federal poverty level starting in 2020. So the tax credit is based on a sliding scale using Magi income calculation. So that means looking at the amount that's on your that you kind of would file on your tax return. And they can be to you can take them in advance so like month to month that in that case CoverCalifornia would directly pay the premium to the health plan. Or you can just wait and get a big credit when you file your taxes. But you would have to be in a CoverCalifornia plan and found eligible for their credits in order to get the refund when you file your taxes. Most people get them in advance because the whole reason why you're why you are getting these premiums is because because health insurance is really expensive and it based on your income might be affordable for you to pay in advance or pay the full premium and then get a tax credit later. But you would need to report any changes in income, like throughout the year, because when you apply you estimate what your income is going to be throughout the year. And then when you do file your taxes you have to what's called reconcile. And that's where you where the IRS kind of compares what you got to what you should have gotten. And if you got too much in tax credits, then you may have, you know, a debt to the IRS. So that can kind of be remedied by regularly updating your income with CoverCalifornia during the year so that they can adjust the rest of your premiums for the year so that to try to avoid any kind of overpayment. Yeah, so that the premium assistance is paid directly to buy the federal government to the health plan. And then the enrollee just pays the health plan the difference between the premium assistance and the premium and cost during reductions, lower what the consumer pays for deductibles co-payments and insurance and these are for people whose income is 250% of the poverty level are below and you have to enroll in a silver plan which is what they call benchmark plan. So just enroll in the very cheapest plan that has the highest co-pays and deductibles and then have all that paid for you have to enroll in a silver it's a sliver on there but it is silver plan. And these are these are only available if you buy a plan that's on the cover California exchange you don't have to do it on the internet you don't have to do cover California calm, but you would have to get a cover California plan. These are the tiers of the health plans. The bronze plans have the lowest premium but highest out of pocket costs and platinum is the inverse it has the highest monthly premiums with the lowest out of pocket costs. And those percentage or the actuarial values so the total covered average cost for the cover benefits that the plan actually would pay for. Okay, normal normal open enrollment happens during the open enrollment period, which in California happens in the late fall. The California open enrollment period is always different than the federal one. So make sure if you you may see on TV or wherever you get your news, talk about the, the enrollment period for, you know marketplace health plans and cover California is always different it's always longer than it is for the federal federal plans for a federal marketplace and that affordable care act open and special enrollment rules don't apply to other health programs specifically for medical programs so for medical or for cover California programs you can apply for medical at any time. During the year so it doesn't have and same with Medicare has its own roles about enrollment so the open enrollment period is only for it's a cover California thing and private insurance but they're the specific open enrollment period for cover California is it's it's unique to its own program or its own plans. So under cover California if you want to enroll in a plan outside of the open enrollment period, you have to qualify for a special enrollment period and they're they're triggered by qualifying life events, which could be loss of health coverage, not due to filling the pay premiums and change household changes like a birth or adoption of a child marriage divorce, and it applies 60 days before or after the qualifying life of that but I'll put an asterisk here that this has changed during the pandemic and there are changes that are still in place during the pandemic and there's some coven 19 specific slides that will talk about that. So, we're getting to the appeals portion. Excuse me of the presentation. And Medicare appeals process has several steps you start with predetermination, then reconsideration, reconsideration is done by like a third party contractor but it's decisions have the same impact as it would if it were if it were directly by the Medicare program and then you have a right to administrative law judge hearing and there are a couple steps after that so it's a long process doesn't doesn't happen quickly if you're appealing a Medicare decision. Health plan appeals. You can any kind of health. So not any kind of health plan, but most health plans that are regulated any, any health plan that's regulated by the state of California, and any medical plans, anything on the cover California marketplace. You have the right to, to challenge a decision that your health insurance company makes. It's kind of an informal process that you have to start with before you want it before you're able to elevate it in other ways, but within 60 days of a notice you can. Your health plan will have a number customer service number that will tell you exactly how you do a grievance or an appeal with your health plan. So you can use it when you're when your health plan denies or changes changes of treatment, or when you're just unhappy they didn't cover something that you thought they should cover they're treating something is out of network that you think should be in network. That's when you can file an internal health plan appeal. And if you have a plan that is regulated by the man department, the California Department of Managed Health Care, then you can ask for an external review of the health plans decision once you get a decision back from the health plan about your complete your grievance with the plan internal grievance plan with the plan. And the department managed health care has a process where they can they oversee all cover California plans and most but not all Medi-Cal health plans and a lot of private health plans to. So, and a lot of different plans you have this opportunity to go to the California Department of Managed Health Care. And you do a you prepare a complaint you explain what the problem is you can submit documents and support of it. And then the Department of Managed Health Care can order the health plan to take a certain action or to not take a certain action. And there is a process to do this on an expedited basis if it's, you know, if you have an emergency and needed decision quickly but generally these complaints to the Department of Managed Health Care are handled within 30 days for non urgent cases and 45 days. If it if it requires an independent medical review, which means that they have to get kind of a team of doctors to determine whether something is medic medically necessary. You know whether to cover something is in networking or out of network doesn't require a doctor generally it's more of just the plan, a problem with your, with your health plan, and the way that it bills or covers things but maybe if you want a certain that they don't want to prescribe to you that kind of thing might require an independent medical review which is a team, a team of folks that can help determine whether it is medically necessary state fair hearings, you have the right to challenge essentially any adverse benefit determination. And in most cases you get 90, like they have 90 day period to make a decision on the case. Right now there's a 210 day deadline to file an appeal. If you ask for a paid pending before the action takes place then you can continue to get your benefits while you're waiting for appeal this decision. Amy I'm sorry to interrupt I just want to do a really quick time check. It is getting close to 3pm and I know you mentioned that you wouldn't mind staying a little bit longer, especially since people do have questions. I just wanted to just get a quick verbal. Okay, on that because we can just keep running the program as, you know, as long as we need to. Yeah, absolutely. I'm, I'm happy to stay on. I've got just a little bit more to go and then I can also just stay on for a few minutes for people who might have some follow up questions. Okay, terrific. Thank you so much. Let's keep going. Okay, so this is just an appeals timeline. I'm not going to go through all these numbers just because it just it's hard to remember all those numbers. But yeah, there is a process through which you file appeals for any either medical decisions or cover California decisions. And these are the last couple of slides are about the COVID-19 protections. So during the COVID-19 public health emergency, there are a lot of protections that were put in place to prevent people from losing access to their health insurance. And so one major one was prohibition on negative medical actions while the there has been a federal public health emergency. And during that period, which started in March of last year, medical benefits can't be terminated in a share of cost can be added, even if the person no longer meets income or asset limits. Unless the person requested to get out or moves or dies or transitions to long term care. But first time medical applicants can be denied or share of cost can be assessed. So these that protection on negative actions is for people who are already on Medi-Cal. They don't have to have been on Medi-Cal since March 2020. But as long as they have at some point been approved for Medi-Cal, then they can't be terminated. Unless unless the public health emergency is over we we think we I think the Department of the federal Department of Health and Human Services has indicated that the public health emergency would go to the end of 2020 so and state actors are still trying to figure out how they're going to unwind that like what will happen once they can start denying people again and how what that's going to look like. State Fair Hearing deadlines have been extended. It used to be 90 days for people to file, excuse me, a State Fair Hearing request, but now it's been extended to 210 days. And for the 250% working disabled program or the Children's Medical Program, they're waiving premiums right now. You have to ask for it. It's not automatic, but if you, you know, can't afford the premiums, then you can ask for them to be waived and they will even retroactively waive ones that you paid since March 2020. And for Cover California, the exchange is open throughout 2021, and this is California only. So, the federal government, I believe is is closing the open in moment in August they reopened it earlier in the year and they were closing it in August but California is is keeping it open for the rest of the year, just due to the public health emergency. And the federal government through the American Rescue Plan Act increased the advanced premium tax credits to make the health, health care more affordable. And anyone who's received unemployment insurance at any time in 2021 will pay $1 premiums regardless of their actual income. So that's the lowest, the lowest amount that you can pay in premiums. So even if they end up making a lot more than the threshold for Cover California, anyone who's been on unemployment during 2021 will pay $1 premiums for their Cover California plan. And the stimulus checks are not counted for Cover California purposes, but the supplemental pandemic employment benefits are accountable. Excuse me. And people who had an overpayment after we re, after they reconciled their tax credits for 2020 don't have to pay them back. Usually we get a lot of people who have like a $20,000 debt to the IRS because they failed to update Cover California throughout the year about their income. But because it was just such a year that there was a lot of instability and employment, they just didn't make anybody pay those back. So this, this is probably what you are talking about with the uninsured COVID uninsured group. I, I guess I didn't know that it was ending this week but the COVID-19 uninsured group allows for free COVID-19 testing and testing related services and treatment services for people who are uninsured, or have private insurance that doesn't cover free COVID-19 testing and treatment or have Medi-Cal the share of cost. So it covers all the care that pretty much is related to cover to COVID-19. But COVID-19 treatments are already free to full scope Medi-Cal beneficiaries. Okay, and these are just not going to read those off, but the Department of Managed Healthcare manages a lot, most health plans in California. There are some plans that don't fall under their purview. They may be offered, maybe someone is employed and their employer is in a different state. Then they, California wouldn't have jurisdiction to regulate their plans and there are also certain plans called self-funded plans which don't fall under their purview either. And a lot of other insurers are covered under the Department of Insurance and some plans are only regulated by the Department of Labor, the United States Department of Labor. So these are some of the resources that we will direct you to us. We're the top one. And then in Help in Western Center are two organizations that provide a lot of information about health programs generally. And California advocates for nursing home reform. Their acronym is CANNER, but they're kind of the experts in advising people on long-term care, long-term care Medi-Cal and long-term care options and rights for people who are in nursing homes or skilled nursing facilities. Okay, I'll open it up to anyone who has questions. I know I went through that really fast and I apologize for running over, but I am, if someone has, you know, some questions that you want to ask right now, I'm happy to do that. Okay, so I am going to go ahead and allow participants to unmute themselves. So if participants, if you have questions, please go ahead and unmute yourself and please feel free to ask your question at this time. And if no one feels like speaking up in the group, I can also just read out some of the questions that were put in the chat as well. I just wanted to make a comment. I helped my daughter apply for health insurance this year. She fell off of my insurance when she turned 26. And I'm not a complete idiot and I do know something at my age. I'm 66 now. In the case of going over the plans for her that she might be eligible for, I absolutely had to give up. We were lucky enough that she found a free broker. And the broker actually found a plan for her that we never even saw after three days of looking at everything. I want to comment on people in that situation and how you would find a broker or someone to help with this. It's really complicated. Yeah. Yeah, a lot of people go through brokers to sign up for a cover California plan. I believe that cover California calm keeps a list of people who are certified cover California brokers they have to be licensed by cover California to enroll people in in cover California plans. So that is a good option for people who really just want to get have a real person to talk to about what plan might work best for you. It can be hard to get the information that you need if just, you know, reading through what is available on the cover California page so some people do choose to go through a broker and that's totally, totally fine. It doesn't, it doesn't, you know, cost extra or anything it's free. I have a question. Um, so I, there was a period of time where I didn't have medical or any health insurance at all. And I went to general hospital once in the emergency room. Um, but never got a bill in the mail. Will anything happen to me will I have to pay more in taxes, or I don't know because I never got a bill or anything I was uninsured at the time, but I was working at that time, and I made above the medical threshold. Um, well, that would be something that we can definitely advise on. It's kind of hard to do. We would have to ask, you know, more specific questions about your situation. If you advise on it, it may be something that you have some options for. Sometimes we just kind of have to tell people, you know, kind of how to deal with it if something, you know, if some with medical debt if there if it's really, if it's valid and there's no kind of insurance to pay for it is possible that that the providers can sue people on debt on medical debt. And we definitely advise on that too. We, you know, we can help people come up with defenses to lawsuit so I would just recommend you call us our, you know, our health consumer center line and we can give you some individual advice based on your situation. I guess I had a question that actually also came up in the chat, which was about the clinics and hospitals that aren't aren't accepting cover California and Vanessa did you want to go ahead and ask your question. Yes. Yeah, just my question is about covered California plans. How's the, I used to be on the covered California plan probably around 2018. And I found out majority of my physicians not accepted the cover the California plan. And so how's the, how's the situation now for is that improved. It really, really depends on the plan, because each plan is going to have a completely different network than the next one. So, it's hard to say whether those providers like whether those providers are except any medical plans. What I usually recommend is if you have some providers that are that you really want to keep like their, their, what's most important to you is staying with these providers. I usually have people work backwards by asking the providers, either them directly or their billing department what plans. If any, what cover California plans they do accept and then try to get into that one, because it can be hard to find a plan that covers all of your providers, but that's true with any time you get health insurance, because just now. Man, that's what managed care means it means like health insurance plans that have, you know, in network out of network. It's, they contract with providers and it just is going to vary a lot from plan to plan. Now I'm in the private group health insurance plan. It's, it's through the employees so through the sorry through the employer and most of the physicians. I mean the private clinics in San Francisco they cover but not in the case of like a covered California plans they only have the coverage I have to say really low really small in a few years ago I don't know now. Also, a while ago I think it's a 2018 or 2019 I don't remember that when I was in cover California and actually medical I think it's medical plan. When I was a clinic I go to see they they require me to you know the the physician to not see me because I'm on the medical medical plan I have to go through the other clinic to wait for the approval and I'm asking if I can I just doing a cash payment for the for the conditions because I have I have some eye condition I have to see the physician right away but they said no as I said they are offered office internal procedure they they cannot allow that. This is really scared me off of the covered California plan. Well, medical, medical is different from cover California so there are medical plans but they're, they're different than cover California ones for medical specifically. The reason why a lot of providers do that is because they're afraid because of these rules about how medical beneficiaries cannot be billed for by medical providers for medical covered services. They're afraid that people just, you know, they'll get stuck treating people and not get paid for it. And even you know if you're paying up front I don't know some of them they're allowed to have whatever policies about, you know, paying cash up front that they want. It's just a good idea to find out from your plan, where you can go based on the network because every network is going to be different some of them are just better than others it just depends on on. It sounds like your employer health insurance is a little better. It's much better it's, yeah, it's a network thought it's wide. That happens I mean even employer plans, they just really vary on how good they are. We get calls from people who have employer plans that are just so bad that they're unable to really access any providers and they want to get into a cover California plan because they're their employment plan is so bad. It just there's so much variation in the quality of health plans that you just really a lot of people get into plans that they're really unhappy with. Oh sorry I have a clarification here it's a it's a, it's not covered California plan it's medical plan was encountered back into 18 or 2019. Yeah, so medical plans also most people have to be in a plan in a medical plan. And it, you know each county in the Bay Area, most of the counties have two options one of them is usually Anthem Blue Cross and one of them is. It depends on what what county you're in San Francisco health plan is one is the other option in San Francisco is Alameda Alliance and Alameda County. So, and they just like any other health plan are going to have a network. Sometimes the ones for medical plans are smaller because Medi-Cal plays pays lower rates than anyone else in the healthcare realm. So their networks can be smaller that you still have a right to, you know, timely access to care. And if they're if you need medical care and you're not getting it then that's definitely something that you can, you know, raise and push back on and have them. And basically you can, we get we help people, you know, force their plans to let them go at a network because they haven't been able to find a provider in network. And that's definitely appropriate because you do have rights as a consumer in accessing timely care. Amy, this is Marina. I have a quick question regarding how do in terms of the federal poverty line. When it said like under 600%. It seems such a huge percent percentage how do is that derived. How are these percentages determined. You mean how are, how is the federal poverty level determined or just why does Covered California go up to 600%. Exactly and why 600%. It seems so huge and kind of. It is. So for the for the federal federally across the country, it's 400% is the maximum, but for a household of two. The limit for this year is somewhere around 60. 69, 68,000 dollars between like 400 and, you know, 401. And so for, you know, even at about $70,000 a year for two people, especially with how expensive it is to live in California anywhere in health insurance, you know, as you get older, there are limits on how much health insurance can charge you for health insurance, but they can charge you for what do you get. So, I mean it's still paying $2,000 a month for health insurance, even at 600% of the poverty level is still not necessarily affordable so I think they recognize that and raised it for California residents. I see so that's how they adjust accordingly accordingly. Yeah, it's, it still remains a challenge but I was just when I saw that 600% under 600% federal poverty line I'm like whoa. Yeah, most programs are way lower than that but California starting January 2020 expanded it for because there was a cliff between 400 and 401 or anything after for 401. And those people end up with a huge tax debt if you go $1 over the cliff. So this kind of gives a little bit more of a gradual like sliding scale to prevent from ending up with huge tax debt. I see. Thank you very much. It looks like Vanessa has one more question we should make this the last question it's already three, almost 320. So Vanessa why don't you go ahead. Oh, thank you. Yeah, this is a simple as my husband is in the process of appeal of hospital bill not covered by his health plan. And then now it's he did the grievance and then now it's denied. So he's planning to appeal. It's probably it's called the department of management health center. Department of managed health care. Yeah. Yeah, it's probably external reveal. It's, yeah, he actually we have really stressed out about this. This appeal is how you know if we don't want to do all do the documents by ourselves can I can we get to help from your place. You can definitely call us and we would provide at minimum legal advice we just we don't have the capacity to take every request for assistance beyond advice. So it would you could call us and do an intake we could. We could definitely do advice it's possible that we could help with the complaint but we just can't guarantee it. Okay, thank you. Okay, well, thank you. Thank you so much, Amy, I'm going to go ahead and just put up our final just our outro slide here. And thank everyone for coming to attend the San Francisco public library government information centers program on know your rights Medi-Cal Medicare and covered California. I want to thank Amy Freeland from the bottom of our hearts for a wonderful presentation full of full of information and we will make sure that the slides are saved and sent out to participants and also that the link to this program which was recorded is is shared with shared with everyone so thank you again so much.