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6 Cards in this Set

  • Front
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What is Covered California?

· Think of Covered California as a one stop shopHealth coverage Marketplace


· Consumers can apply for Medi-Cal and Purchase Health Coverage in one place


· www.coveredca.com


If the consumer can apply online, why do we need HSS’s?

· Covered CA is just a tool to allow the consumers to apply, HSS’s are needed to apply program regulations and determine what the applicant is eligible for.


· Applications are screened and any application with potential Medi-Cal eligibility is sent to the appropriate county for evaluation



The HSS (you) will then determine which Medi-Cal Program or Covered CA Insurance Plan the applicant is eligible to.

How to determine eligibility?

· Not a manual procedure, use 2 systems to determine eligibility

· CalWin

o All applications are entered into CalWino Determines eligibility for some Medi-Calprograms by running EDBC


o Conncects to CalHEERS to run eligibility for MAGIMedical and Covered CA Health Plans


o Keeps record of all applications and houses all Medi-Cal cases for annual renewals


· CalHEERS

o Is the back end of www.coveredca.com


o Receives online applications through Covered CA


o Keeps record of all applications and houses only Covered CA Health Plan cases for annual renewal


o Receives information from CalWIN to determine eligibility for MAGI and Covered CA Health Plans

What if the consumer comes into the office instead of applying online?

· No problem – The application is entered into CalWIN and once EDBC is run the Eligibility Determination Request (EDR) is sent to CalHEERS, once received and evaluated CalHEERS will return a DeterminationEligibility Response (DER) to CalWin


o Can take minutes to hours.


· If anyone in the Household is eligible toMedi-Cal.. the county is responsible for the case, including all changes reported and annual renewals


· If the consumer is only eligible to Covered CA healthplans the State is responsible for the case, including all changes reported and annual renewals