Chapter 4B - Maternal and Child Health Access
Contents
1. The application ID number is listed on this screen An application ID is a Unique Identifier that can assist you in locating the application again in the One e App system You will be navigated back to the main menu when you click on Next LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A HEALTHY FAMILIES APPLICATION When you click on submit you will begin the processing for Healthy Families You have succesfully collected all the required data elements for Medi Cal for Children and Pregnant Women a H applications Medi Cal for Children and Pregnant Women Completion ED Notes 200633200338 5 Joel Ruiz Referred Healthy Families a Beth Ruiz Medi Cal for Children and Pregnant Women Note Each Indicates that the application is ready to be transferred to Health e App Note Each Indicates that the application is not ready to be transferred to Health e App Note Each Indicates that the person s information is complete Note Each Indicates that the person s information is incomplete LA County One e App User Manual 85 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer D Ul IA SJAP Per HT program information help suspend cancel s to Health Care Healthy Families P TEN English Espa ol Los Angeles County Special Population Plan If your2. APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A HEALTHY FAMILIES APPLICATION N onezJapp step program information help suspend cancel Indicate if you are Processing a Healthy G to Health Care Families Renewal here Healthy Families One e App does not process Healthy Families Fnglish MEN ee Renewals electronically the system will Healthy Families Renewal details E Note generate a pre populated renewal form to print and mail to the Healthy Families Program Is this a Healthy Families Renewal applicatio O yes O No ae Are there new family persons that you would like to add to Healthy Familiek O ves O No Refer to the Healthy Families Renewal Section for more detailed information LA County One e App User Manual 87 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A HEALTHY FAMILIES APPLICATION Healthy Families Completion J Notes When you reach this screen you are ready to submit your application to Health e App You have succesfully collected all the required data elements for Healthy Families Please click the Submit button in order to be presented with the options to either submit this application to Health e App right away or route this application to the Program Submission workload for a later submission You must click on the box next to the _ i application ID and then click on the Submit al Beth Ruiz M
3. continued Rights and Declarations Medi Cal Confidentiality Notice The information given in this application is private and confidential under Welfare and Institutions Code Sections 10850 and 14100 2 The information will be disclosed only in accordance with those laws Medi Cal Privacy Notice The Information Practices Act of 1977 and the Federal Privacy Act require the Department of Health Services to provide the following notice to individuals who asked by Healthy Families to supply information Welfare and Institutions Code section 14011 and regulations in Title 22 CCR require applicants for the Medi Cal program to provide the eligibility information requested in this application This information may be shared with federal state and local agencies for purposes of verifying eligibility and for other purposes related to the administration of the Medi Cal program including confirmation with the INS of the immigration status of only those persons seeking full scope Medi Cal benefits Federal law says the INS cannot use the information for anything else except in cases of fraud The information will be used by Electronic Data Systems to process claims and make 81 THINGS TO CONSIDER If the applicant is denied Medi Cal the applicant has 90 days after receiving the denial notice to ask for a hearing to tell Medi Cal why he or she thinks the decision was wrong The applicant can call the Health Consumer Center 1 800 896 3203 f
4. and Pregnant State of California Dept of Health i Maxwell Women Services a Contact Information Health e App State of California Dept of Health Swwices Fax 888 123 4567 Ss Note Each indicates that the member information has been successfully submitted to He Tiag App system Note Each indicates that the member information was not successfully submitted to Health e App Los Angeles County Congratulations You have completed the application process Your One e App Application ID 200634800037 Click the Next button to return to the Menu screen Sprint Languages Report a Bug Make a Suggestion 84 PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION This screen will indicate if the application was successfully submitted to Health e App A state contact number for Medi Cal or Healthy Families is provided if the applicant was found potentially eligible Once you have completed the submission process a Health e App Application Summary is generated and will pop up on the screen You can also generate the Application Summary by clicking on the Document Control Number DCN If you do not receive the pop up you may have a pop up blocker that is preventing you from accessing it Call the One e App Help Desk for more information You can access the Health e App Summary from the Menu function Re print Forms Congratulations You have completed the application process
5. family Applicants can search for a specific provider or health plan that they want If families who do not make a choice cannot be reached by phone within 20 days with four attempts or in writing the child will be defaulted into the Community Plan for that county so that health coverage can start The family can change plans within the first 90 days with no questions asked LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Please select a health dental and vision plan For those individuals potentially eligible for Healthy Families please select a health plan below HEALTH PLANS MOLINA 9 888 665 4621 BLUE SHIELD HMO 9 800 424 6521 CARE 1ST HEALTH PLAN 9 800 605 2556 L 4 CARE HEALTH PLN 9 888 839 9909 COMMUNITY HEALTH PLN 6 800 475 5550 BLUE CROSS HMO 9 800 845 3604 HEALTH NET 9 888 231 9473 1 0 0 0 0 0 0 90 KAISER PERMANENTE 9 800 464 4000 DENTAL PLANS WESTERN DENTAL 800 605 8000 SAFEGUARD DENTAL 800 880 3080 ACCESS DENTAL 888 849 8440 HEALTH NET DENTAL 800 977 7307 VISION PLANS EYE MED VISION CARE 513 492 3541 SAFEGUARD VISION 949 425 4301 VISION SERVICE PLAN 800 877 7239 Do you want to
6. family is in any of these groups there is a statewide health dental and vision plan combination offered to your family This plan combination allows families to maintain the same insurance plan even if they move around the state following the seasonal job For more information about the Rural Health Demonstration Project refer to the Healthy Families Handbook Blue Cross EPO Delta Dental Vision Service Plan VSP an Please check all that apply C Native American Indian Seasonal or Migratory Jobs C Agrilculture C Forestry _ Fishing Special Population Plan Do you want Special Population fin Oves Ono Do you want to select a Primary Care Physician n Oves Ono 86 PROCESSING A HEALTHY FAMILIES APPLICATION SPECIAL POPULATION PLAN Within Healthy Families there is a special insurance plan called the Special Population Plan which offers health dental and vision coverage for American Indians and families employed in seasonal jobs in agriculture fishery or forestry This plan combination is available statewide see Resources lt allows families to keep the same health plans even if they move around the state Indicate whether the applicant wants the Special Population Plan by clicking Yes or No If the applicant selects Yes they can also Opt to select a Primary Care Physician If the applicant selects No click on next LA County One e App User Manual Help Desk 1 866 429 1979 Program Application
7. for anything else except in cases of fraud The information will be used by Electronic Data Systems to process claims and make Signatures declare under penalty of perjury under the laws of the State of California that the answers have given in this application the declarations made and the documents submitted are true and correct to the best of my knowledge and belief declare that have read and understand the application instructions the declarations and all information displayed in this application Applicant Signature Witness if person signed with a mark Date Authorized Representative if any Date CAAH oneeapp EE 07105 Information continued next page 80 PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION RIGHTS AND DECLARATIONS REMEMBER 1 Review the Medi Cal Rights and Declarations with the applicant 2 Print a copy You will need this signed form faxed with other verification documents It is also a good practice to give a signed copy to the client for his her records 3 Provide the signatures as required 4 Fax the Rights and Declaration with the verification documents to the number listed on the Health e App Fax Cover sheet LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION STEP 8 Health e App Data Transfer Medi Cal Rights amp Declarations
8. indicates that he she would like to be screened for Medi Cal eligibility be sure to remind them that in order for the county to determine whether he she is eligible supplemental forms such as asset or documentation will have to be provided LA County One e App User Manual 79 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Medi Cal Rights amp Declarations Rights and Declarations Medi Cal Confidentiality Notice The information given in this application is private and confidential under Welfare and Institutions Code Sections 10850 and 14100 2 The information will be disclosed only in accordance with those laws Medi Cal Privacy Notice The Information Practices Act of 1977 and the Federal Privacy Act require the Department of Health Services to provide the following notice to individuals who asked by Healthy Families to supply information Welfare and Institutions Code section 14011 and regulations in Title 22 CCR require applicants for the Medi Cal program to provide the eligibility information requested in this application This information may be shared with federal state and local agencies for purposes of verifying eligibility and for other purposes related to the administration of the Medi Cal program including confirmation with the INS of the immigration status of only those persons seeking full scope Medi Cal benefits Federal law says the INS cannot use the information
9. select 4 primary care physician now O ves No 91 PROCESSING A HEALTHY FAMILIES APPLICATION Health Plan Selection continued Applicants will be able to select their health dental and vision plan from the list LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Health Plan Selection You have selected the following Health KA amp ISERPERMANENTE Dental ACCESSDENTAL Vision VISIONSERVICEPLAN Your monthly premium amount is estimated to be 9 00 The Healthy Families Program will make the final premium determination 92 PROCESSING A HEALTHY FAMILIES APPLICATION Health Plan Selection continued Review the plans that the applicant has selected and confirm that they are correctly listed on screen The system will give an estimate of the premium payment based on the health plan selected The Healthy Families program will make the final premium determination Coverage may start without payment and families will be billed LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A HEALTHY FAMILIES APPLICATION REMEMBER 1 Review the Medi Cal Rights and Rights and Declarations Declarations with the applicant Healthy Families Declaration 2 Print a copy You will need this signed form faxed with other v
10. 7 to pay over the phone Payments maybe taken electronically from the applicant s banking account with Electronic Fund Transfers EFT To pay by EFT follow the steps on the back of the monthly statements received once enrolled in Healthy Families LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer 2 0 0 6 8 6 1 3 3 0 5 health app Documentation Fax Cover Sheet This page must be the first page of the fax transmission Your documentation must be submitted immediately Date To Fax Number From Address Phone Document Control Number Document Checklist Premium Mailing Address December 15 2006 Healthy Families Medi Cal 1 666 845 4976 Holly Tower 325 W Ave 45 None Los Angeles 90065 Home 323 222 2222 20068613305 Please check the appropriate box to indicate which documents you are attaching 0 Signed Rights and Responsibilities Page C Proof of Income pay stub last year s federal income tax filing etc If you know that your family s income will go up or down in the next few months due to overtime promotion raises in pay expected increases in child support alimony layoffs furloughs etc please explain on a separate piece of paper and fax it along with your supporting documents C Proof of Residency if not using in State pay stub recent bills sent to your c
11. Care If you have any questions call L A Care at 1 888 4LA KIDS 1 888 452 2273 to find out more You can also call the Consumer Hotline at the DMHC at 1 888 HMO 2219 PRIVACY NOTICE The Information Practices Act of 1977 and the Federal Privacy Act require Healthy Kids to provide the following notice to individuals who are asked by Healthy Kids to supply information Personal and medical information requested is for member identification and program administration purposes only Member s information may be shared with state and local agencies involved in administration of health programs Information about persons who apply will be used only for eligibility determination and program administration Failure to provide this information may result in the return of application as incomplete The following information on the application is optional C I declare that I have applied to enroll the se eligible child ren listed on this application in the Healthy Kids Program Oi certify that the information in this application is true and correct Applicant Signature Date Witness if applicant signed with a mark Date I decline to sign the above declaration For System Use Please enter the date the declaration was signed 76 PROCESSING THE HEALTHY KIDS APPLICATION Healthy Kids Declaration You will now be navigated to the screens that require the applicant s consent declaration and signature You will need to p
12. Program Application APPLICATION PROCESS STEP 5 Eligibility Determination ADDITIONAL INFORMATION This screen will gather the immigration Jump Back To information needed to make the appropriate application submission English Espa ol Los Angeles County If the applicant is a U S Citizen or Additional Information E notes National he or she has the option to indicate it on this screen The The following additional information is needed as indicated Please note that applicants will be able to opt out of program once the preliminary eligibility has been determined immigration inform ation gathered on Daniel John this screen is optional and the family U S Citizen or National Optional may choose not to provide this aon n information at all This information may Do you have Legal Permanent Resident or other satisfactory immigration Yes No Additional Immigration Information be needed to make the appropriate status application submission If the person checks that he she does not have Legal Permanent Residency or other satisfactory immigration status the system will prompt you to enter a Date of Entry You will not be able to move forward until a Date of Entry is entered If person has a green card the Date of Entry can be found on the reverse side of the card But if the applicant is concerned about entering a date he or she may be more comfortable with a paper application LA County One e App Us
13. You have succesfully collected all the required data elements for Medi Cal for Children and Pregnant Women sent to the state through Health E App tee ee ee ee ee ee For problems with data transfers refer to C 2006347000218 the Data Transfer Error section TEREE Note Each Indicates that We spplcation is ready to be transferred to Health e App When you reach this screen you are ready to Note Each Indicates that the application is not Peaeta be transferred to Health e App submit your application to Health e App Medi Cal for Children and Pregnant Women Completion E Notes Note Each Indicates that the person s information is complete Note Each Indicates that the person s information is incomplete You must click on the box next to the print Languages Generate Universal Summary Generate Fax cou m DY application ID and then click on the submif icon The system will go through a data transfer process that is interactive This may take several minutes You will see a Data Transfer Pop Up each time a section of the application is transferred into the Health e App system Health e App Data Transfer Please wait while the data is being transferred to Health e App Transferring data to Health e App Getting Started E E E H THINGS TO CONSIDER Remember that it is a best practice to send the Medi Cal eligible pregnant woman to a PE provider and the full Medi Cal application directly to Los Angeles Coun
14. ation ID is a Unique Identifier that can assist you in locating an application in the One e App system You will be navigated back to the main menu when you click on next LA County One e App User Manual Help Desk 1 866 429 1979
15. eased monthly premium cost Families may voluntarily report the income change to Healthy Families e It is a good idea to report address changes to Healthy Families by calling 1 866 848 9166 e Ifthe family believes that the children are wrongly denied Healthy Families the family can request a review by filing an appeal with Healthy Families The family can also call the Health Consumer Center at 1 800 896 3203 for help e Remind the family that they will receive an Annual Eligibility Review that must be completed and returned to Healthy Families for benefits to continue and that you can help them LA County One e App User Manual 93 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Please sign ONLY if you have been helped by a Certified Application Assistant CAA I certify I had help completing this form from the Certified Application Assistant listed below This C44 help was FREE of charge Applicant Signature C44 Signature Date lf you would like information released to a CAA please sign below By signing below give permission for the Healthy Families and Medi Cal to give information over the telephone about the status of this application to a CAA of the Enrollment Entity organization identified below This permission will end on the date the program mails the results of the eligibility determination on this application Premium Payment Method The first month s premi
16. edi Cal for Children and Pregnant Women ICON The system will go through a data transfer Note Each Indicates that the application is ready to be transferred to Health e App ee Note Each Indicates that the application is not ready to be transferred to Health e App process that IS interactive Note Each Indicates that the person s information is complete Note Each Indicates that the person s information is incomplete This may take several minutes print Languages Generate Universal Summary Generate Fax Cove C submit D You will see a Data Transfer Pop Up each time a section of the application is transferred into the Health e App system LA County One e App User Manual 88 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Other Household Members who want Medi Cal Do any of the people listed below want Medi Cal Yes No Applicant Beth Ruiz Health e App Preliminary Eligibility Determination Based on the information you have submitted to Health e 4pp the following members in your household may be eligible for Beth Ruiz Medi Cal Joel Ruiz Healthy Families 89 PROCESSING A HEALTHY FAMILIES APPLICATION The system will ask if any people listed below want Medi Cal This screen gives a final opportunity to add a household member who did not request benefit enrollment The system will list the household members and the pro
17. er Manual 73 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 6 Preliminary Eligibility Determination Based on the immigration status provided Preliminary Eligibility Results L notes the One e App system will again provide sn Pee oe Preliminary Eligibility Results Applicants Based on the information you have provided the following persons in your household may be eligible for the following programs may opt out of programs here They will be navigated to select a provider for Healthy E Nancie Rigetti Medi Cal for Children and Pregnant women Primary Kids and Healthy Families and to consent C1 Manin rises a mile Me app icant snare Each program has its own application forwarding process CONFIRM INFORMATION THINGS TO CONSIDER Be sure the information entered is correct and as complete as possible You can do this by viewing the Universal Application Summary The One e App system does not make the final eligibility determination The system gathers the information and electronically sends the application to the appropriate program After you cross the second preliminary eligibility screen the only way to make changes to the application is to have your application reset by a System Administrator LA County One e App User Manual 74 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 7 Program Information Healthy Kids Los Angeles C
18. erification documents declare that each person am applying for is a resident of California is nat in jail or in a mental hospital 3 It is also a good practice to give a signed is not eligible for Medicare Part A and Part B is not eligible for any California Public Employees Retirement System Health Benefits copy to the client for his her records Program s or is eligible for a California Public Employees Retirement Health Benefits Program but the employer contribution for dependent s is less than 10 4 Provide the signatures as required further declare that i f 5 Fax the rights and declaration along with all individuals listed on this application will abide by the rules of participation the utilization review process and the dispute resolution process of the participating plans in which the the other verification documents to the LU number listed on the Health e App Fax Cover Sheet Rights and Declarations Medi Cal Confidentiality Notice The information given in this application is private and confidential under Welfare and Institutions Code Sections 10850 and 14100 2 The information will be disclosed only in accordance with those laws Medi Cal Privacy Notice The Information Practices Act of 1977 and the Federal Privacy Act require the Department of Health Services to provide the following notice to individuals who asked by Healthy Families to supply information Welfare and Institutions Code sec
19. faxed This will help keep the documents from getting lost 3 Fax all the documents to the fax number listed on the Fax Cover Sheet For more information on faxing please refer to the Fax Tip Sheet located in the Resource section LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Congratulations B Notes You have completed the application process for Health e App for the following members Click on the next button to continue 200634800052 DCN 20068613305 Healthy Families State of California Dept of Health Services Contact Information Health e App State of California Dept of Health Services Fax 888 123 4567 Re Note Each indicates that the member information has been successfully submitted to Health e App system Note Each indicates that the member information was not successfully submitted to Health e App system Congratulations You have completed the application process Your One e App Application ICAs 200633300054 Click the Next button to return to the Menu screen 96 PROCESSING A HEALTHY FAMILIES APPLICATION This screen will indicate if the application was successfully submitted to Health e App A state contact number for Medi Cal or Healthy Families is provided Congratulations You have completed the application process The Application ID number is listed on this screen An Applic
20. fied provider LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 7 Program Information Healthy Kids Declaration E Notes Application ID 200633300054 Representative Name Nancie Rigetti DECLARATIONS I declare that each child I am applying for e Lives in Los Angeles County Is notin the juvenile justice system or in a mental hospital I further declare that All individuals listed on this application will follow the rules of the program the utilization review process and the dispute resolution process of Healthy Kids I agree to a pay the premiums If I do not pay the premiums I will either apply for premium payment by the Healthy Kids Premium Assistance Fund or I understand my child will be taken off the program I give Healthy Kids permission to check my family income health coverage and all other facts on this application I agree to notify L 4 Care Health Plan within 30 days of any of address or any person listed here who is accepted into the program and any changes in billing address RESOY YLING DISPUTES If you enroll in Healthy Kids you have certain rights to file a grievance or appeal with L 4 Care concerning any dispute you may have In addition you may ask for mediation to resolve a grievance You may still appeal to the Department of Managed Healthcare DMHC even if you use mediation or request a grievance resolution or an appeal of L A
21. ghts and Declarations If you are not navigated to the Health e App Fax Cover Sheet you can access it from the Menu page For more information on printing Health e App Cover Sheets please refer to Chapter 3 page 39 or call the One e App Help Desk 1 866 429 1979 The final step in the Data Transfer from One e App to Health e App is the printing of the Health e App Fax Cover Sheet The system will verify using a pop up that you have printed the Fax Cover Sheet before you click next REMEMBER Once you have completed the Data Transfer Process you have 24 hours to fax over the verification document to Health e App 1 Print the Fax Cover Sheet 2 Review the document check list located on the fax coversheet Check off the verification documents that will be faxed 3 Write the Document Control Number DCN on each document faxed This will help keep the documents from getting lost 4 Fax the all the documents to the Health e App fax number listed on the Fax Cover Sheet 5 For more information on faxing please refer to the Fax Tip Sheet located in the resource section LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Congratulations You have completed the application process for Health e 4pp for the following members Click on the next button to continue SS 200634800037 Coon 20068613302 valere Medi Cal for Children
22. grams for which they are potentially eligible When you click next you will begin the consent and signature process LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Health Plan Selection Same members of the household appear to qualify for Healthy Families You are required to pick a health plan before the coverage is activated Do you want to choose health dental and vision plans now O ves O no If yes please select one of the options below I would like to see if a specific provider is in one of the participating plans in my county I would like to select a health dental and vision plan in my county THINGS TO CONSIDER Applicants should be advised to be prepared to make plan and provider choices when they come to the One e App enrollment They should be allowed to discuss the choices with family members their providers or others They should be allowed time to do so if they are unsure of their health plan or provider choice Never pressure an applicant to choose a provider just to complete the application 90 PROCESSING A HEALTHY FAMILIES APPLICATION Health Plan Selection The applicant can choose a health plan or a specific provider at this time or wait and contact Healthy Families later If the applicant does not choose and does not contact Healthy Families Healthy Families personnel will contact the
23. ied Application Assistant listed below This CAA help was FREE of charge Applicant Signature CAA Signature Date lf you would like information released to a CAA please sign below By signing below give permission for the Healthy Families and Medi Cal to give information over the telephone about the status of this application ta a CAA of the Enrollment Entity organization identified below This permission will end THINGS TO CONSIDER Even though the Healthy Families consent expires you may assist a family having trouble with the Healthy Families program 82 PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION The primary informant applicant needs to certify that the application was completed free of charge This screen also allows the applicant to provide consent for release of information to the Healthy Families Program This gives the Application Assistor the ability to work with Healthy Families on behalf of the applicant This consent will last until Healthy Families enrolls the child into the program LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer 2 0 0 6 8 6 1 3 3 0 2 health e app Documentation Fax Cover Sheet This page must be the first page of the fax transmission Your documentation must be submitted immediately Date December 15 2006 To Healthy Families Medi Cal Fax Nu
24. mber 1 566 848 4976 From aliere Maxwell Address 1111 VV 6th ST Los Angeles 90017 Phone Home 213 222 2222 Document Control Number 20068613302 Document Checklist Please check the appropriate box to indicate which documents you are attaching Document Checklist Please check the appropriate box to indicate which documents you are attaching O Signed Rights and Responsibilities Page C Proof of Income pay stub last year s federal income tax filing etc If you know that your family s income will go up or down in the next few months due to overtime promotion raises in pay expected increases in child support alimony layoffs furloughs etc please explain on a separate piece of paper and fax it along with your supporting documents C Proof of Residency if not using in State pay stub recent bills sent to your current address C Proof of Pregnancy note from your doctor or clinic 0 Citizenship birth certificate Mailing Address Healthy Families Medi Cal for Children and Pregnant Women P O Box 13800 Sacramento CA 95813 9984 a o Fax Within 24 Hours Once you have completed the Data Transfer Process you have 24 hours to fax over the verification document s 83 PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION You will be navigated to the Health e App Fax Cover Sheet This should automatically happen after you have completed the printing and signing of Ri
25. or assistance If the applicant does not speak English explain that Medi Cal is required to communicate with the applicant in his or her language The applicant can ask for Medi Cal to provide someone who speaks his or her language lt is important to read over and review this document with your client since 53 percent of adults in Los Angeles have low literacy Skills To be a resident means that the Medi Cal applicant must live in California at the time of the application and intend to remain in California for the indefinite future the term is NOT related to immigration status There is no requirement that the applicant have lived in California for a certain time before applying to Medi Cal It is a good practice to remind the applicant that if information submitted with this application changes the applicant must inform the Medi Cal Eligibility Worker assigned to the applicant s case within ten 10 days of the change Changes include things like address changes increase or decrease in work income family composition i e parent or child enters or leaves the household pregnancy or change in immigration status LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer Please sign ONLY if you have been helped by a Certified Application Assistant CAA certify had help completing this form from the Certif
26. ounty Provider Search and Selection Notes You can search for a provider or clinic by city or by the provider s last name Specialty gender and language or any combination of these preferences can be used to further filter the results within the primary search criteria Provider Clinic Provider ID ZIP City No Preference v Provider Last Name O 2476m CENTRAL CITY COMMUNITY g0001 N A Enalish TD s ARROYO VISTA HEALTH mo C r lt Q eee CENTER FIGUEROA 90042 wre Armenian 12 19 PROCESSING THE HEALTHY KIDS APPLICATION The following series of screens are for those applications that have been found preliminarily eligible for the Healthy Kids program The client will need to select a provider or clinic for both medical and dental services Vision care is provided through the medical plan and does not need to be selected You are able to find a provider by any one or more of the following e zip code e city e provider name e provider specialty gender or language spoken Make sure you click on both the clinic selection and the household member which will be assigned to that provider You will receive a Provider Selection Summary which can be printed for the client s records You may change the provider selection by clicking on the applicant s name in the Provider Search Summary page The system will continue to return to this page until all children have an identi
27. rint and fax documents to complete the application submission process Anytime there is a need to give consent and a signature is required it is a good practice to read and review the consent and to give a copy to the client for his her records Since Healthy Kids has a Premium Assistance Fund it is a good practice to explain how and when this may be used see Resources REMEMBER 1 Review the Healthy Kid s Rights and Declarations with the applicant Print a copy You will need this signed form faxed with other verification documents Itis also a good practice to give a copy of the signed document to the client for his her records Provide the signatures as required You will need to add the date that the application was signed LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 7 Program Information Healthy Kids Completion You have succesfully collected all the required data elements for Healthy Kids Upon click of the Submit button your application will be completed in One e App 200634700021 al Mega Bucks Healthy Kids Healthy Kids Summary Note Each Indicates that the application is ready to submit Healthy Kids Note Each Indicates that the application is not ready to submit Healthy Kids Note Each Indicates that the person s information is complete Note Each b Indicates that the person s information is incomplete o P
28. rint kJ Languag Ce enerate Universal Summary Jenerate Fax Cover Submit gt 11 PROCESSING THE HEALTHY KIDS APPLICATION Healthy Kids Completion When you reach this screen you have completed the intake process and are now ready to submit the application At this point you can print fax cover sheets by clicking on the cover sheet icon It will create two cover sheets for temporary and permanent documents It will have a list of documents on the fax cover sheet that you can check off to indicate that they are being sent i WARNING This cover sheet should be used ONLY for the documents for this application problems are caused when multiple or other applications are sent with a cover sheet that does not correspond to the documents behind it You can click on the Generate Universal Summary icon to print a program summary that can be given to the applicant for his her records If you have other programs to process continue until the end of the whole application process before you print either the Fax Cover Sheet or Universal Summary For more information on faxing please refer to the Fax Tip Sheet in the resource section LA County One e App User Manual Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION In One e App applications for Medi Cal for Children and Pregnant Women are
29. tion 14011 and regulations in Title 22 CCR require applicants for the Medi Cal program to provide the eligibility information requested in this application This information may be shared with federal state and local agencies for purposes of verifying eligibility and for other purposes related to the administration of the Medi Cal program including confirmation with the INS of the immigration status of only those persons seeking full scope Medi Cal benefits Federal law says the INS cannot use the information for anything else except in cases of fraud The information will be used by Electronic Data Systems to process claims and make Benefits Identification Cards BICs Failure to provide the required information may result in denial of the application THINGS TO CONSIDER e Children eligible for Healthy Families must reside in California with the intent to remain for the indefinite future There is no length of time a child must reside in California before applying for Healthy Families e There is NO ten 10 day requirement to report changes for Healthy Families like there is in Medi Cal Once the child is enrolled in Healthy Families changes in income or household composition in the following 12 months do not matter If family income decreases during the year the child can apply for Medi Cal and request that the Healthy Families case be terminated once the child is on Medi Cal Decrease in income may also lead to a decr
30. ty see Resources Apply through One e App separately for her children Apply for the Access for Infants and Mothers AIM program separately for women who meet AIM criteria see Resources LA County One e App User Manual 78 Help Desk 1 866 429 1979 Program Application APPLICATION PROCESS STEP 8 Health e App Data Transfer PROCESSING A MEDI CAL FOR CHILDREN PREGNANT WOMEN APPLICATION The system will ask if any people listed below want Medi Cal and gives one last chance to add a household member that did not request enrollment Other Household Members who want Medi Cal Do any of the people listed below want Medi Cal Yes No Remember that adults needing immediate coverage or with past medical bills or Applicant expenses should apply elsewhere see Valiere Maxwell Resources If the adult checks yes on this application she or he should follow up with the Department of Public Social Services to ensure timely application See Things to Consider below for CAA Best Practice Tips The system will list the household members Health e App Preliminary Eligibility Determination and the programs for which they are Based on the information you have submitted to Health e App the following members in your household may be potentially eligible eligible for When you click nex you will begin the consent and signature process for Medi Cal Valiere Maxwell Medi Cal Things to Consider If an adult
31. um must be paid in order to process your application If your family is not eligible for the Healthy Families program your premium payment will be refunded to you Please check the appropriate box to indicate the type of payment you will make Western Union Credit or Debit Card Online Personal Check Mail Payment PROCESSING A HEALTHY FAMILIES APPLICATION The applicant will need to certify that the application was completed free of charge This screen also allows the applicant to provide consent for release of information to the Healthy Families Program This gives the Applicant Assistor the ability to work with Healthy Families on behalf of the applicant This consent will last until Healthy Families enrolls the child into the program Premium Payment Method Indicate the method for paying the premium There are four ways to pay premiums in the Healthy Families program 1 Payments may be made by mail with a Personal Check Cashier s Check or Money Order Make checks out to the Healthy Families Program Mail payments to Healthy Families P O Box 537019 Sacramento CA 95853 7019 Payments may be made by cash in person at certain Western Union Convenience Pay Locations Call 1 800 354 0005 option 5 to find a Western Union near the client There is no charge for this service 94 3 Payments may be made by Credit or Debit Card online or by phone Click on the link to pay online or call 1 888 256 616
32. urrent address 0 Citizenship birth certificate 15 00 per month Pay for 3 months total of 45 00 get the 4 month free The first month s premium must be paid in order to get coverage Please check the appropriate box to indicate how you will submit payment C Sending a personal check money order or cashier s check to address below Please make sure that your Document Control Number is written on the check and make it payable to Healthy Families Program Healthy Families Medi Cal for Children and Pregnant Women P O Box 138005 Sacramento CA 95613 9984 95 PROCESSING A HEALTHY FAMILIES APPLICATION Documentation Fax Cover Sheet The final step in the data transfer from One e App to Health e App is the printing of the Health e App Fax Cover Sheet For additional examples and options for required documentation see Resources The Fax Cover Sheet will list the amount of premium payment along with the mailing address The system will send you a pop up screen to verify that you have printed the Fax Cover Sheet before you click next Fax Within 24 Hours Once you have completed the Data Transfer Process you have 24 hours to fax over the verification document s to Health e App REMEMBER Print the Fax Cover Sheet 1 Review the document check list located on the Fax Cover Sheet Check off the verification documents that will be faxed 2 Write the Document Control Number DCN on each document
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