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The ___ regulates Health Plans serving medi-cal at the Federal level
Center of Medicare and Medicaid (CMS)
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Name the three systems a beneficiary may receive medical services under medi-cal.
- MediCal Fee for Service
- MediCal share of cost
- MediCal managed care
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Who regulates the health plans serving MediCal at the state level?
DHCS-Dept of health care services
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When did LA Care go live in the MediCal managed care program?
April 1997
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Which model in the MediCal managed care system is offered in Los Angeles county?
Two Plan model
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Name LA Care Health plan's plan partners
- Anthem Blue Cross BCSC
- Care 1st- CFST
- kaiser KAIS
- LA Care MCLA
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Who does LA Care health plan serve?
The vulnerable, low income population who live in LA county.
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MCLA is a/an ____ providing health care services to its members through contracted medical groups, hospitals, pharmacies, and ancillary facilities.
HMO/Plan
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Members are assigned to a ____ who manages and coordinates all of their health care needs.
PCP
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What is the difference between Clinic and IPA?
A clinic has PCP, specialist, ancillary services all in the same building. The doctors are employees of the clinic.
- IPA Independent Physician Association
- Individual doctor working in an office contracted with a medical association.
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What does S/R mean? Explain what it is.
Shared/Risk. The health plan delegates the Medical Group to be responsible for all the professional services and fees, while the health plan is responsible for all the facility services and fees.
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Wat two aid code categories qualify for the MediCal managed care program?
Mandatory and Voluntary
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What is PPG? Explain what it is.
Participating Physician's Group- they are all the medical gropus contracted under LA Care directly or indirectly.
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If a member asks you "what is the difference between LA Care and Health Net", what would you say?
They both have the same services. Only the doctors, hospital, and Pharmacy may be different. Health Net is for profit and has two plan partners: Molina and Health Net, and LA Care is non profit and has four plan partners: Anthem Blue Cross, Care first, Kaiser and LA Care.
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Who are our MediCal members? Name the groups who make up our membership?
- Pregnant women
- Parents with minor children
- Under 21
- 65 & over
- Blind Aged Disaled
- Forster Care
- Receives Cal-Works or SSI
- 250% of FPL
- US Citizens/Socumented Immigrant
- Lives in LA County
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Explain the process for a member to see a specialist?
If the member needs to see a specialist the member's PCP will submit a referral to the PPG. The PPG then sends the approval letter to the PCP, Specialist and the member. The member then has 10 days to call the specialist and make the app or the approval will expire and the process has to start over.
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When a MediCal member is enrolled into the Managed Care program they are assigned to
A health plan, medical group and a PCP
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Name the five Primary doctor specialties with the code and age range
- 01 General Practice 0-150 yrs; 10-150 yrs
- 08 Family Practice 0-150 yrs
- 16 OB/GYN 16-75 yrs
- 40 Pediatrician 0-21 yrs
- 41 Internal Medicine 16-150 yrs; 14-150 yrs (if CHDP certified)
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Name LA Care Health Plan's lines of business.
- MediCal
- Healthy Families
- Healthy Kids
- MediCare SNP
- IHSS
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