CMISP Eligibility


 
Eligibility Standards
 
The CMISP eligibility standards are reviewed and approved by the Sacramento County Board of Supervisors and are amended from time to time. The CMISP patient eligibility standards are very similar to those of the State Medi-Cal program. The basic criteria for eligibility standards are Sacramento County residency, income, and personal property assets which are dependent upon the number of persons sharing common support. Under the CMISP eligibility standards, a patient may have a share-of-cost if his/her income exceeds the defined standard. The Department of Health and Human Services bills the patient for the share-of-cost. Both Eligibility and Medical Case Management staff are key persons in the coordination of benefits to assure that all proper funding sources are utilized. 
 
Coverage of benefits under the program is subject to program policies and the CMISP Scope of Service.
 
Non-emergency services require CMISP prior authorization for payment.
 
 
Referrals from Sacramento County Hospitals to CMISP Eligibility
 
Emergency Inpatient - Contract hospitals must contact the CMISP Eligibility Unit at (916) 874-9238 within 72 hours of admission when making a referral for an emergency admission. Hospitals may FAX referrals to the CMISP ELIGIBILITY FAX line 874-9328. Be prepared to provide the following:
 
  ■ Date of Admission
  ■ Patient Name
  ■ Complete Address
  ■ Telephone Number
  ■ Social Security Number
  ■ Date of Birth
  ■ Diagnosis
 
In the case of other available resources, the hospital is required to aggressively pursue that resource. If a patient is a veteran of the United States Armed Forces, the hospital must verify their VA coverage, if any, and document daily attempts on their part to transfer to a Veteran’s Administration facility. CMISP benefits will be considered when the Veteran’s Administration denies coverage/transfer of the patient. The patient may complete a mail-in application or schedule an appointment at the CMISP Eligibility office if the patient has been discharged. A direct hospital admit from a physician's office is subject to Medical Case Management review and will be authorized for emergency situations only.
 
For Emergency Inpatient Services rendered at Non-Contracted Sacramento County hospitals, the patient must bring a copy of the discharge paperwork to Department of Human Assistance to initiate the CMISP eligibility process.  If you become eligible for CMISP, it is also your responsibility to provide copies of your medical records to CMISP Case Management.
 
 
Outpatient Emergency Referrals
 
Sacramento County hospitals may refer emergency outpatients to the program by use of the CMISP Hospital Emergency Outpatient Referral Form #SC1188CMISP. The emergency department physician must follow the provider instructions on the form and sign the form to initiate the CMISP referral process. The referral form is given to the patient. The patient has ten (10) working days to contact the CMISP Eligibility Unit to schedule an appointment. Specific instructions for the patient are on the reverse side of the form. Payment is subject to Medical Case Management review and patient eligibility. If the patient has been certified eligible and the emergency service is authorized, an authorization will be entered into our computer system and the patient and hospital will receive notification of the authorization. 
 
 
CMISP DOES NOT PAY FOR FOLLOW UP CARE AT EMERGENCY ROOMS. 
 
 Clients should be referred to a County Clinic for follow up care.
 
 
  
Out-of-County Patient Transfers/Services
  
CMISP does not authorize out of county transfers/services of CMISP patients.
 
 
Disability Referrals 
 
Eligibility workers and Medical Case Management staff work closely with patients who may have a disability. These patients are referred to Department of Human Assistance Eligibility workers to apply for Medi-Cal benefits.
 
 
Non-enrolled Providers
 
In emergency situations any payment to non-enrolled providers is subject to CMISP maximum reimbursement guidelines.


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