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Adult Systems of Care

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General Healthcare for Adults

There are fewer healthcare programs for adults than for children

Most are for adults with disabilities or Pregnant women

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Medicaid (Medi-Cal)

California’s Medicaid program

Health insurance for some low-income individuals

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Fee for Service Medi-Cal

Go to any doctor who accepts Medi-Cal Don’t need a referral to see

a specialist

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Eligibility for Fee for Service Medi-Cal

People who receive SSI Most adults aren’t eligible for

this

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Medi-Cal Managed Care

Most common kind of Medi-Cal

For most adults this is your only choice

Primary care provider • gatekeeper

• need referral to see a specialist

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Medi-Cal Managed Care

Different Plans Los Angeles

• LA Care• HealthNet

Orange County• Cal Optima

• All Medi-Cal programs are managed care

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Automatically Qualify for Medi-Cal if …

You receive cash benefits from Supplemental Security Income /

State Supplementary Program (SSI/SSP).

California Work Opportunity and Responsibility to Kids Program (CalWORKs).

Refugee Cash Assistance (RCA).

In-Home Supportive Services (IHSS).

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You may also be eligible if you are

65 years of age or older. Blind or disabled, even if you are working receiving care in a skilled or intermediate

care facility. Pregnant have certain chronic conditions such as

tuberculosis or kidney dialysis. And other exceptions

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Share of Cost Medi-Cal

For people with disabilities who make too much money for regular Medi-Cal

pay a certain amount (share of cost) each month that you receive medical care before Medi-Cal begins to pay

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Eligibility for Medi-Cal

Income

Few resources

United States Citizen or documented resident

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Important Points about Medi-Cal

There are many ways to qualify for Medi-Cal An adult with a disability may qualify

even if the rest of the family doesn’t It can be very confusing to figure

out if you qualify.

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Important Points about Medi-Cal

You can get help with things like finding out if you are eligible, filling out applications or problems

at places like the Consumer Health Center of Los Angeles

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Denti-Cal

Program for dental care. Provides

regular cleaning and check-ups

needed dental work Full dentures

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Eligibility for Denti-Cal

Eligible for Medi-Cal

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Important points about Denti-Cal

California provides Denti-Cal services for adults

You can receive a list of dentists who accept Denti-Cal from CHDP

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Medicare

A federal health insurance program for: Seniors over age 65 People under age 65 who

• Are disabled and eligible for Social Security Disability Income (SSDI)

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Medicare

Not a comprehensive program Doesn’t pay for

• routine physicals, • hearing aids, • eyeglasses, • prescription drugs (limited

payment), or • long-term care at home or in a

nursing home

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Medicare

Medicare is not free You get Part A

(Hospital Insurance) when you enroll

But you must pay extra to get Part B (Medical Insurance)

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Eligibility United States Citizen or

documented resident and Seniors over age 65, or

Has worked at least 10 years at a job that pays into Medicare

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Eligibility People under age 65

who Are disabled eligible for Social

Security Disability Income (SSDI)

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Adult Programs for Special Populations

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Aged, Blind & Disabled (ABD) Program Only for people

who are Seniors - Over 65

or Blind or Disabled

And make too much money to qualify for SSI

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250% Working Disabled Medi-Cal Program Special Medi-Cal

program for adults with disabilities who are working but still need health coverage

Monthly premium

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Medi-Cal and Medicare (dual eligibility)

Can qualify for both Medi-Cal and Medicare

Medi-Cal may pay Medicare HMO fees

May have a share of cost before Medi-Cal pays

+

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Genetic Health Prevention Program? (GHPP)

State program for people 21 and older some genetic diseases

medical case management and pays the medical and dental costs

Some people under age 21

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County Department of Mental Health (DMH)

care for adults with Serious Mental Illness (SMI).

Examples of these are severe depression or bi-polar disorder.

not for people with developmental disabilities or substance abuse

unless they also have a SMI.

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Mental Health Programs

Care can include • therapy, • medication, • hospitalization

and • other services

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Mental Health Programs

Mental Health services who don’t have a SMIMedi-Cal, Private pay

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Access for Infants and Mothers (AIM) Program

AIM provides low-cost health coverage for pregnant women and their newborns (ages 0-2). Woman – to 60 days after the

pregnancy has ended. The newborn- up to second

birthday.

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Other Related Programs

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IHSS

An alternative to out-of-home care, nursing homes or

board and care facilities

Two Types Residual program Personal Care

Services Program (PCSP)

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IHSS

An alternative to out-of-home care,nursing homes or board and care

facilities Services can be provided by

a spouse or someone who isn’t related to you

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Residual Program

An alternative to out-of-home care,nursing homes or board and care

facilities For people

with disabilities (including blindness)Who don’t need personal care or

paramedical services Must meet SSI/SSP disability criteria

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Personal Care Services Program (PCSP)

An alternative to out-of-home care,nursing homes or board and care

facilitiesCovers similar services

• Provides personal care and/or• Paramedical services• Doesn’t fund protective services

Must receive SSI to qualify

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IHSS

Services can be provided by A hired care provider A parent or spouse

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IHSS Services include

housecleaning, preparing meals, laundry, grocery shopping, personal care services taking people to medical

appointments, and protective supervision for

people with cognitive disabilities

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Eligibility for IHSS

United States citizens or qualified aliens; and California residents.

Live at home Current recipients of SSI/SSP (PCSP) or Current recipients of SSI/SSP (Residual)

• Are eligible for SSI/SSP but their family income is too high

• May have share of cost• are eligible for SSI/SSP, including income,

but don’t get SSI• Get Medi-Cal and meet SSI/SSP disability

criteria.

Limited resources

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Important Points About IHSS

You can qualify for both Residual and PSCP If service is covered by both

programs, it will be funded by PSCP

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Supplemental Security Income (SSI)

not a healthcare system provider

federal program that gives a monthly payment

automatically eligible for fee for service Medi-Cal

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SSI

Adult programs• List of eligible

diagnoses. • If not on the list,

you may not be eligible.

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Important Points about SSI

Diagnosis on the list Different requirements for

children and adults Financial eligibility Provides a cash payment

you eligible for fee for service Medi-Cal

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The Health Insurance Premium Payment Program (HIPP)

may pay premiums for private health insurance for people who are on Medi-Cal a high-cost medical condition covered by private health

insurance

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Regional Center & Health Care Services

Serves people with developmental disabilities

Not a healthcare provider

Can help their clients get some of the healthcare services they need.

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Important Points about Regional Center & Health Care Services

May fund healthcare services related to the developmental disability

They are the payer of last resort