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Spousal/Dependent Medical Out-of-Pocket (M​OOP) Benefit

Frequently Asked Questions (FAQs) and Scenarios for Enrollment Workers (EWs)​

​B​​​enefit Overview Q​uestio​​ns

1.      What is th​e Spousal/Dependent M​OOP Benefit?

California Department of Public Health (CDPH), Center for Infectious Diseases (CID), Office of AIDS (OA) created a benefit that pays an AIDS Drug
Assistance Program (ADAP) client's portion of their MOOP costs who have elected to participate in the Spousal/Dependent MOOP Benefit and meets the requirements.​

2.      Who is eligible for the Spousal/Dependent MOOP Benefit?

To be eligible, the spouses, registered domestic partner (RDP) and dependents (RDP and children must be at least 18 years old) are:

  • Actively enrolled in ADAP,
  • Named on an OA insurance assistance program (IAP): OA Health Insurance Premium Payment (OA-HIPP) program or Employer Based Health Insurance Premium Payment (EB-HIPP) program client's insurance policy (referred to as the primary client),
  • Not on a Temporary Access Period (TAP), Medi-Cal Eligibility Exception Request (MEER) or Eligibility Exception Request (EER).

​Note: Medicare clients are not eligible for the Spousal/Dependent MOOP Benefit since Medicare plans cannot be family plans.

3.      Who is t​​​he Primary Client?

The primary client refers to the client in the ADAP Enrollment System (AES) that is having their insurance premiums paid by OA-HIPP or EB-HIPP. They can also be listed as the primary policy holder on the billing statement.

4.      What services ​​​are covered under the Spousal/Dependent MOOP Benefit?

The Spousal/Dependent MOOP Benefit includes the following:

  • Pays for outpatient expenses that count towards the insurance plan's out-of- pocket maximum (does not include medications not covered by ADAP).
  • Pays for co-payment, coinsurance and deductibles for medical care as part of the OA-HIPP and EB-HIPP plan benefits.
  • Have claims processed through the Pool Administrators Inc. (PAI) CARE4 system.

5.      Will the spouse/RDP/depe​ndent receive a PAI/OA-HIPP or EB-HIPP benefit card?

Yes, the spouse/RDP/dependent will receive their own PAI/OA-HIPP or EB-HIPP benefit card.

6.      Will the spouse/RDP/dep​endent have access to their MOOP claims submissions?

Yes, the spouse/RDP/dependent will receive communication regarding the status of their MOOP claims submitted by PAI and directly contact PAI regarding their MOOP claims submissions.

Enrollment Questio​​ns

7.      What supporting documentation do clients ne​ed to enroll into the Spousal/Dependent MOOP Benefit?

For initial and re-enrollment, ADAP needs the following:

Note: These forms can each be signed once initially and used for each client's enrollment into ADAP, HIPP or the Spousal/Dependent MOOP Benefit that year. For annual re-enrollments, all the forms can be signed once in the following year and used for each of the annual re-enrollments for both the primary client and the spouse/RDP/dependent client. Forms only need to be signed at the time of whichever client's birthday comes first in the annual re-enrollment process and then used again for the other opposite client later in the year.

​Example:

Peter (Pri​​​mary Client): ADAP eligibility end date 12/17/2022; OA-HIPP end date 1/31/2023

Sam (spouse): ADAP eligibility end date 11/5/2022

Sam re-enrolls in ADAP and Spousal/Dependent MOOP by his annual due date of 11/5/2022. When Peter re-enrolls in ADAP and OA-HIPP on 12/17/2022, he can submit the applicable ADAP forms (refer to the list above) that were submitted for Sam's ADAP re-enrollment in addition to the other required documents.

8.      What are​ the enrollment steps for the Spousal/Dependent MOOP Benefit?

Step 1: The EW determines that both the client and the spouse have ADAP eligibility and screens for Spousal/Dependent MOOP Benefit eligibility.

Step 2: The EW will need to log into the ADAP Enrollment System (AES):

  • Update the Health Coverage and Insurance Tab of the primary client's AES profile,
  • Submit supporting documentation as outlined in question #7 via a HIPP work item,

  • enter a work item case note that the spouse/RDP/dependent is enrolled in ADAP as well,

  • ​Submit a Spousal/Dependent work item under the spouse/RDP/dependent's AES profile. Upload required documentation and enter a case note indicating the spouse/RDP/dependent is enrolling in the Spousal/Dependent MOOP Benefit and include the primary client's ADAP client ID number in order to link the clients in AES.

Step 3: The ADAP HIPP analyst will review all documentation submitted and process the work item. Once approved, the analyst will go into the spouse's AES profile and enter the effective start date for the Spousal/Dependent MOOP Benefit.

Note: ADAP clients who are spouses/RDPs/dependents covered under the primary client's insurance will be covered within the span of the primary client's active HIPP eligibility. Please note if the primary client lapses from the ADAP or their HIPP, the spousal/RDP/dependent client will lose the Spousal/Dependent MOOP Benefit.

​Re-Enrollmen​t

9.      What is the re-enrollment process for the Spous​​​al/Dependent MOOP Benefit?

The timeline is the same as enrollment (refer to question #8). However, when the primary client re-enrolls, be sure to enter a case note to also extend the spouse/RDP/dependent eligibility in the Spousal/Dependent MOOP Benefit and include spouse/RDP/dependent's client ID.

​10.  Will I need to re-submit all Spousal/Dependent MOOP supporting documentation at re-enrollment?

When the spousal/RDP/dependent client is due for their ADAP re-enrollment, the EW will need to submit a Spousal/Dependent work item, upload required documentation (refer to question #7) and enter a case note indicating the spouse/RDP/dependent is re-enrolling in the Spousal/Dependent MOOP Benefit and provide the primary client's ADAP client ID number in order to link the clients in AES.

Eligibil​​ity Dates

11.  How are eligibility dates deter​​mined?

Once the ADAP HIPP analyst reviews the application, the analyst will populate the spouse/dependent's AES program start date to mirror the primary client's HIPP start date. For the program end date, the analyst will enter one of the following:

  • The primary insurance holder's HIPP end date or
  • The client's ADAP eligibility end date, whichever date comes first.

Note: The Spousal/Dependent MOOP Benefit end date cannot exceed the primary client's ADAP eligibility end date.

Scenario 1:

An existing ADAP client wants to enroll OR re-enroll in the Spousal/Dependent MOOP Benefit.

Primary client and spousal/dependent MOOP client submit required documentation (refer to question #5).

Example 1:

Peter (Primary Client): ADAP eligibility end date 12/17/2022; OA-HIPP end date 1/31/2023

Sam (spouse): ADAP eligibility end date 11/5/2022

Sam re-enrolls in ADAP and Spousal/Dependent MOOP by his annual due date of 11/5/2022 but since Peter is the primary client and does not need to re-enroll until 12/17/2022, Sam's ADAP re-enrollment is extended to 11/5/2023 but his Spousal/Dependent MOOP eligibility can only be extended until 12/17/2022 to match Peter's eligibility end date. Once Peter re-enrolls in ADAP and OA-HIPP, then Sam's Spousal/Dependent MOOP eligibility will be extended to Sam's own ADAP eligibility end date of 11/5/2023.

Scenario 2:

The Primary client in a Spousal/Dependent MOOP ​Benefit lapses from ADAP.

Primary client must complete the re-enrollment process for ADAP and OA-HIPP for eligibility to be reinstated for both the primary client and the Spousal/Dependent MOOP client.

​Example 1:

Peter (Primary client): ADAP eligibility end date 12/17/2022, OA-HIPP end date 1/31/2023

Sam (spouse): ADAP eligibility end date 11/5/2022

Sam re-enrolls in ADAP and Spousal/Dependent MOOP by his annual due date of 11/5/2022 but since Peter is the primary client and does not need to re-enroll until 12/17/2022, Sam's ADAP re-enrollment is extended to 11/5/2023 but his Spousal/Dependent MOOP eligibility can only be extended until 1/31/2023 to match Peter's eligibility end date.

Unfortunately, Peter does not complete his ADAP and OA-HIPP re- enrollment by 12/17/2022 and lapses from ADAP and OA-HIPP. This means Sam loses the Spousal/Dependent MOOP Benefit but is still enrolled in ADAP.

On January 7, 2023, Peter re-enrolls in ADAP and OA-HIPP, so his ADAP re-enrollment is extended to 12/17/2023 and his OA-HIPP to 1/31/2024.

The EW should enter a case note on Peter's account to also extend the Spousal/Dependent MOOP Benefit for Sam. Sam's Spousal/Dependent MOOP Benefit will then be extended to his own ADAP eligibility end date of 11/5/2023.

Scenario 3:

The primary client in a Spousal/Dependent MOOP Benefit lapses from ADAP for multiple​ months.

The primary client must complete the re-enrollment process for ADAP and OA- HIPP for eligibility to be reinstated for both the primary client and the Spousal/Dependent MOOP client. During the lapsed months the spouse/RDP/dependent would not be eligible for Spousal/Dependent MOOP Benefit. The clients will be responsible for any premiums and MOOPs during the lapsed months.

​Scenario 4:

The Spousal/Dependent MOOP client lap​ses from ADAP.

The spouse/RDP/dependent must complete the re-enrollment process for ADAP and the Spousal/Dependent MOOP Benefit for eligibility to be reinstated for the Spousal/Dependent MOOP Benefit.

For​​ms

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