5. Applications...Page 5-1 Update #20-08 Medi-Cal 5. Applications 5. Applications 5.1 HIPAA/PII All...

Medi-CalMedi-Cal 5. Applications

5. Applications

5.1 HIPAA/PII

All applications must be kept strictly confidential. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 reduces health care fraud and abuse, standardizes electronic billing and other processes, and includes strict confidentiality mandates.

Medi-Cal (MC) Personally Identifiable Information (PII) is electronic, paper, verbal, or recorded information directly obtained in the course of performing an administrative function related to Med-Cal that can be used alone, or in conjunction with any other information, to identify a specific individual. PII includes any information that can be used to search for or identify individuals, or can be used to access their files, such as name, social security number, date of birth, driver’s license number, identification number, and address. This information is confidential and must be safeguarded.

In compliance with HIPAA it is critical that we safeguard client PII so the client is not exposed to undue hardship as a result of county actions. County workers must only use or disclose client information to perform their official job related functions. Unauthorized disclosure is a violation of Welfare & Institutions Code Section 14100.2 and County policy. Violators could be subjected to disciplinary action as well as civil and criminal sanctions.

Reminder:

No case information may be released from the custodial parent’s case to the non-custodial parent. In addition, the non-custodial parent's case information cannot be shared with the custodial parent.

[Refer to Chapter 40, "Confidentiality”]

5.2 Mandatory Reporting

5.2.1 Reporting Child Abuse

All Agency staff are MANDATORY REPORTERS. A referral must be made to the Child Abuse and Neglect Center (CANC) of Child Protective Services (CPS) when a complaint indicates that the child may be in danger and/or something specific has happened to a child.

Update #20-08Page 5-1

page 5-2Medi-Cal 5. Applications

5.2.2 Reporting Numbers

• Reports to Child Protective Services via the Child Abuse and Neglect (CAN) Units are made through the following numbers:

• San Jose Area (408) 299-2071

• Gilroy or Morgan Hill Area (408) 683-0601

• Palo Alto Area (650) 493-1186

• Referrals must include only the minimum information as follows:

• Name of person making the referral

• Name of applicant/client

• Current location of the applicant/client

• Nature and extent of the injury

• Fact that led the person making the referral to suspect abuse.

The Mandated Reporter, MUST do the following:

Table 5-1: Steps for Mandated Reporter

STEP ACTION

1. Document the details provided by the person making the report of suspected child abuse.NOTE: The SS8572 is available in the DEBS online Forms Library and may be used to make sure all the necessary information is obtained.

2. Immediately call the Child Abuse & Neglect Center Hot Line, (408) 299-2071.

3. • Prepare a written report on the “Suspected Child Abuse Report” (SS8572).

• Forward all copies of the report, except the yellow copy, to the Child Abuse Screening Unit at 373 W Julian Street, 3rd Floor, within 36 hours of receiving the information concerning the abuse.

• Scan the yellow copy to IDM under Benefits-F6.

NOTE: The SS8572 is available in shelf stock.

5.2.3 Reporting Adult Abuse

For complaints of adult abuse for dependent adults with disabilities age 18 through 59, or persons age 60 or older, refer any report to the “Adult Abuse Reporting Lines” by calling:



• (408) 975-4900,

• 1-800-414-2002, or

• (408) 928-3901 (after hours message machine).

5.3 Application

In addition to basic application requirements, this chapter includes information about the various forms and procedures that are used to determine MC eligibility if certain criteria are met.

The “Single Streamlined Application” (SSApp) is an application for MC, Advanced Premium Tax Credit (APTC) and Qualified Health Plan (QHP). [Refer to Chapter 5, Section 5.6 "How to File an Application,” page-20]

5.3.1 MC Application

For MC applications, the following forms are given to an applicant in the initial contact packet:

Table 5-2: MC Application Forms

Form # Form Name EW Must Explain

Available Languages

Eng. Sp. Viet. Other

SCD 41 Identification and Intake Record No X X X

CCFRM 604 Application for Health Insurance (Also known as the SSApp) Yes X X X

SCD 115 Consent to Exchange/Release Information - Children’s Health Initiative

Yes X X X X

SCD 508 Would you like to Register to Vote? No X X X Farsi, Kor., Lao., Camb., Chin., Hmong Tag., Russ., Jap.

SCD 1264 Language Survey-Interpreter/Translation Request

Yes X X X Arm., Chin., Russ.

SCD 93 (A, B, C, D)

Application Coverletter (Specific to District Office)

No X X X X

SCD 2300 Proof Needed No X X X

SCD 2304 Additional Information Notices No X X

SCD 2263 Consent to Release Public Assistance Information for Health Services Reimbursement

Yes X XX X



Note:

A county postage-paid return envelope must be included with all mail-in applications.

MC Intake Informational Packet

The following forms are to be used in the MC Intake Informational packet:

Table 5-3: MC Intake Informational Forms

Form # Form Name Hard Copy

DEBS Forms Library

EW Must

Explain

Available Languages


DHCS 7077

Notice Regarding Standards for Medi-Cal Eligibility

Yes Yes No X X

DHCS 7077A

Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/ Beneficiary

Yes Yes No X X

MC 003 Early & Periodic Screening, Diagnosis & Treatment (EPSDT) Flyer

Yes Yes No X X

MC 004 Important Information for Nursing Home Patients

No Yes No X X

MC 007 Medi-Cal General Property Limitations

Yes Yes No X X

MC 018 Medi-Cal Information for Applicants

No Yes No X X X Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.

MC 18 Important Notice About Your Medi-Cal Benefits

No Yes No X X

MC 219 Important Information for Persons Requesting Medi-Cal (Rights and Responsibilities)

Yes Yes NoX X x Arm., Chin., Farsi,

Hmong, Khmer, Korean, Lao., Russ.,

MC 325 Transitional Medi-Cal Yes Yes No X

MC 372 Breast and Cervical Cancer Treatment Program

Yes Yes No X X

PUB 13 Your rights Under CA Welfare Programs Yes Yes No X X X

PUB 68 Medi-Cal - What it Means to You Yes No No X X

PUB 183 CHDP Brochure Yes No No X X X

SCD 391 Keep Your Medi-Cal on Target No Yes No X X X



Note:

A county postage-paid return envelope must be included with all mail-in applications.

MC Intake Packet

A county postage-paid return envelope, the “MC Application Coverletter” (SCD 93 A, B, C, D), the appropriate application forms and informing notices must be given or sent to the client.

The “Important Information for Persons Requesting Medi-Cal” (MC 219) must be sent to the applicant but does NOT have to be signed or returned by the client. It must be documented in the case that it was sent.

If the client calls, the MC 219 must be read to the client completely.

Note:

The SAWS 1 is NOT required. MC applicants are not required to sign the SAWS 1.

Minor Consent

A mail-in application may NOT be used when applying for Minor Consent services.

[Refer to “Application Requirements,” page 32-6]

SCD 827 Citizenship Fact Sheet No Yes No X X X

SCD 830 Important Notice about Domestic Abuse No Yes No X X X

SCD 2341

My Benefits CalWIN Yes Yes No X X

WIC 2 Families Grow Healthy with WIC Yes Yes No X X X Chinese

Informing Notice of IRS Form 1095-B

Informing Notice of IRS Form 1095-B

No Yes No X X

Table 5-3: MC Intake Informational Forms

Form # Form Name Hard Copy

DEBS Forms Library

EW Must

Explain

Available Languages




Applications from the Single Point of Entry

[Refer to Chapter 5, Section 5.8 "Single Point of Entry Applications,” page-28]

CalWORKs

When an applicant applies for MC, explore eligibility for CalWORKs (CW) and inform the applicant if he/she is potentially eligible.

The EW will either process the CW application or complete an “Informal Application Refusal” (SCD 166) if they refuse. If the SCD 166 is completed, then scan it into IDM to document that the applicant was informed of potential CW eligibility.

CalFresh

Explore CalFresh (CF) eligibility and inform the applicant if he/she is potentially eligible. [Refer to Chapter 5, Section 5.20 "CalFresh Application for MC,” page-69]

5.3.2 Paper Applications

Following the implementation of the Affordable Care Act (ACA), clients can complete applications on the phone, in person, online, mail, or fax.

Paper forms are not required; however, when processing an application without the forms (i.e. by phone) the Eligibility Worker (EW) is required to read the MC 219 to the client and document clearly that the client understood and provided approval to submit the application.

5.3.3 Additional Information/Verifications Needed

Review the application for completeness. If additional information is needed to determine eligibility, and the client/family has an open case or a case that has been closed within the last 90 days, the EW must use information/verifications in the case file when available.

Follow Ex Parte requirements when requesting information if necessary information is not in the case file.

5.3.4 Outdated but Acceptable Forms

The Department of Health Care Services (DHCS) allows counties to continue receiving outdated MC applications. The following forms are no longer available and should not be printed, ordered or distributed (but can be used to determine MC eligibility if received from an individual):

• “Medi-Cal Mail-In Application and Instructions” (MC 210)



• “Additional Family Members Requesting Medi-Cal” (MC 321 HFP)

The client must not be required to complete a second application if they have submitted an outdated application form. Eligibility Workers must contact the client for additional information or supplemental forms, as needed.

5.3.5 Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP (SAWS 2 PLUS)

A current SAWS 2 PLUS can be used for MC when:

• A CW/CF application is denied and the client wishes to apply for MC, or

• A SAWS 2 PLUS was completed within the past 12 months and circumstances have not changed that would require a new application for MC.

Applicants must not be required to complete an additional application or Statement of Facts (SOF) form if the information on file is sufficient. A SAWS 1 is used to preserve the date of application for MC. EWs must obtain all other required forms and verifications according to the family's circumstances and provide all mandatory informing notices to the applicant.

Note:

Clients are NOT initially required to provide supporting verification of information until after an attempt has been made to electronically verify through the Federal Data Services Hub (Federal Hub). If an applicant’s information cannot be electronically verified, then paper verifications (i.e. paystubs, SSN card, etc.) will be required. For Non-MAGI MC applicants/clients, paper verification is required.

5.4 Who Can Complete a MC Application

The following individuals may file an application for MC.

• Any person who wishes to receive MC,

• An applicant or spouse,

• A primary tax filer,

• An adult who is caring for a child who is not a relative may apply for MC for the child, if the parent is not available.



• An applicant's guardian or conservator or executor (A copy of the court order must be filed in the case record),

• A public agency representative. If an applicant does not have a spouse, conservator or guardian and is:

• Unable to apply • Incapable, • Incompetent, • Comatose,• An amnesiac,• Deceased,

• A person who knows of the applicant's need to apply,

• A child, if:

• Requesting minor consent services, [Refer to “Application Requirements,” page 32-6]• No person or agency accepts legal responsibility for that child. This includes minors who are

living on their own and not claimed as a tax dependent.

• A non-custodial parent.

Note:

Individuals approved for CW are automatically eligible for cash-linked MC and are not required to submit a separate MC application.

IMPORTANT: [Refer to Chapter 5, Section 5.4.2 "Persons Who May Represent a Client,” page-9] for complete information about who can represent the client and the requirements for persons who are representing an incompetent client, LTC, etc.

5.4.1 Applications from Non-Custodial Parents

Generally, the person or agency having legal responsibility for a child completes and signs the SSApp. If the custodial parent is incompetent, comatose or is suffering from amnesia, then a non-custodial parent can complete the SSApp.

Note:

Notices for the non-custodial parent's case must only be sent to the non-custodial parent.



5.4.2 Family Members

Some applicants or clients want family members to assist in the eligibility determination process at application, redetermination (RD) or at any other time.

EWs must consider the client's circumstances when a client requests to have family members help with the application process. Family members most often have an ongoing interest in the affairs of the client, whereas an authorized representative (AR) is usually a non-family individual who has no interest in the client other than the approval of MC benefits. This difference is important and EWs must consider it when determining whether a person may assist a client beyond the application and RD process.

In all situations, EWs must make sure client information is kept confidential. Client information is released to family members only with client's specific knowledge and consent. If the client would like to appoint a family member to act as an AR, then the MC 382 or another authorized method of appointing an AR must be completed by the client.

Note:

A telephonic signature (verbal consent) is valid for one time and must be documented in the Search Case Comments window in CalWIN.

Example:

The EW has questions about the unreported earnings on an Income Eligibility Verification System (IEVS) report. Darlene Talamazoo wants her sister to help clarify those questions. At Darlene's request, the EW must allow the sister to attend the interview scheduled with Darlene to explain the IEVS information. Darlene's sister is not an AR and therefore is not restricted to only providing assistance during an application, MC RD, or an appeal.

5.5 Persons Who May Represent a Client

5.5.1 Authorized Representatives

Who can be Appointed

Applicants who are competent to handle their affairs and understand their responsibilities may appoint in writing an individual to accompany, assist and represent them in the MC application, redetermination or appeals process. This person is often referred to as an AR and may be:

• A family member,



• A friend,

• A representative of an organization or law firm,

• An organization (including any representative from the organization who has a signed agreement to adhere to AR rights and responsibilities may act on behalf of the applicant/client),

• A legal aid staff member, or

• Any other person the client chooses.

MC regulations do not prohibit a provider or provider's representative from serving as an AR for the applicant, although it may appear inappropriate for an employee of a provider (who has a financial stake in the eligibility of a client) to be an AR. EWs must make sure that clients understand that they have a free choice to appoint any person as the AR, and that designation of a provider representative as an AR is not mandatory to receive medical services.

Note:

Competent is the ability to act on one's own behalf in business and in personal matters.

The Disability Determination Service Division (DDSD) accepts “Authorization for Release of information” (MC 220) forms signed by legal representatives only. A legal representative, per HIPAA, is a spouse, relative, legal guardian, conservator, executor, court appointed representative, or EW.

Client Responsibilities

The applicant/client may:

• Authorize an AR with an electronic signature, telephonic signature, handwritten faxed or scanned document (SSApp, SAWS 2 Plus, MC 382).

• Designate multiple ARs.

• Appoint an individual or organization to serve as an AR.

• Choose the role each AR services (i.e. application, redetermination, ongoing case maintenance.

• Choose which notices, if any should be sent to the AR.

The AR designation is effective until the client or AR reports that the individual or organization is no longer an AR.

Applicants/clients who are incompetent/comatose/deceased, or otherwise unable to decide for him/herself, can not appoint an AR. However, his/her representative who has signed the DHCS 7068 may sign an AR form to request an AR to assist in the MC application process or resolve issues.



Authorized Representative's Role

The AR may:

• Accompany the applicant/client if a face-to-face interview is requested or required at application or redetermination.

• Assist the client in understanding and answering questions during the interview.

• Help the client obtain required verifications at application and redetermination.

• Obtain information from an EW or DDSD regarding the status of an application.

• Provide medical records and other information to an EW and DDSD for a disability evaluation.

• Review the client's case record with or without the client being present.

• Obtain copies of non-confidential documents from the case record if requested.

• Accompany and assist the client in the appeal (fair hearing) process,

• Fully act on behalf of the client, with the permission of the client,

• Receive a copy of a specific Notice of Action (NOA) from the EW at the request of the client,

• Sign the application and complete and submit the renewal form on behalf of the client, and

• Inform the EW that he or she is no longer the AR for the client.

Authorized Representative Limitations

The AR may NOT:

• Receive a NOA unless the client has requested that a specific NOA be sent to the AR or it is for an appeal (fair hearing).

• Receive the client's Benefits Identification Card (BIC).

• Receive a Letter of Authorization (MC 180) if the AR is an organization, law firm or group.

• Assign another or new AR.

Note:

The above limitations do not apply to incompetent clients in LTC facilities.



5.5.2 Representative Payees

A Representative Payee is a person who is appointed by the Social Security Administration to SSI clients who are not capable of handling their own affairs. (Representative Payees may also be appointed for individuals by other governmental agencies.) The Representative Payee receives and manages the benefits for the client.

ARs for MC clients are individuals appointed only to assist another person in the MC application, RD, and/or appeals process. The authority of a Representative Payee and an AR are different, the limitations of ARs to act on behalf of clients do not apply to Representative Payees.

5.5.3 Durable Powers of Attorney

Eligibility Workers may encounter individuals who have obtained Durable Powers of Attorney (DPA) which enable them to act as ARs for clients. These persons may present DPA documents to EWs and indicate their intent to act in place of the MC client.

This section provides information regarding an AR with Durable Powers of Attorney and the MC policies pertaining to them.

Definition

A power of attorney, as defined in Senate Bill 1907, is a written instrument that is executed by a person having the capability to enter into a contract, and that grants authority to an attorney-in-fact.

A durable power of attorney contains a clause which states that it will not be affected by the incapacity of the principal, or it may state that the DPA will become effective at the time the principal becomes incapacitated (Civil Code Section 2400).

• The principal is the person who appoints the attorney-in-fact.

• The attorney-in-fact is the person who is authorized to act on behalf of the principal.

Types of Durable Powers of Attorney

There are two types of durable powers of attorney:

• A Durable Power of Attorney for Property Management (DPAP) which authorizes an attorney-in-fact to handle an individual's financial affairs.

Note:

An MC 382 or other proof of legal authorization is still required for an individual who is a DPAP.



• A Durable Power of Attorney for Health Care (DPAHC) which allows an attorney-in-fact to make health care decisions for a person who is unable to act on his or her behalf, i.e., comatose, incompetent, etc.

Note:

An MC 382 or other written authorization is not required for an individual who is a DPAHC.

For purposes of obtaining MC benefits, a Durable Power of Attorney for Property Management (DPAP) is required.

Conditions of Durable Powers of Attorney

• Anyone with the ability to enter into a contract may appoint an attorney-in-fact.

• A DPAP is valid only when executed by a COMPETENT adult.

• Civil Code Section 1556 prohibits a DPA from being executed by a minor, a person of unsound mind, or a person deprived of civil rights (incarcerated or institutionalized).

• The DPAP may become effective immediately upon its execution, or it may not become effective until the principal becomes incompetent.

State Policy

Any competent adult may appoint an AR, with or without a DPAP document, to assist him or her in the MC application or redetermination process.

EWs must treat ARs with DPAP the same as an AR without DPAP. A signed letter or MC 382 must be on file for a non-family member AR with or without DPAP. The assistance of an AR with or without DPAP is limited to:

• Completing the initial application for benefits,

• Assisting the applicant in the interview, and

• Helping the client obtain verifications.

Durable powers of attorney does not give a person any additional authority to act on behalf of a MC client. ARs with DPAP must be allowed to assist the client wherever necessary, but are not entitled to act in place of the client.

Specifically, an AR with a DPAP document may not:

• Complete and sign a MC application for the client,



• Complete the face-to-face interview (if requested or required) for the client, or

• Accept responsibility for the MC client to report any changes that may affect eligibility.

Expiration of Authority

The time period in which the AR, with a DPAP document, may act on behalf of the competent applicant or client ends when the client or the AR themselves removes the AR at any time, either orally or in writing.

5.5.4 Public Guardian

The Public Guardian is a government representative who has court-appointed authority. Their ability to act on behalf of a client is not limited to those activities defined under [Refer to Chapter 5, "Authorized Representative's Role,” page-11]. A Public Guardian may complete and sign the MC application and receive the BIC card on behalf of someone who is a conservatee.

5.5.5 Appointment of an Authorized Representative

The following methods are the only acceptable and valid means for a MC applicant/recipient to appoint an individual or organization to act as an AR.

• The “Appointment of Authorized Representative” form (MC 382)• The online/paper Single Streamline Application• Statewide Automated Welfare Systems (SAWS) 2 PLUS/online SAWS application portal

Note:

Legal documentation of authority to act on behalf of the applicant/beneficiary under state law substitutes for a completed MC 382 form.

All of the three approved methods above may be received in person, by mail, telephone (with a telephonic signature), Internet or e-mail. Legal documentation may not be received via telephone as the actual document appointing authority must be received.

5.5.6 Time Frame of Authority

The authority of an appointed authorized representative does not expire until the applicant/recipient or the authorized representative themselves cancels or changes the AR.

Cancellation of an AR can be done by contacting the county electronically, by phone, in person or in writing.Upon cancellation by either the AR or the client the EW must update the AR information in the



case and send the “Cancellation or Change to a Medi-Cal Authorized Representative Appointment” letter (MC 381) to both the client and the AR.

Note:

If an AR is appointed and the case is denied or discontinued, the AR appointment remains valid for 90 days after the denial or discontinuance for the purposes of acting on behalf of the client on issues related to the applicants eligibility.

5.5.7 Forms and Notices

Appointment of Authorized Representative (MC 382)

The purpose of the MC 382 is to provide a competent Medi-Cal applicant/recipient with a written method to designate an AR, specify the scope of the AR’s role and authorize an AR to receive some or all copies of notices and correspondences. The MC 382 may be used to appoint either an individual or an organization as an AR.

Important:The MC 382 has been created to replace the MC 306. Use of the MC 306 must be discontinued immediately.

Signature Requirements

The MC 382 must be signed by the applicant/recipient in order for the appointment of the AR to be valid. The appointed AR may also sign the MC 382, however, the ARs signature is not required.

Appointment Requests Without the MC 382

If the appointment of an AR is completed via any other method (i.e. phone or request sent in on unauthorized form) the EW must complete the MC 382 on behalf of the client, and scan it into IDM. In order to complete the MC 382 the EW must contact the client and obtain the following information:

• AR name• AR contact information• Authority given to the AR• Confirm if the AR should receive some or all copies of notices and correspondence

Once the information is obtained and the form completed the EW must document how the required information was received. If the required information is received over the phone the EW must read Section D “Acknowledgment and Signatures” of the MC 382 to the applicant/recipient. A telephonic signature must be obtained and copies of the completed form must be sent to both the applicant/recipient and the AR.



Note:

If you are unable to reach the client to obtain the required information the MC 382 must be mailed out and the AR not added to the case until it has been returned.

Single Streamline Application and Statewide Automated Welfare System (SAWS 2PLUS)

Until the paper and online applications are updated to allow the applicant/recipient to choose the scope of the AR’s duties and the notices to be copied to the AR, when an applicant/recipient appoints an AR via an application, the AR is considered to have full authority. Full authority does not however include authorization to receive copies of notices or other correspondence. In order for an AR to receive correspondence the applicant/recipient must make a request directly to the county.

If an AR is appointed via the SSAPP or SAWS 2PLUS the EW is required to complete an MC 382 on behalf of the client informing them of the authority given to the AR. Copies of the MC 382 must be mailed to both the client and AR. The copies are not required to be returned and a signature is not required as it has already been obtained on the original request (SSAPP or SAWS 2PLUS).

Notice of Appointment of Authorized Representative (MC 380)

The purpose of the MC 380 is for counties to notify the applicant/recipient and the new AR of the AR appointment and the scope of that appointment. This notice also informs the applicant/recipient that they may modify, cancel and/or limit the scope of duties of the appointed AR at any time. It also provides the newly appointed AR their rights and responsibilities and notifies them of their ability to opt out as an AR at any time.

The MC 380 must be sent to both the applicant/recipient and the AR at the initial appointment.

Authorized Representative Standard Agreement for Organizations form (MC 383)

The purpose of the MC 383 is for an individual acting on behalf of an organization that was named as an AR to sign an agreement under penalty of perjury to adhere to federal and state regulations. This form is not to be used to appoint an AR and should not be provided to applicants/recipients. The MC 383 must be provided to an individual who is designated to represent a larger organization.

Cancellation or Change to a Medi-Cal Authorized Representative Appointment Letter (MC 381)

The purpose of the MC 381 is to be used to inform both the applicant/recipient and the AR of the cancellation or change in duties of the AR appointment. Only the applicant/recipient can modify the AR duties at any time by contacting the county. This request may be made in person, over the phone, electronically or in writing. After receiving a request the EW must update the case and mail the MC 381 to both the client and AR within 10 days of the request.



Forms/Notices sent to Applicant/Recipients Forms/Notices sent to the AR

Initial AR Appointment (individual)Initial AR Appointment (individual)

Initial AR Appointment (Organization) Initial AR Appointment (Organization)

Modification of AR Appointment Modification of AR Appointment

Cancellation of AR Appointment • Cancellation or Change Letter MC 381

Cancellation of AR Appointment

Appointment of Representative Form and notice Distribution

5.5.8 EW Action

When an EW receives a request to add an Authorized Representative (AR) via the approved methods the Medi-Cal section of the Collect Authorized Representative Detail window in CalWIN must be updated to reflect the new information. The EW must update the Collect Authorized Representative Window to mirror the authority granted on the MC 382.

• Appointment Notice (MC 380)• Copy of Appointment form (MC 382)

• Appointment Notice (MC 380)• Copy of Appointment form (MC 382)• Rights and Responsibilities (MC 219)

• Appointment Notice (MC 380)• Copy of Appointment Form (MC 382)

• Appointment Notice (MC 380)• Copy of Appointment form (MC 382)• Rights and Responsibilities (MC 219)

• Cancellation or Change Letter (MC 381) • Cancellation or Change Letter (MC 381)

• Cancellation or Change Letter (MC 381)

If the Client... And... Then...

Appoints an AR via the SSAPP or SAWS 2PLUS

N/A Check the box to indicate Limited Authority and select all types of authorization allowed. A new line with the same AR information will need to be added in order to grant all types of authority. (Full authority may not be selected as Client Correspondence cannot be approved without the client’s request)

Does not limit authority in Section C of the MC 382

Checks the box indicating the AR can receive all Medi-Cal notices and mail

Check the box to indicate Full Authority (this will automatically check the Client Correspondence box as well)

(Chart page 1 of 2)



Note:

Per DHCS the only method for the AR to receive the 1095B is to request via the process outlined in the UGGS Handbook [Refer to Chapter 1, Section 1.11 "IN9D - IRS 1095B Detail/Reprint Screen,” page-91] Though this button auto checks when full authority is granted, there is currently no functionality behind it. EW staff must complete the normal 1095-B process if a request is made to issue one to the client’s AR.

Once updates have been made, the Notice of Appointment of Authorized Representative” (MC 380) along with a copy of the Appointment of Representative (MC 382) must be mailed to both the applicant/recipient and the AR within 10 days of obtaining all required information.

The EW must also send the MC 219 “Rights and Responsibilities” and document in CalWIN case comments that it was sent.

Limits or does not limit authority in Section C of the MC 382

Checks the box indicating the AR cannot receive all Medi-Cal notices and mail

Check the box to indicate Limited Authority and select all approved types of authorization. A new line with the same AR information will need to be added in order to grant each approved types of authority.Note:

Full Authority may not be selected as Client Correspondence cannot be approved without the client’s request)

Limits or does not limit authority in Section C of the MC 382

Checks the box indicating they only want certain types of notices issued to the AR

• Check the box to indicate Limited Authority and select all approved types of authorization. A new line with the same AR information will need to be added in order to grant all approved types of authority.

• The client will have to request if/when they want a specific NOA or form issued to their AR.

Note:Full Authority may not be selected as Client Correspondence cannot be approved without the client’s request)

If the Client... And... Then...

(Chart page 2 of 2)



5.5.9 Appointment of an Organization as an AR

In order to appoint an organization as an AR, the applicant/recipient must complete the request via an approved methods (listed in 5.5.5) and the AR must provide the “Authorized Representative Standard Agreement for Organizations” form (MC 383). The same MC 383 may be signed by multiple individuals from that organization that are appointed as an AR.

If the MC 383 is not received, the EW may contact the organization to have the form completed telephonically (telephonic signature is required).

Upon recipient of the form the designated individual named on the MC 383 is authorized to act as the clients AR.

Note:

When an organization is appointed and copies of correspondence are authorized to be sent to the AR, they should be sent to the organization and not to the individual acting on behalf of the organization.

Multiple Authorized Representatives

The client may have any number of individuals acting as his/her AR. However, each person must be appointed on a separate MC 382 (or other authorized method of appointing authorization).

5.5.10 Authorized Representation Documentation

The Authorized Representative case comment Type in the Search Case Comments window in CalWIN must be used, but not limited, to document the following information:

• The type of consent received (verbal or written). If a written consent is received, then also include the type of document (i.e. MC 382, DHCS 7068, etc.).

• Name of caller or AR (Individual or Organization).

• The Effective Begin Date of the AR form.

NOTE: A verbal consent from the applicant/client is only valid for the current call.

• Information released to the caller or AR.

All contacts with ARs, including in-person, must be documented using the Authorized Representative case comment Type in the Search Case Comments window in CalWIN.



EWs must make sure that the AR form viewed is for the individual and/or organization who is requesting information. Or, obtain a one-time verbal consent from the client and follow-up with a written consent form (i.e. mail an AR form to the client).

The AR’s name and address must be entered into CalWIN on the Collect Authorized Representative Detail window. EWs must update the window as the AR changes or ends. EWs must enter the Effective Begin Date at the time this window is completed and/or Effective End Date if the client reports a change in ARs or cancels an AR. This action in CalWIN will make sure NOAs and other correspondences are mailed to the appropriate AR.

5.5.11 Mental Health Sub Payee Cases

These cases are processed in the same manner as Public Guardian cases with one exception. Instead of a “Letter of Conservatorship”, a letter from the Mental Health Agency is required, stating that they are accepting responsibility as the AR for the client.

5.6 How to File an Application

There are many ways to file an MC application. Clients can choose whichever method meets their needs.

• Online

• Phone-In

• Mail-in

• Walk-in

MC applications are received from external sources, including but not limited to:

• Application Referrals from the Children’s Health Initiative (CHI) Toll-free Number (1-888-244-5222)

• Outreach Events

• The Single Point of Entry (SPE)

• Hospitals

• Non-Profits

• Covered California



5.6.1 My Benefits CalWIN (Online)

My Benefits CalWIN (MyBCW) provides the general public and current clients with an easier method to self-screen for potential eligibility and apply for MC, CF and CW at www.mybenefitscalwin.org. MyBCW is the web version of the paper application.

My Benefits CalWIN allows clients to:

• Apply for benefits or cancel/withdraw an application.

• Find out if they are eligible for other assistance programs.

• Check benefit status and amount.

• Report changes

• Submit verifications.

Note:

The MC RD cannot be completed on MyBCW at this time. However, clients can call our district offices and complete it over the phone.

The retrieval, registering and distribution of the MyBCW online applications are handled by appointed clerical staff.

[Refer to Chapter 20, Section 20.1 "My Benefits CalWIN (MyBCW),” page-1]

5.6.2 Mail-In and Phone-In MC Application Procedures

Clients may complete and return all necessary forms and verifications by mail. However, if the applicant has an immediate need for MC the option to come into a District Office to apply is available.



Note:

An applicant can request a face-to-face interview at any time, regardless of immediate MC need.

Table 13: Mail-In/Phone-In MC Application Procedures

Who Action

Client • Calls any District Office and indicates he/she would like to apply for MC benefits

OR

• Mails in the SSApp.

Designated District Office Staff

• If a client calls requesting other programs (i.e. GA) refer the client to the appropriate district office.

• IDs the client or application.

• Completes the SCD 41 (For phone applications).

• Performs preliminary File Clearance procedures to make sure the application is valid.

• Completes application registration in CalWIN.

• HCR STAFF: Completes the application by phone.

EW • Receives the MC application.

• Contacts the client if there are missing verifications.

NOTE: At initial application, paper verifications must only be requested after a CalHEERS BRE eHIT and ex parte review. For the ex parte review, documents or information must be within 90 days. [Refer to Chapter 16, Section 16.5 "Federal Data Services Hub,” page-3]

• Provides the client with the case number and instructs him/her to write the case number on the documents to be provided.

If the client prefers to... Then the EW...

Provide paper verifications in person, • Explains to the client to bring in the verifications and have clerical photocopy them, or

• Schedules an appointment for the client to bring the verifications to the EW.

Mail/Fax the paper verifications, Explains to the client that when the paper verifications are received, the application will be processed and he/she may be contacted if further verification is needed.

Upload paper verifications, Explains the MyBCW process, or explains the Covered CA process.

Client • Gathers the necessary paper verifications.

• Mails or brings paper verifications to the District Office.



5.6.3 In-Person/Walk-In MC Application Procedures

Applicants are not required to go to a district office to apply for MC; however many clients prefer to file in-person and have a face-to-face interview with an EW. An applicant who comes into the office will be given an intake packet and may mail it back, or may switch from a face-to-face interview to the mail-in process at any time.

Reminder:

Clients applying in person should complete and sign the SSApp and submit it BEFORE leaving the office whenever possible, and therefore avoid any delays that may occur due to mailing forms back and forth.

EW • Receives the necessary paper verifications.

• Enters information into CalWIN Data Collection windows.

• Runs EDBC and approves or denies benefits.

• Mails NOAs.

• Documents actions in the Search Case Comments window.

• Checks MEDS in 2 business days.

• Prints and IDMs the MEDS, CalWIN, and CalHEERS screenshots to verify eligibility and manual verifications verified by the Federal Hub. [Refer to Chapter 5, Section 5.17 "Intake Documents to IDM,” page-56]

• Follows district office CHI process, if children are not determined eligible for MC. [Refer to Chapter 5, Section 5.25 "Children's Health Initiative,” page-84]

Table 14: In-Person/Walk-In MC Application Procedures

Who Action

Client Requests MC at a district office.

Table 13: Mail-In/Phone-In MC Application Procedures

Who Action



Clerical • IDs the client.

• Performs a preliminary File Clearance to make sure the application is valid.

• Provides the client an intake packet and required informing notices.

NOTE: The applicant or the person acting on behalf of the applicant should sign the application.

• Completes the SCD 41.

If the client does not want to complete the application in person:

• Provides the client a date-stamped intake packet and required informing notices.

• Provides a postage-paid return envelope to MC applicants who wish to mail back their application, additional forms and/or verifications.

Note:This date is only valid for 10 days. On or after the 11th day, the date of application is the day the application is actually returned. Example: OnMay 4th, a client comes in to the office asking to apply for Medi-Cal but wants to take the application home. On May 23rd, the application is received at the office. The date stamp is no longer valid as more than ten days has passed. The application date will be May 23rd.

If the client requests a Face-to-Face interview, completes SAWS 1 and schedules appointment.

If the client completes and submits the application in person:

If the application is... Then clerical...

Not valid, Refers the client to the correct district office or EW.

Valid, • Date stamps the SSApp.

• Provides the SSApp to the client.

• Instructs the client to complete the forms in the lobby and return to the window when they are complete.

Client • Completes the application forms.

• Returns to the window and submits the application to clerical.

Clerical • Receives the MC application forms.

• Provides the client with a MC Intake informing packet.

• Explains that the client may schedule an appointment with his/her EW when the EW contacts him/her, if preferred.

• Forwards the completed application to the Centralized Application Registration unit.


Who Action



Centralized Application Registration Unit

• Receives the completed MC application.

• Performs the Application Registration function in CalWIN.

• Assigns the case to an EW.

• Forwards the application packet to the assigned EW for processing.

EW • Receives the MC application.

• Determines if an immediate medical need exists, schedules the client for an interview as soon as possible.

• Contacts the client and requests any additional verifications needed to complete the application process.

NOTE: Paper verifications are not required if the client’s information is e-verified in CalHEERS.

• Provides the client with the case number and instructs him/her to write the case number on the documents that may need to be provided.

If the client prefers to... Then the EW...

Come into the office for an appointment,

Schedules an appointment with the client to complete the application process.

Provide the paper verifications in person,

• Explains to the client to bring the paper verifications and have clerical photocopy them, or

• Schedules an appointment for the client to bring the paper verifications directly to the EW.

Mail the paper verifications,

Explains to the client that when the paper verifications are received, the application will be processed. The client will be contacted if any further paper verification is required.

Client • Gathers necessary paper verifications.

• Mails or brings verifications to the district office.


Who Action



5.6.4 Forms Not Returned

Forms must be returned within 10 calendar days from when they were mailed. When application forms are not received by the due date, the appointed district office staff must follow these procedures:

Table 5-4: Forms Not Returned Procedures

If... Then...

The application forms are returned, Assign the case to an EW for processing.

The applicant does not return their forms by the due date or keep their scheduled appointment for the intake interview,

A appointed person sends the “Medi-Cal Application 2nd Notice” (SCD 823) allowing the applicant an additional 10 calendar days to complete and return the application.

The application forms are not returned by the second due date,

A appointed person initiates a phone contact with the applicant to determine if assistance is needed to complete the application process.

The phone contact is unsuccessful, OR the applicant has not indicated a desire to complete the application process OR the application forms have still not been returned,

Assign the application to an EW for the appropriate denial.

5.7 Face-to-Face Interview

Face-to-Face interviews are not required for MC. State law mandates a simplified MC application process for clients which may not request paper forms. The intent is to limit the impact on the client.

EW • Receives the requested paper verifications.

• Enters information into CalWIN Data Collection windows.

• Runs EDBC and approves or denies benefits as appropriate.

• Mails NOAs.



• Prints and IDMs the MEDS, CalWIN, and CalHEERS screenshots to verify eligibility and manual verifications verified by the Federal Hub. [Refer to Chapter 5, Section 5.17 "Intake Documents to IDM,” page-56]

• Follows district office CHI process, if children are not determined eligible for MC. [Refer to Chapter 5, Section 5.25 "Children's Health Initiative,” page-84]


Who Action



At the time of application, the option of scheduling a face-to-face interview with an EW may be presented. This will make sure that applicants understand that they can get assistance with completing the forms, answers to questions and information about other programs they may be eligible for.

5.7.1 When a Face-to-Face Interview is Required

A face-to-face interview is required:

• For Minor Consent applications,

• When there is suspicion of fraud,

• At the applicant's request, or

• When at least one of the following criteria is met:

• There is questionable information on the application form or with the verifications provided.

• Obvious discrepancies exist between the information reported on the application and information received from IEVS about the applicant's income or property.

A face-to-face interview may not be required if questions or discrepancies can be resolved by follow-up telephone and/or mail contacts.

The reason that the EW is requiring a face-to-face interview MUST be thoroughly documented in Case Comments.

Failure to Keep an Appointment

When an MC applicant chooses to schedule an interview and fails to keep their scheduled appointment, the following procedures apply:

Table 5-5: Failure to Keep an Appointment Procedures

If... Then...

The applicant requests a face-to-face interview, and later does not keep his/her scheduled appointment,NOTE: This process also applies to persons applying for both CW/GA and MC.

The eligibility determination process automatically reverts to the mail-in application process for MC. [Refer to Chapter 5, Section 5.6.2 "Mail-In and Phone-In MC Application Procedures,” page-21]

MC APPLICANTS CANNOT BE DENIED FOR FAILURE TO KEEP THEIR SCHEDULED APPOINTMENT FOR AN INTAKE INTERVIEW.

The appointment for a face-to-face interview is not rescheduled,

The SCD 823 must be sent to the applicant allowing 10 calendar days to return the completed application form and verifications.



Note:

If a case is discontinued due to no show to Face-to Face Appointment when fraud is not suspected, the case must be rescinded.

5.8 Single Point of Entry Applications

The Single Point of Entry (SPE), in Sacramento, was established by the state to coordinate application activities for MC. SPE receives applications from clients who have been assisted by Certified Application Assistors (CAAs) located in medical clinics. Individuals may also pick up the SSApp from other community organizations and mail their application directly to SPE.

5.8.1 One-e-App

“One-e-App” is an automated internet-based application for MC used in our county by the CAAs located at medical clinics that are part of Santa Clara Valley Health and Hospital Systems.

Application Process

• The CAA interviews the applicant at the clinic and enters the information directly online into One-e-App.

• When all necessary paper verifications are provided, the CAA electronically forwards the application to SPE. In addition, the CAA faxes the paper verifications and a copy of the signature page to SPE.

• When the CAA submits the completed application, the client receives the following information from SPE:

• A real-time preliminary screening.

• An electronic confirmation of receipt.

• A unique application number.

The application forms/information/verifications are not returned by the requested date, and the EW has explored all options to obtain them,

The application may be denied for failure to provide the information/forms/verifications necessary to complete a MC eligibility determination.

Table 5-5: Failure to Keep an Appointment Procedures

If... Then...



SPE Actions

SPE screens the application for completeness and forwards the application to SSA to determine eligibility for MC. Hard copies of the MC applications and all related documentation are currently delivered to the Assistance Application Center (AAC), including:

• A “One-e-App Application Summary” printout.

• A transmittal form.

• Copies of verifications submitted by the applicant.

• A signature page with a photocopy of the original signature.

The “One-e-App Application Summary” is an official application for MC. The same procedures apply when processing this application form.

Application Date

The date of application is the date that the “One-e-App” is electronically submitted to SPE. The date is on the transmittal form, as well as on the MEDS [INQP] screen.

Clerical Role

Follow current district office procedures for completing file clearance, registering, and assigning procedures. In addition, the MEDS [INQM], [INQ1], and [INQP] screens are needed for these applications.

5.8.2 Application Tracking System

The application tracking system allows client information to be shared between SPE, MEDS, and the individual counties. Sharing of information is accomplished through the Client Index Number (CIN). This process is intended to provide:

• Better service to clients.

• A more efficient data collection process.

• Fraud prevention.

Applications are also received electronically from the MAXIMUS SPE system providing an electronic method of transferring data and images for new applications from MAXIMUS to the county through the CalWIN Search for External Referral Data window.



5.8.3 SPE Screening Process

All applications for children ages 6 - 18 years old processed at SPE are screened for potential eligibility for MC. The forms include:

• One-e-App

• Online Covered California Application

SPE has four (4) business days to complete the screening process. During the screening process, SPE:

• Completes the File Clearance process to see if a child is already known to MEDS.

• Identifies ownership of income, family relationships, and income disregards (i.e., income from disability, self-employment, education, pension or retirement).

• Screens children for potential MC eligibility.

• Reviews for CW client status during the prior four months.

• Reviews infants under 1 year old for Deemed Eligibility (DE).

• Contacts the applicant for missing or additional information.

• Establishes Accelerated Enrollment (AE) eligibility on MEDS for children under 19, if applicable. [Refer to “Accelerated Enrollment (AE) for Children,” page 35-11]

• Generates the mailing of a BIC for children enrolled in AE, if one was not previously issued.

• An Integrated Voice Response system automatically generates a call to the client when an application is forwarded for a MC determination or is determined to be receiving full-scope, no-cost MC benefits.

5.8.4 CIN Assignment

SPE completes the file clearance and assigns a CIN to all individuals who are included on form submitted to SPE.



• If the client is on the Statewide Client Index (SCI), then SCI and SPE will find and use the existing CIN.

Note:Note:If the client is known to CalWIN and also has a prior MEDS record, the person completing the file clearance MUST confirm that the CIN on the transmittal form belongs to the MEDS record associated with the county ID.

• If the application does not contain adequate information and the SPE staff is unable to obtain the information within 4 days, a CIN is not assigned to that individual.

5.8.5 Accelerated Enrollment Process

When a child appears to be eligible for a zero SOC MC program based on the income screening performed at SPE, the child is placed on AE aid code 8E. The SPE forwards the case to the residence county for a MC determination. MC eligibility under aid code 8E continues until a determination for MC eligibility is completed.

Children in AE will appear on the monthly Exception Eligibles Report (EER) in aid code 8E. Once an MC eligibility determination is completed and reported to MEDS, the 8E record will be cleared and MEDS will accept the MC eligibility as long as the information entered into CalWIN EXACTLY matches MEDS. The AE program eligibility continues under aid code 8E until this takes place. The EER can also be used as:

• An informational tool for determining MC eligibility.

• A useful way to track missing documentation from SPE.

Note:

The 8E records on the EER must be cleared as soon as possible. Staff must make sure that aid code 8E is terminated once the MC application is approved or denied.

5.8.6 SPE Transmittal Forms

The following transmittal forms are used with applications received from SPE:

1. Summary Transmittal This form lists all applications referred to the county in the batch. This listing is for inventory control and contains specific information on individual family members. When received, appointed office staff must cross-check the Summary Transmittal from SPE with the applications referred in the batch. If the Summary Transmittal contains applications not



included in the batch, or, if applications included in the batch are not listed on the Transmittal, the SPE Liaison must be contacted immediately by phone at (916) 673 - 4602 or e-mail at [email protected].

2. SPE Transmittal Form Each application form forwarded to SSA from SPE is attached to a Transmittal form. The transmittal is a summary of each application sent and informs the EW how each person was screened, the family composition, and income used. The transmittal form lists each child on the application, and indicates:

• Family income,

• What programs the children were screened for,

• If Retroactive MC is requested,

• If additional family members are requesting MC, and

• The CIN assigned to each child.

5.8.7 Processing SPE Applications

Missing Information

SPE keeps copies of all applications and verifications received and forwarded to counties for a MC determination. If an application is received from SPE with missing information (i.e. verifications, a signature page, etc.), the EW will need to request the information. The request for verifications is limited to only those that are required. For example, the EW does not need to contact SPE for property verifications, as SPE does not collect property information.

For requests for missing information or for questions regarding SPE screening, or transmittals, contact the SPE County Liaison by:

• Phone: (916) 673-4602, or• E-mail: [email protected]

When requesting information from SPE (by phone or e-mail), the following information must be provided:

• Case Control Number

• Child's Name

• Child's Date of Birth



• Child's SSN or Pseudo Number, if available

• Date of Application

Note:

Staff must use the secure email function when communicating with SPE. The email must be encrypted [Refer to “WebSafe Email Quick Reference Guide”]. http://intranet.ssa.co.santa-clara.ca.us/department/is/websafe_email_qrg.pdf

Required Forms

The following forms are required to be provided to the family:

• CHDP Brochure

• MC 003

• MC 219

• SCD 115

Additional Forms:

• Medical Support forms

• “Support Questionnaire” (CW 2.1 (Q))

• “Notice and Agreement for Child, Spousal, and Medical Support” (CW 2.1 Notice and Agreement)

• “Paternity Affidavit” (SCD 95)

• MC 322 (as applicable)

• MC 210 A (“Supplement to Statement of Facts for Retroactive Coverage/Restoration”)

• MC 371

Adding Adults

When adults are requesting MC, the EW will need to contact the client for additional information. SPE only screens MC eligibility for the children. The EW may need to obtain the MC 322 and the MC 371 to Add a Person.



Applications originating at SPE are processed as follows:

Table 5-6: SPE Application Procedures

Step Who Action

1. Clerical • Reviews Transmittal Form to make sure all applications listed are received.

• Performs File Clearance and prints the INQM and INQ1 screens for each individual on the applications.

• Checks the MEDS INQP screen for the date of application.

• Registers the application in CalWIN if no active case is found.

• Forwards the application with paper verifications to the Continuing EW if the case is active.

2. EW • If SPE indicates Retroactive MC Only is requested, sends MC 210 A to the applicant for completion and signature.

• Processes the MC Application and takes the following action:

If... Then...

MC is approved, • Completes CalWIN entries to establish eligibility on MEDS.

• Reviews MEDS to make sure that the AE record is terminated.

Child on AE is denied, Makes sure that the denial is correctly reported to MEDS and the AE MEDS record is terminated.

Note:

AE continues until an approval or denial transaction is sent to MEDS for the existing CIN. Staff MUST make sure all systems (CalWIN, CalHEERS, and MEDS) have the same information.



SPE File Clearance Procedures

Special File Clearance procedures for processing SPE applications are as follows:

Table 5-7: SPE File Clearance Procedures

Step Who Action

1. Clerk and EW Sup

Checks the MEDS record for the transmittal CIN and the date of application.

If SPE erroneously linked to a MEDS record belonging to a different individual, and the individual on the transmittal is...

Then...

Known to SCI/MEDS, • Request MEDS coordinator to call the ITSD help hotline immediately to restore the erroneously chosen individual’s record to what it was prior to the SPE update.

• Once the record is restored to its condition prior to the erroneous update, the prior BIC, if any, will be valid.

NOT known to SCI/MEDS, • Request MEDS coordinator to call the ITSD help hotline immediately to restore the erroneously chosen individual’s record to what it was prior to the SPE update.

• Once the record is restored to its condition prior to the erroneous update, the prior BIC, if any, will be valid.

• Submit an AP18/AP20 for the individual and check MEDS the following day to determine the CIN assigned during the MEDS batch update process.

2. EW Checks for multiple MEDS records.

If... Then...

The File Clearance identifies more than one MEDS record for the individual on the transmittal,

Completes an SCD 1296 to request the MTO to complete one or more EW 11 transactions as needed to merge the MEDS records.

5.9 Applications from MC Benefits Assistance

Refer to Common-Place Update 2014-21: “VMC Referrals for Adding-a-Program & Adding-a-Person”.


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/cp/updates2014/cp14-21.upd.pdf


5.10 Homeless Applicants

The following procedures must be followed for clients who have no address:

Table 5-8: Homeless Applicant Procedures

Who Action

Client Applies for MC and indicates he/she is homeless and has no address.

Clerical • Provides client with an SCD 41 and SAWS 1.

• Explains client must complete paperwork in office.

Client • Receives paperwork.

• Completes forms indicating homeless.

• Submits paperwork to clerical.

Clerical • Receives SCD 41 and SAWS 1.

• Performs application registration in CalWIN.

• Performs case assignment in CalWIN.

• Provides assigned EW with necessary paperwork and MEDS screens.

EW • Receives application.

• Processes application as immediate need.

• Initiates CalWIN Intake Workflow and enters information.

• Uses district office address most convenient to client. (Do not use BSC physical address)

[Refer to Chapter 28, "Homeless Mailing Address”]

• Makes every attempt to secure all needed verifications at the first contact. If unable to do so, makes arrangements to have client return.

• Runs EDBC and approves/denies MC (as appropriate).

• Submits documents for IDM scanning and supervisor review.

EW Supervisor

• Receives and reviews case.

• Submits to clerical for transfer or returns to EW for corrections, as appropriate.

Clerical • Receives and scans into IDM.

• Makes necessary entries in CalWIN to transfer case.



5.11 Informing Requirements

The following forms and/or information must be provided to clients:

• EWs must provide clients with the MC 219 and document that it was given/sent to the client. (The client is not required to sign and/or return it.)

• The “Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives” (DHCS 7068) must be completed and signed by the client's representative, if applicable.

• Scan the original copy in IDM, and

• Give a copy to the applicant/client.

• For Non-MAGI: The “MC General Property Limitations for All MC Applicants” (MC 007) must be reviewed with applicants, and applicants must be informed of:

• Property limits.

• How property is exempted, counted, and valued.

• Their right to reduce non-exempt excess property within the month of application.

• Options of how excess property may be reduced and how adequate consideration may be obtained to establish eligibility for the month MC is requested.

• If the client declares other health, dental, or vision insurance, the correct other health coverage (OHC) code must be posted on MEDS. For mail-in applications, the EW must check the HIAR screen in MEDS and/or contact the client by phone to obtain the necessary information.

• If the client declares a pending lawsuit due to accident or injury, the EW must ask the client to complete the “Potential Third Party Liability Notification” (DHCS 6168) form. [Refer to Chapter 13, "Third Party Liability (TPL)”]

• Your Rights Under California Welfare Programs” (PUB 13) must be given to the applicant or to the AR.

• Women, Infants and Children” (WIC) information must be given to pregnant women and to families with children (included in CW Intake packets).



• “Child Health and Disability Prevention” (CHDP) (PUB 183) brochures are included in CW packets. The brochure describes support services (scheduling and assistance with finding transportation) provided by CHDP as well as how and where services are provided. The correct information must be entered in CalWIN to make sure a referral reaches the CHDP unit. This form is shelf stock.

Note:

The Prenatal Care Guidance Program is available to pregnant women through CHDP. This program focuses on informing, motivating and assisting pregnant women with early and appropriate care. EWs should inform pregnant applicants and clients about this program and refer them to CHDP for guidance. The correct information for a referral must be entered in CalWIN.

5.12 New Application During 90 Day Cure Period

If part of a household applies for MC and there is an existing case still within the 90 Day Cure Period, it must be processed according to the following table:

If... Then... Example

The individual(s) applying provide the missing information from the original Redetermination,

The Continuing worker must rescind the existing case, complete the RD, and create a new case for the individual(s) that are applying on their own, per existing business process.

A family is discontinued June 3rd for not providing the 20 year old son’s pay stubs. August 10th, the 20 year old who now files taxes on their own, applies in office for Medi-Cal and includes pay stubs with the application. Because this was the only information missing from the existing case’s Redetermination, it can be rescinded and processed and the continuing worker will remove the 20 year old son from the home and create a new case.

The individual(s) applying do not provide the missing information from the original Redetermination,

The Continuing worker must forward the application to Intake for processing.

A family is discontinued in April for not providing Mom’s pay stubs at Redetermination. In June, the 20 year old daughter who now files taxes on her own, applies for Medi-Cal. Because the daughter’s information is not sufficient to rescind the existing case, the application is forwarded to Intake for processing, and the existing case remains discontinued.

Note:

This policy is only for cases discontinued for 90-Day Cure Period reasons.



5.13 Date of Application

The application date is one of the following:

• The date the client contacts the county by telephone.

• The date of the CalHEERS application.

• The date stamped on a paper application (if its within 10 days).

Note:Note:If the application date stamp is over 10 days use the date the application was submitted to the district office, by mail, in person, etc.

• The date the SAWS 1 is received/completed by the county taking the application.

• The date SPE received and recorded the initial application.

• The date the completed and signed form “Good News for California Families!” (SCD 90) is received by the county.

• The date of request for MC when adding a family member to a case.

Note:Note:When adding a newborn, the date of application is the date of birth.

5.14 Verifications

Each case, whether the application is filed in person, by mail-in, or forwarded by SPE, must contain adequate information and support documents to verify eligibility. Initially, this information can be electronically verified through the Federal Data Services Hub (Federal Hub), MEDS, and/or IEVS. If a client’s information cannot be electronically verified, then paper verifications (i.e. paystubs, bank statements, SSN card, etc.) may be required. For the ex parte review, documents/information must be within 90 days.

Non-MAGI MC Verification

If the case information cannot be verified through an Ex Parte review (i.e. MEDS, IEVS, etc.) Non-MAGI MC applicants/clients must provide paper verification.



MAGI MC Verification

At initial application, verifications must only be requested from MAGI MC clients after a CalHEERS BRE eHIT and ex parte review are completed. If information is verified via the Federal Hub, then paper verifications are not required. [Refer to “Federal Data Services Hub,” page 16-3] If information cannot be verified by the Federal Hub, then paper verification is required.

It is mandatory that each case contains adequate information with support documents in the CalWIN Search Case Comments window to determine eligibility, including any follow-up activities needed.

The following information must be verified before an MC eligibility determination can be completed:

Table 15: Verifications

Verification Documentation

Signed Application CalHEERS e-signature, telephonic signature, or a signature on a paper application.

NOTE: All MC applications received through the External Referral Data (ERD) subsystem have been electronically signed.Exception: One-e-App will fax the signature page.

Identity [Refer to Chapter 5, Section 5.14.1 "Identity Proofing and Identity Verification,” page-41]

Social Security Number Copy of card, IEVS Report, or MEDS showing SSN verified status

California Residency Driver’s license, utility bill, vehicle registration, school enrollment, rent receipt, or current check stub.

Immigration Status USCIS documents

Income Verification Check stub, income tax return, signed statement from employer, bank statement with direct deposit, child support court order.REMINDER: MC applicants are only required to provide one pay check stub for the purpose of calculating earned income.

Income Deductions Child care receipts, court ordered child support paid, health insurance premium paid.

Medicare Health insurance card, award letter showing the individual's health insurance claim number (HIC), explanation of Medicare benefits (EOMB) issued by Medicare fiscal intermediary, bill for premium for Medicare Part A, B or D, IEVS and/or MEDS information

Property/Assets Bank statements, vehicle registrations, life insurance policies, stocks, bonds, IRAs, 401Ks, real property.

Pregnancy Verification Women may self-attest to pregnancy. The EW must only request paper verification if the pregnancy reported is questionable.

Marital Status of Parents Clients Statement for Sneede Determination (Not required for Sneede Property Waiver)

OHC Information Information for ALL Family Members with Other Health Coverage, Insurance policy which specifically names the applicant/recipient, Health benefit ID card, Letter from health care benefit provider, Health care benefits from Workers Compensation employers or insurance companies



Table 16: Documentation Needed for Retro Applications

MC 210 A Retro MC Application (Up to 3 prior months)

Income Verification Actual income for ALL retro months requested

Property Verification Actual amounts for ALL retro months requested (Not applicable for children/pregnant women).

SSN Verification

SSNs are required for citizens and documented non-citizens.

Once an individual’s SSN is entered in CalWIN/CalHEERS, MEDS verifies the SSN through daily SSN validation process. If the individual has a MEDS record with fully or partial unverified SSN-VER code and they receives full scope benefit, MEDS alerts in “4xxx” series will be generated to display discrepancies. An EW should follow the instructions outlined in the UGSS Chapter 4 “County Eligibility Worker Alerts:400-8999” and/or Chapter 3 “MEDS/CDB Record Changes to clear the discrepancies to fully verify an individual’s SSN. If the SSN cannot be verified through MEDS, the EW must request verification and allow the client 60 days to provide. If verification is not provided, the individual must be discontinued from MC.

Refer to UGSS Chapter 4, Section 4.8 for the list of unverified SSN-VER codes and Chapter 3 for MEDS-ID/SSN Changes.]

Note:

An SSN is not required for Victims of Human Trafficking and Serious Crimes and for undocumented children under the age 19 under SB75 to receive full scope MC benefit.

5.14.1 Identity Proofing and Identity Verification

For MC there are two layers of identity checks:

1. Identity Proofing A process to make sure that a person who is applying, or acting on behalf of another individual, is who they say they are. Identity Proofing is required to allow an application to be submitted for an eligibility determination (i.e., to run EDBC or to complete a CalHEERS online application) or to allow certain record changes to be made (i.e., CalHEERS Primary Contact information changes).


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/ugss/ugchap04.pdf



2. Identity Verification A process to meet identity verification requirements as a condition of eligibility for MC. These verification requirements include DRA requirements.

Identity Proofing

There are three options for Identity Proofing:

1. Signature The applicant can complete and send or deliver a paper application to the county or the Covered California Service Center for processing. The applicant’s signature on an application qualifies as proof of identity when a Covered CA Service Center Representative (SCR), or county EW processes the application.

2. Visual Verification The applicant can mail in or upload a digital copy of an identity verification document, which an EW or Covered CA SCR can then visually verify (this is also known as Administrative User Attestation). Or, if in person, the EW or Covered CA SCR can scan and upload the document received from the applicant. Visual Verification can be accomplished via the MC Identification process described under Identity Verification below.

3. Remote Identity Proofing (CalHEERS ONLY) This process is used when using the electronic/phone signature process (i.e., while applying online via CalHEERS or over the phone via Covered CA). Either the applicant, EW, or Covered CA SCR can use the Remote Identity Proofing (RIDP) service to which CalHEERS connects through the Federal Hub.

a. To complete the RIDP process for phone and online applications, do the following:

• Client will complete an electronic check through Experian using CalHEERS.

• EW completes an ex-parte review of any prior case or current CF case in the IDM to determine if acceptable identity documentation is on file to serve as proof of identity. If so, the Identity Proofing requirement is met.

• Client provides a copy of acceptable ID documentation, in person, by mail, by fax, or electronically.

b. A telephonic or electronic application can be submitted to CalWIN without Identity Proofing. However, the Remote Identification Process Verification Complete [Y/N] field under the [DRA Detail] tab must be completed on the Collect Individual Demographics Detail window prior to running EDBC.



Identity Verification

There are three options for Identity Verification:

1. CalHEERS BRE The CalHEERS BRE verifies identity and citizenship by checking the Federal Hub during a determination of eligibility. This process includes verifying an SSA match.

• If identity and U.S. citizenship are verified through an SSA match (i.e., through the Federal Hub), both the original MC Identification requirement (Title 22 of California Code of Regulations 50167(a)(6)) and DRA requirement are met, and remain met without any further verification.

2. MC Identification Original MC regulations [Title 22 of California Code of Regulations 50167(a)(6)] require EWs to verify the identity of a client. This verification is required from the primary applicant at every application. This requirement is met by SSA Match which verifies citizenship (e.g., through the Federal Hub). Requirement can also be met with a photocopied document. In addition, current and old information can be matched up. For example, there is an old picture ID in the case, and the signature on the current SOF matches. The following are acceptable forms of identity verification:

• A Driver’s License or ID card issued by the DMV

• Marriage Record

• US Citizenship or Alien Status document (i.e., passport)

• Work Badge

• Social Security Card

• School Identification Card

• Church Membership or Baptism/Confirmation Record

• Birth Certificate.



Note:

If an individual has no other possible method of verifying identity a signed affidavit may be accepted as a last resort.

3. Deficit Reduction Act (DRA): Citizenship and Identity Verification The DRA passed in 2005 and in 2007 California introduced the requirement that every applicant alleging US Citizenship (adult and child) must prove citizenship and identity.

a. Always check MEDS to see if the DRA citizenship and identity requirements have already been met.

b. Do not pend for verification of citizenship and identity until an SSA match is attempted. According to DHCS, the SSN Data match results should be used prior to requesting acceptable documents.

c. Once DRA is met, it remains met. If the MEDS [INQE] screen shows that DRA requirements are met, send a copy of the MEDS [INQE] screen to IDM.

d. Photocopies are not acceptable for DRA; in cases where the SSA match fails, and DRA requirements were not otherwise met, the client must present in-person original documents to verify ID and citizenship. EWs should use the MC 239 DRA-6 to pend a case for verification of citizenship and identity after an unsuccessful SSA match. Reminder: Clients should not mail original documents to the county. They must provide original documents in-person.

The following table summarizes examples of Identity Proofing and Identity Verification process depending on how the application is submitted.

Table 17: Identity Proofing and Verification Examples

Application submitted through...

Citizen Identity Proofing Identity Verification

CalHEERS Yes • Client performs RIDP.

• If RIDP fails, follow alternative Proofing paths.

• BRE call verifies identity.

• DRA is met by BRE SSA citizenship verification.

No • Client fails RIDP; clicks on CalHEERS Link to find Certified Enrollment Counselor nearby.

• Certified Enrollment Counselor helps client scan/submit required document to complete ID Proofing.

• BRE call pends for citizenship.

• Perform MC identification.

• DRA is not appropriate for non-citizen.



Paper application to Covered CA

Yes Signature on paper application is sufficient. • BRE call verifies identity.


No Signature on paper application is sufficient. • BRE call pends for identity and citizenship.



Paper application to the county

Yes Signature on paper application is sufficient. • BRE call verifies identity.


No Signature on paper application is sufficient. • BRE call pends for identity and citizenship.



BCW Yes EW visual verification. • BRE call verifies identity.


No EW visual verification. • BRE call pends for citizenship.

• MC identification completed with visual verification at Identity Proofing.


Phone call to Covered CA

Yes • Client performs RIDP.




No • Client performs RIDP.


• BRE call pends for identity and citizenship.








5.14.2 Self-Attestation for Plan to File Taxes

An EW must accept an individual’s self-attestation as true to the following questions:

• Is the tax filer planning to file taxes this year?

• Is the tax filer’s child or tax dependent expected to be required to file taxes this year?

The self-attested answers to the above tax filing questions must be accepted as true, regardless of other information provided within the application that may appear to conflict with the individual’s statements, such as the amount of their income and/or deductions.

This is due to the fact that there may be circumstances known to the Internal Revenue Service (such as partnership losses and net loss carryovers for up to 20 years) or to the individual (such as an upcoming marriage or a terminal diagnosis) that are not included or reported on the application. Such circumstances may affect the individual’s expectations/requirements for filing taxes or claiming deductions.

5.15 Timeframes for Processing Applications

5.15.1 Application Processing

The determination of MC eligibility must be completed within 45 days; except, when determination depends on establishing disability or blindness, in which case the limit is 90 days.

If the application cannot be processed within the required time limit, there must be good cause and it must be documented. The extended time must not exceed three months from the application date.

Phone call to the county

Yes • Telephonic signature is sufficient.

• If no telephonic signature, follow visual verification Proofing paths.



No • Telephonic signature is sufficient.

• If no telephonic signature, follow visual verification Proofing paths.

• BRE call pends for identity and citizenship.








5.15.2 Immediate Need Criteria

If the applicant has an immediate medical need, the EW must expedite the MC eligibility determination within available resources.

Pregnant women and/or persons with medical emergencies are to be given priority appointments, if there is an available appointment. Pregnancy, in and by itself, signifies an immediate medical need and applications must be processed immediately.

Note:

These requirements apply whether or not a pregnant woman intends to terminate the pregnancy.

5.15.3 Beginning Date of Eligibility

MC Only

The beginning date of eligibility for persons applying for MC only is the first day of the month:

• Of application, or date of request to add a family member to an ongoing case, if all eligibility requirements of the appropriate MC program are met within that month,

OR

• Following the month of application in which the eligibility criteria of the appropriate MC program are met.

Note:

For the purposes of this section, eligibility requirements are considered to be met for the entire month if they are met at any time during the month except individuals who are incarcerated or pending incarceration.

Cash-linked MC

The beginning date of MC eligibility for persons who apply under any public assistance program is the first day of the month of application, regardless of the beginning date of the cash grant, providing the person meets the following criteria:

• Citizenship

• Residency



• Financial eligibility.

For persons who do not meet these eligibility criteria during the month of application, the beginning date of eligibility for cash-linked MC is the first day of the first month in which the above criteria are met.

Note:

When cash-linked MC is established in a month after the month of application, MC Only eligibility requirements must be explored for the month of application.

CalWORKs Denials

The beginning date of eligibility specified above also applies to a CW applicant who meets eligibility requirements in the month of application but whose application is denied because they no longer meet eligibility requirements at the time CW eligibility is determined.

5.16 Courtesy Applications

The “County of Responsibility” is the county responsible for evaluating and redetermining the MC benefits. In the event that a county which is not the county of residence receives an application, the receiving county must date-stamp the application and forward it to the correct county as soon as administratively possible. The receiving county must use the date stamp from the sending county as the date of application.

These charts are intended to function as guidelines when determining the county of responsibility. There will be situations other than those identified in these charts. When resolving county of responsibility issues, staff should be flexible and keep in mind the best interest of the applicant/recipient and/or his/her representative. Staff must consider criteria such as:

• Age of the applicant/recipient and his/her representative,• Physical and mental condition of the applicant/recipient,• Travel distance for the applicant/recipient and his/her representative, and• Possible delay in the processing of the application and eligibility determination that will create

undue hardship for the applicant/recipient and/or his/her representative.

Courtesy Application

• Refer to CA 301.1. Cross County CalWIN Applications


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/calwin_searchable/calwin_announcements/ca_301.pdf

https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/calwin_searchable/calwin_announcements/ca_301.pdf


5.16.1 Courtesy Applications

Table 5-9: Courtesy Applications

COURTESY APPLICATIONS

Situation County of Responsibility

An application from different sources (i.e. CalHEERS External Referral, mail-in etc.) made in a county other than the county of responsibility.

The county in which an applicant or his/her representative applies for MC benefits is the county responsible for making the initial eligibility determination, even if it is not the applicant’s county of residence.If all information needed to determine eligibility is available, the county must issue benefits then initiate eICT to the client’s county of responsibility.Otherwise, the county must forward the application and all information collected within 15 days from the date of application to the county of responsibility for follow up and completion of the initial eligibility determination.

Example 1:An individual lives in Santa Cruz and becomes ill in Santa Clara County. The individual is immediately admitted to VMC. The outstationed EW at the hospital receives a MC referral from the hospital staff. The client completes the necessary application form(s), and provides sufficient information for the EW to determine initial eligibility. The EW would approve MC, then initiate an eICT to Santa Cruz County, the client’s county of responsibility.Example 2:An applicant’s representative applies in Santa Clara County on behalf of an individual who resides in Alameda County. The individual is hospitalized and unable to complete and participate in the application /eligibility determination process in Alameda County. Santa Clara County must accept the MC application from the representative. If the representative has knowledge of the applicant’s income/resources and can provide Santa Clara County with information to process the MC application, Santa Clara County must determine initial eligibility and grant MC benefits to the individual. Santa Clara County would then transfer the continuing eligibility case responsibility to Alameda County.

5.16.2 Person Maintains a Home

Table 5-10: Person Maintains a Home

PERSON MAINTAINS A HOME


Person maintains a home and resides permanently. The county where person lives.

Person maintains a home but works out of town seasonally.

The person is considered temporarily absent from home. The county where person maintains his/her home is the county of responsibility.

Person maintains a home but is vacationing in another county.

The person is considered temporarily absent from home. The county where the person maintains his/her home is the county of responsibility.



5.16.3 Homeless Individuals

Table 5-11: Homeless Individuals

HOMELESS PERSONS


Person is homeless with no permanent living arrangements.

County of physical presence at time of application is the county of responsibility. If the homeless person moves to another county or requests the case be transferred to another county, an eICT must be initiated.

Homeless person intends to reside in one county but maintains a mailing address or P. O. Box in another county for mail pick up and delivery.

County where the homeless person intends to reside is the county of responsibility. An eICT is not required.

5.16.4 Individual with a Guardian

Table 5-12: Individual with a Guardian

PERSON WITH A GUARDIAN


Client has a private guardian. Private guardian has no effect on county of responsibility. Determine as if there were no private guardian.

Client has a public guardian. Public guardian is a county agency. County in which public guardian is located is the county of responsibility.

5.16.5 Individuals Under 21 Years of Age Not living at Home

Table 5-13: Individuals Under 21 Years of Age Not Living at Home

PERSONS UNDER 21 YEARS OF AGE NOT LIVING AT HOME


Person is between 18-21 years of age and NOT claimed as a tax dependent and NOT under parental control.

County in which the person resides. This person is NOT considered living in the parent’s household.

Person is between 18-21 years of age and living away from home and IS claimed by his/her parent as a dependent for state or federal income tax purposes.

County in which the claiming parent resides if the parent lives in the state.If the parent resides in another state, the county of responsibility is the county in which the child resides. However, the parent must complete the application/redetermination form(s), provide the county with information/ verification, and cooperate with county staff in the child’s eligibility determination process. The EW must grant benefits to the child if eligibility conditions are met.



Example 1:

A 19-year old applied for MC in San Joaquin County. During the interview, the applicant informs the eligibility worker that his/her parents reside in Santa Clara County and claims him/her as a tax dependent. San Joaquin County must deny the application unless the applicant is applying for the Minor Consent program. San Joaquin County must inform the applicant that if he/she wants full-scope benefits, his/her parents must file an application in Santa Clara County.

Example 2:

The applicant is an 18 year old attending school in California. The applicant’s parents reside in the state of Oregon but he/she is the parents’ tax dependent. The parents must apply for the child because the child is claimed as a tax dependent of his/her parents. The county of responsibility is where the child resides because his/her parents reside out of state.

[Refer to “MN/MI and Non-MAGI MC MFBU,” page 19-1]

[Refer to “MAGI MC Tax Household,” page 14-1]

Person is under 21 years of age and is living away from home and doesn’t have any information on tax dependency status.

County in which the person resides.

Table 5-13: Individuals Under 21 Years of Age Not Living at Home

PERSONS UNDER 21 YEARS OF AGE NOT LIVING AT HOME




5.16.6 Deceased Individual

Table 5-14: Deceased Individual

Deceased Individual


The deceased individual incurred hospital bills, The county where the person was residing at the time of death.

NOTE: If the deceased person’s family or representative applies in any county within the state, the county in which the applicant’s representative applies must accept and process the application under the courtesy application procedures.

5.16.7 Out of Home Placement

Table 5-15: Out of Home Placement

OUT OF HOME PLACEMENT


Foster children and children eligible for the Adoption Assistance Program (AAP).

County in which the placing agency is located.

Person is placed in county or private facility in another county by a county agency.

County that made placement, unless counties and individual agree otherwise.

Person is placed in county or private facility in another county by a private party.

County in which the facility is located unless the person’s family resides in another county.NOTE: This does not apply to persons who are in separate MFBUs from their families, e.g., LTC persons.

Person is placed in state hospital by county mental health agency or Regional Center for the Developmentally Disabled.

County in which state hospital is located. NOTE: This situation supersedes all other situations except situations where MFBU/Tax Household includes other family members.

Persons placed in county or private facility in another county after release from a state hospital.

County in which the facility is located.NOTE: This situation supersedes all other situations except situations where MFBU/Tax Household includes other family members.



5.16.8 Pending DDSD Determination

Table 5-16: Pending DDSD Determination

PENDING SP-DDSD DISABILITY DETERMINATION


Case has MFBU/Tax Household member(s) already active on MC and one of them has a pending DDSB determination,

The county where the family currently resides is the county of responsibility.

• The Sending County must initiate an eICT to the new county of residence. Include copies of the DDSB referral in the ICT packet.

• The Receiving County must notify DDSB of the client’s new address.

Case consists of only the applicant (there is no active case),

The original (Sending) county that initiated the DDSB referral must keep the case until a decision is received:

• If the client is disabled, approve MC and then initiate eICT.

• If the client is not disabled and there is no eligible for other MC programs, deny the MC application. No eICT is required.

5.16.9 Withdrawals/Requests for Discontinuance

A client may withdraw an application for or request discontinuance from MC by any of the following:

• Verbal request specifically stating MC. (EWs must still mail the MC 215 or SCD 166.)

• Completion of the MC 215 (scan into IDM and give a copy to the applicant) or SCD 166 (automatically populates in the CalWIN print queue when the withdrawal is added to CalWIN, this form does not need to be returned for the EW to complete the withdrawal action).

• Submitting a signed written request specifically stating MC. The signed request should be scanned into IDM.

Note:

The client must indicate that he/she clearly understands the process by signing the withdrawal form. A withdrawal/request for discontinuance should be a free and willing decision based on an understanding of all available information.


5.17 Intake Documents to


IDM

5.17.1 System Screenshots to Print

Following an eligibility determination EWs must print the screenshots from each system (CalWIN, CalHEERS and MEDS) and send those screen prints to IDM. Each screen should show the same aid code, confirming that all three systems have the same eligibility for the client.

Note:

It takes two days for eligibility to be sent from CalWIN to MEDS. If there is a change in eligibility, the EW must wait for the new information to show on MEDS before printing the screenshots mentioned below.

5.17.2 CalWIN Screenshot to Print

Print the individual’s Inquire on Medi-Cal Aid CalWIN screenshot for each active household member.

Table 5-17: Printing CalWIN Screenshot

Step Action

1. Go to Inquiry subsystem.

2. Select Case Inquiry.

3. Click on Inquire on Medi-Cal Aid.

4. Enter Case Number.

5. Click the [Open] button.

6. Select each active individual in the drop down menu.

7. Enter the appropriate date range in the Month From and Month to fields.

8. Click the [Search] button.

9. Print the Screen. Repeat for each active member in the household.

10. Send all printouts to IDM.



5.17.3 MEDS Screenshot to Print

Print the individual’s [INQM] MEDS screen for each active household member. Depending on the case/individual the EW may also need to print screens [INQ1], [INQ2] and/or [INQ3] to capture all eligibility. Send all printouts to IDM.



5.17.4 CalHEERS Screenshots to Print

Program Eligibility by Person

Each household members’ eligibility appears together on the Program Eligibility by Person page in CalHEERS.

Table 5-18: Printing CalHEERS Screenshots

Step Action

1. On Search Individual page in CalHEERS:

• Enter CalHEERS case number.

• Click the [Search] button.

• Select radio button next to any case member’s name.

• Click the [View Case] button.

2. On left hand side of CalHEERS, click on Program Eligibility by Person.

3. On Program Eligibility Summary by Person page, select the application year from the dropdown menu of the View Enrollment Information for field.

4. Print the Program Eligibility Summary by Person page. Make sure all information is visible on the printed page(s). (This may require printing more than one page.)

5. Send all printed pages to IDM.





Manual Verifications

Print CalHEERS Personal Verification page (i.e. Federal Hub verifications) for each eligible individual and send to IDM.

Table 5-19: Printing CalHEERS Manual Verifications Page

Step Action

1. On Search Individual page in CalHEERS

• Enter CalHEERS case number.

• Click the [Search] button.

• Select radio button next to any case member’s name.

• Click the [Manual Verifications] button.

2. On Household Verifications page, click on client’s name. (This will open the Personal Verifications page for the selected client.)

3. Print the Personal Verifications page. Make sure all information is visible on the printed page(s). (This may require printing more than one page.)

4. Repeat above steps for each active member in the household.

5. Send all printouts to IDM.

Note:Highlighting the Personal Verification table only and selecting print will reduce the blank space on the printed copy.





5.17.5 Printing External Referral Data Report

When processing a CalHEERS application from the External Referral Data (ERD) subsystem, the application can be printed from CalWIN.

Table 5-20: Printing External Referral Data Report

Step Action

1. Go to Interface Activities.

2. Select External Referral Data subsystem.

3. Select on Search for External Referral Data.

4. Click the [Open] button.

5. Enter client information and click the [Search] button.

6. Select the appropriate ERD record.

7. Click the [Detail] button.

8. Click the [Summary View] button.

9. In the Summary View window, click the [Print Report] button.

10. Select the [Print] button.

11. Send the printed report to IDM.



5.18 Retroactive MC

An applicant for MC, CW, SSI/SSP, or RCA may be eligible to receive MC for any of the three (3) months immediately before the month of application. Any written request for retroactive coverage must be considered an application.



When adding an individual to an ongoing MC case the individual’s date of application is the date of request.

Example:

An active MC case exists with a mother, father and child with an original application date of 1/25/2014. The father is not requesting aid but he does live in the home. He requests MC coverage for himself on 10/13/2017, he is potentially eligible for Retroactive MC for the months of 09/2017, 08/2017 and 07/2017.

For SSI/SSP applicants, the application date is the same date as the Social Security Administration application date, even if SSI/SSP is never approved for the month of application. The application date can be obtained from the [SDX3] screen in MEDS.

5.18.1 Retroactive MC Request Time Limit

An application for retroactive MC must be submitted within 12 months from the month of service. If a request for retroactive MC is made for any of the 3 retroactive months more than 12 months from the date of service, then the retroactive MC request will be denied. When adding a person to an ongoing case the individual’s retroactive MC period is also from the date of service and the individual’s request date.

Example:

Mr. Cobblesworth applied for MC on 4/1/17. He had medical expenses in January, February and March of 2017, but did not apply for Retroactive MC because he thought his insurance would cover the cost. In February 2018, he discovers that his insurance did not pay and applies for Retro. In February 2018, he can be approved for MC for February and March 2017 but it is too late for January 2015. (Retro MC for January 2017 will be denied.)

Example:

An active MC case exists with a mother, father and child with an original application date of 1/25/2014. The father is not requesting aid but he does live in the home. He requests MC on 10/13/2017, he is potentially eligible for Retroactive MC for the months of 07/2017, 08/2017 and 09/2017. He has until 07/2018, 08/2018 and 09/2018, respectively to request Retroactive MC if he has medical bills in 07/2017, 08/2017 and/or 09/2017.

5.18.2 Eligibility Conditions

In order to be eligible for retroactive MC, all of the following conditions must be met in each retroactive month:



• The applicant would have been eligible for MC had an application been filed.

• The applicant received a health care service. (The applicant has medical bills.)

• The applicant was not previously denied MC for the month in question unless the denial was due to:

• County error, or

• Circumstances beyond the applicant’s control.

5.18.3 Retroactive MC Applications

Eligibility for retroactive MC must always be explored at the point of intake and/or at any time an applicant makes a request. A person applying for retroactive MC must submit a MC 210 A. If the application is for retroactive MC coverage only, then an SSApp or any other acceptable MC application/SOF form must be submitted.

Note:

For SSI/SSP applicants requesting Retroactive MC, EWs are to request only the MC 210 A, and information and documents that is not available through MEDS/SDX inquiry screens, and is necessary to determine eligibility. SSI/SSP applicants are not required to submit the SSApp, but an MC 210 A must still be submitted.

When an Intake EW receives an application (e.g. SAWS 2 Plus, etc.) which indicates the individual wants Retroactive MC, they must contact the individual to confirm the request. The confirmation must take place before the EW can request the application registration for Retroactive MC. The table below outlines the process for the Intake EW:

Exception:Exception:

Many applications that come from Valley Medical Center (VMC) are for hospitalized individuals and often, additional attempts to contact the applicant may fail. The EW must still try to contact the applicant and document the outcome of the attempt (i.e. phoned or visited applicant but unable to confirm request for Retroactive MC due to applicant’s unavailability.) In these instances, the Retroactive MC application may be registered without confirmation.



Table 18: Retroactive Medi-Cal

If... And... Then...

The client is reached The client clarifies they do NOT need MC for any of the three months prior to the month of application

Clearly document in case comments that per conversation with the client, Retroactive MC is not being requested

The client confirms they are requesting Retroactive MC and incurred medical bills for any of the three months prior to the month of application

• Complete the MC 210 A with the client by phone and obtain a telephonic signature

• Submit the application registration request to Clerical for the required months of Retro MC

• Process the Retroactive MC

**If verification is required to disposition the Retroactive application, a request for verification should be sent to the client and the case must remain assigned to the Intake EW until the verification due date**If MC 210 A is received but the client later verbally withdraws their request, case comment and send the SCD 166 to be completed and returned by the client

The client is NOT reached N/A • Mail the MC 210 A to the client and allow a 10-day due date for the return.

• Clearly document in case comments that attempt to reach client by phone was made and the MC 210 A was mailed

**Intake EW must hold the case until the 10-day due date and case comment before transferring it to continuing, OR if client responds before the due date, the Intake EW must disposition the case and case comment before transferring it to continuing

Important:Clerical staff must not complete the application registration for Retroactive MC until the Intake EW has requested it.



Requests for retroactive Medi-Cal can be approved in Santa Clara County regardless of residency during the month(s) of request. This will prevent the client from having to apply for ongoing MC in Santa Clara county and retroactive MC in their previous county of residence. Retroactive MC is fee for service so there is no impact to the clients coverage.

5.18.4 Retroactive MC for Mail-In Applications

Anyone requesting retroactive MC using the SSApp or any other acceptable MC application form must also complete the MC 210 A. The EW must send the MC 210 A when retroactive MC is requested. The EW may assist the client by completing the MC 210 A over the phone. A telephonic signature for the MC 210 A is acceptable. EWs must clearly document actions in the Search Case Comments window in CalWIN.

5.18.5 Retroactive MC Based on Disability

This section only applies to clients who do not qualify under MAGI MC rules. Individuals applying on the basis of disability must have their disability determined prior to approval of retroactive benefits.

For SSI/SSP pending applications, a determination of MC under any other program must be made for the retroactive months.

Refer to MC Update 2012-7: Changes in Processing Disability Determinations Pending with Social Security Administration (SSA)

The EW must:

• Record an application for retroactive MC to be kept pending until the State Programs - Disability Determination Service Division (SP-DDSD) determination is received.

• Determine eligibility for each retroactive month.

• Transfer the case to Continuing in “pending” status, if applicable.

• Issue an approval or denial notice, and BIC if necessary, when the disability determination is received.

5.19 Supplemental Forms

Supplemental forms may be required when additional information is needed beyond what is asked on the MC Application.


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/medical/updates2012/mc12-07.upd.pdf


EWs must use supplemental forms when a client answers “YES” to questions about residency, property/resources, and income.

Table 19: Supplemental Forms

Supplemental Forms Usage

MC 371 This form can be used to add family members.

MC 210 S-E This form is given to the client if any family member is attending college or a similar educational institution. Information is requested on whether the client is receiving a grant, scholarship, or loan, and any student expenses or transportation costs. This form is optional. Other school verifications may be used.

MC 210 S-I This form serves two purposes:

• Verifies free housing or rent paid to a relative, and this is the ONLY evidence of CA residency.

• May be used to verify income-in-kind (including actual in-kind values when the client does not agree with the chart values).

MC 322 This form is used for property verification.

5.19.1 Other Required Forms/Intake Packets

In addition to the supplemental forms, the following forms and/or verifications are required depending upon the client's circumstances such as, but not limited to:

• “Statement of Citizenship, Alienate and Immigrations Status” (MC 13) is used when citizenship cannot be verified by other documentation.

Note:Note:MC 13 is not required if the applicant is requesting restricted-scope benefits.

• Medical Support forms

• CW 2.1 Notice and Agreement

• CW 2.1 (Q)

• SCD 95

Note:Note:Forms must be given/sent to the client but MC benefits should not be delayed or denied for failure to provide these forms at Intake. The case can still be transferred to Continuing if the forms have not yet been received. [Refer to CP Handbook Chapter 30.1.1 for detailed instructions]

• Verification of income and expense deductions.



• Immigration status verification within 90 days.

• Evidence of residency.

Note:Note:Applicants must provide their social security number (SSN) as appropriate, but are not required to submit copies of their social security cards, unless the EW is unable to verify the number provided via MEDS or the Federal Hub.

If an applicant is requesting other programs (i.e. CW, GA, CF, etc.), then [Refer to Chapter 24, "Intake/RRR Packets”] for a complete list of required forms and informing notices for all programs.

5.20 CalFresh Application for MC

5.20.1 Overview

CF clients who wish to apply for MC may do so at any time. Timely action must be taken on ANY verbal, electronic or written request for MC from a CF client on an active CF case. This applies to both Intake and Continuing cases. The date of application for MC is the date the county is first notified by the CF client that MC benefits are being requested, or the date the written application is received. An approval or denial NOA must be sent.

Note:

If a verbal request is made, the EW must clearly document in the Search Case Comments window in CalWIN to maintain the date of application.

The following forms may be used to determine MC eligibility:

• “Good News for California Families!” (SCD 90), or

• “Application for CalFresh Benefits” (CF 285), or

• “Recertification for CalFresh Benefits” (CF 37).

Note:

If a request for MC is received from someone who already has MC benefits, a NOA is not required; however, the EW must contact the client (by phone or in writing) and explain their eligibility status.



5.20.2 “Good News for California Families!” Requirements

California Welfare & Institution Code Sections 10618.5 (AB 59) and 18925 (SB 493) require counties to provide an informing notice/application for NACF clients who are not receiving MC. This requirement is intended to expedite MC enrollment for parents and their children as well as other adult CF clients.

The form “Good News for California Families!” (SCD 90) is both a MC informing notice and an application for MC. It may be used for CF clients who are not currently enrolled in MC.

5.20.3 Application Process

Initial Intake Applications

Intake EWs are required to explore eligibility for all programs requested and all benefits for which the applicant may qualify. If an applicant requests CF benefits, but not MC, the EW must determine if there is potential eligibility for MC for anyone in the household (linkage, income, etc.)

Table 5-21: Initial CF Intake Application

If... Then the Intake EW...

The client is requesting MC and CF at the same time, Provides the CF 285 to the client.

CF benefits are active and the client requests MC while the case is still in Intake,

• Uses the information on the CF 285 for the MC application, if it is less than 12 months old and it contains sufficient information.

• Document that the client is requesting MC and the information from the CF 285 is being used to determine eligibility.

• Have the client complete any other required MC form, and issue all mandated informing forms and NOAs.

The client is NOT interested in applying, Ask the client to complete an SCD 166. Document the reason for refusal.

.

Continuing (Recertification)

As part of the CF Recertification (RC) process, EWs are to check to see if all members of the CF household are receiving MC coverage and explore eligibility for MC as follows:

• Check MEDS to determine if they are already receiving MC benefits.

• If any household members are NOT receiving MC and there is linkage (a child in the home, disabled adult, etc.), mail the SCD 90 to the client with the CF RC packet.



5.20.4 Processing the SCD 90

• The MC date of application is the date the signed SCD 90 is received (date stamped).

• A completed and signed SCD 90 is processed as a mail-in application, unless the applicant prefers to have a face-to-face interview. [Refer to Chapter 5, Section 5.6.2 "Mail-In and Phone-In MC Application Procedures,” page-21]

Note:

If a signed SCD 90 is received from an individual already on MC, a NOA is not required; however, the EW must contact the client (by phone or in writing) to explain their eligibility status and document the actions taken in the Search Case Comments window.

5.20.5 CalFresh Forms used for MC

CF clients are NOT required to complete a separate or additional MC application form when requesting MC benefits. The CF 285 or CF 37 may be used to determine MC eligibility for CF clients.

The CF 285 or CF 37 on file may be used instead of the SSApp as an application for MC if:

• It is received within 12 months, and

• It contains sufficient information to make a MC only determination.

The chart below explains which application form to use in various circumstances.

Table 5-22: CF Forms used for MC

If... Then...

A CF client applies for MC, The CF 285 may be used for the MC eligibility determination if it is less than 12 months old and it contains sufficient information.

The CF 285/CF 37 does not contain sufficient information and/or verifications to determine eligibility for MC,

Additional information/verifications must be requested from the client by phone or if the client cannot be reached, send an SCD 50 (i.e. tax filing information).

The CF client's most recent CF 285/CF 37 is over 12 months old,

Current information/verification must be requested from the client by phone or if the client cannot be reached, send the SSApp.

A client is applying for CF and MC at the same time, The CF 285 can be used for both CF and MC.

An applicant is approved for or active on CF, then later requests MC while the case is still with the Intake EW,

The CF 285/CF 37 must be used for MC, as the applicant is a CF client.

CF/MC client requests retroactive MC, An MC 210 A must be completed.



5.20.6 Misaligned Redetermination Dates

The MC RD due date is NOT based on the CF 285 application date. DO NOT SHORTEN THE MC RD 12-MONTH PERIOD.

The CF 285/CF 37 may be used to determine MC eligibility if the application is within 12 months, if there is a Change in Circumstance (CIC). [Refer to Chapter 10, Section 10.6 "Change in Circumstance,” page-46]. The MC RD date must be 12 months from the date MC eligibility is reestablished. DO NOT SHORTEN THE MC RD DUE DATE.

Reminder:

Forms are no longer required from the client to complete the annual MC RD. The client can provide the information verbally, which is entered into CalWIN and sent to the Federal Hub for e-verification. The client must provide paper verification of information not e-verified. Clients who are evaluated for Non-MAGI MC must provide paper verifications of income and property. [Refer to “Redeterminations,” page 10-1]

5.20.7 MC Eligibility Determination

Since CF regulations differ from MC, the CF 285 or CF 37 may not have all of the information needed to determine MC eligibility.

Citizenship/Immigration Status

Excluded members of the CF household (i.e., undocumented individuals) may qualify for MC if other eligibility requirements are met. Excluded household members must be evaluated individually based on their current citizenship/immigration status. [Refer to Chapter 10, "Immigration”] and [Refer to Chapter 11, "Noncitizen Categories”] for immigration status and program eligibility.

Property for Non-MAGI MC

Property paper verification must be received.

A CF only client requests retroactive MC, An SSApp must be completed if a current CF 285 is not on file. An MC 210 A must also be completed.

Table 5-22: CF Forms used for MC

If... Then...



Tax Filing Information

Tax filing information is not required for CF, but it is required to accurately determine MAGI MC.

5.20.8 Informing Notices and Other Required Forms

When a CF client requests MC benefits, a complete MC Intake Packet is not required; however, the MC Intake Informational packet must be given to the client. [Refer to Chapter 5, "MC Intake Informational Packet,” page-4]. Also [Refer to Chapter 5, Section 5.19 "Supplemental Forms,” page-67] for a list of other required or supplemental forms.

5.20.9 CalFresh Ineligibility/Discontinuance

The reasons for CF ineligibility or discontinuance do not always apply to MC ineligibility or discontinuance. Follow the chart below to determine what action(s) are necessary:

Table 5-23: CF Ineligibility/Discontinuance

If the reason for the CF ineligibility/discontinuance... Then the EW must...

Is for failure to provide a SAR 7, Continue MC benefits and assume that no change has occurred for MC unless one is reported.

May or may not affect MC eligibility,Example: CF is discontinued due to incomplete SAR 7.

Determine if any of the changes reported on the SAR 7 affect MC eligibility and take appropriate action. Additional information may be requested by using the “Medi-Cal Request for Information” (MC 355) and follow Ex Parte time frames.

Does not affect MC eligibility, Example: Failure to comply with work requirement.

Continue MC benefits.

Affects MC eligibility,Example: Move out of state or death of an individual.

Discontinue MC for the affected individual(s) only.

5.20.10 Required Documentation

EWs must clearly document ALL of the following in the case record:

• The current CF 285/CF 37 in the case record was used to complete the eligibility determination.

• All required information used to determine MC eligibility is on file (i.e., MFBU composition, linkage, OHC, income, property, etc.)

• The date MC eligibility is established and the MC RD due date.



5.21 Express Lane Enrollment Program

This program ended on June 30, 2017.

The Express Lane Enrollment (ELE) Program was created to allow for expedited MC enrollment to CF clients. MC eligibility is granted without the need for an application or a determination for 12 months, unless a CIC makes the individual ineligible for CF. No further information beyond the active CF enrollment is required.

This program targets CF clients who are citizens or lawfully present and under 65 years old. Medicare clients were previously ineligible for ELE; however, effective June 2014, those Medicare clients under 65 years old are eligible for ELE under aid code 7S.

Note:

ELE cannot be based on Transitional or Expedited CF.

5.21.1 Aid Codes

• 7U is for adults aged 19 - 64 years old who are citizens or lawfully present and neither blind nor disabled.

• 7W is for children under 19 years old who are not blind or disabled and do not have full-scope no SOC MC.

• 7S is for Medicare clients under 65 years old, CF parents, legal guardians and caretaker relatives.

The definition of a parent, legal guardian, and caretaker relative for ELE is a CF adult client between 19 and 64 years old who:

• Has at least one child living in the home under 19 years old, and

• Is the parent/caretaker relative/legal guardian of that child(ren).

Note:

The child does not have to be on CF or MC in order for the parent, legal guardian, or caretaker relative to be considered a parent for ELE purposes. The child must only meet the age limit for a child and be in the home.

Clients who have been determined ineligible for APTC due to the Covered CA annual renewal process and have been referred to the county for an MC eligibility determination, have been processed through



AE pending a final MC determination. These clients will show active in MEDS. These clients have been enrolled in a Managed Care Plan and will receive a welcome packet from Managed Care.

5.21.2 DHCS Process

On February 3, 2014, DHCS sent notices to identified adult CF clients to inform them of their ELE eligibility. These notices allowed individuals (not households) to opt into MC.

CF clients were able to respond to the opt-in notice in three ways: completing and returning the notice in the postage paid envelope included, opting in by phone, or opting in by website. DHCS activated the records on MEDS and sent a welcome packet containing:

• Welcome letter (which also satisfies the (NOA) requirements)

• Multi-lingual notice

• NA BACK 9 for fair hearing rights

• List of county phone numbers

• Pub 68 – Medi-Cal What It Means to You

• Notice of Privacy Practices

5.21.3 County Process

If a CF client contacts the county and requests MC because they have received an opt-in notice or have heard about the ELE program, the EW must process an ELE eligibility by using the CF case and person number. ELE eligibility will show on the MEDS special segment screens (INQ1, INQ2, or INQ3).

Once the eligibility is reflected in MEDS, DHCS will send a welcome packet to the individual.

The table below describes the steps in CalWIN to complete an ELE for an existing CF case.

Table 5-24: CalWIN ELE Procedures

Step Action

1. Add a program to register a MC application (adjust the application date as needed).



5.21.4 CalFresh Discontinuance

If a CIC makes the individual ineligible for CF, the Request for Tax Household Information (RFTHI) must be sent to the client to do a MAGI MC eligibility determination. The individual will remain on the ELE aid code until the MAGI MC determination is completed. The two 10-day contact requirement applies. [Refer to “Two Contact Requirement,” page 11-2]

2. Go to Collect Case Summary Detail and enter Yes in the Express Lane [Y/N] field.

3. Run EDBC, review wrap up and authorize case. A MEDS online transaction is no longer required. The eligibility will be sent to MEDS.

4. Document actions in the Search Case Comments window, stating the individual attested to wanting MC based on their CF eligibility, making sure to clarify who is receiving ELE eligibility.

Table 5-24: CalWIN ELE Procedures

Step Action



If CF benefits are reinstated, the individual can also be reinstated to MC using the same ELE aid code the individual was previously on. This reinstatement must be done within 90 days. The MC renewal date continues to be counted from the month in which initial ELE eligibility was determined.

5.21.5 CalFresh Forms

CF 285

CF 285 allows CF applicants and clients to check a box on the form to indicate they would like the information they provided used to determine their eligibility for MC. This form can be used as an ELE application provided that the client is in an appropriate coverage group. ELE coverage begins the first day of the month the individual was determined eligible or recertified for CF.

SAWS 2 PLUS

Clients can request ELE by checking the “Medi-Cal Health Care” box in question 6 indicating to the county that they are interested in receiving MC coverage; they do not need to answer any other health care questions on the application.

CF 285 forms and SAWS 2 PLUS applications received where the client checked the “Medi-Cal box” are to be processed as follows:

Table 20: EW Process for ELE with CalFresh Forms

If the CF application or recertification is... Then...

Approved, • Ensure the individuals meets the ELE requirements.

• Enroll the individual(s) into MC via MEDS with the appropriate ELE aid code (7U, 7W, or 7S).

Denied, • The individual is not eligible to receive ELE MC.

• Initiate a MAGI MC eligibility determination by contacting the client by phone to get tax household information.

• When the tax household information is received, then determine MC eligibility.

5.21.6 Pending Applications

Pending Applications in CalHEERS: Counties will be sent a list of individuals who have pending cases in the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) who were also sent an ELE opt-in letter.

• If an EW cannot reach the client by phone, then mail the Request for Tax Household Information (RFTHI) form to the client. The EW must fill out a SAWS 1 to memorialize the date of application. This SAWS 1 will serve as the application date for the insurance affordability program.



If an individual has a pending CalHEERS case and is already active on an ELE aid code, the county should continue processing the pending case. If found eligible, the individual will then receive a MC aid code and no longer be part of the ELE program. If the individual is found ineligible for MC, the person must be discontinued. An appropriate NOA must be mailed to the client.

Pending Application in CalWIN: Use the existing CF case information to satisfy the needed verifications to complete the eligibility determination process on the pending application. The ELE option would not be used in this instance.

If a MC application is received for a client already active on ELE, the new application must be processed. If found eligible, the individual will then receive a MC aid code and no longer be part of the ELE program. If the individual is found ineligible for MC, the person must be discontinued. An appropriate NOA must be mailed to the client.

If the MC application is denied for Failure to Provide, then the client is to remain active with ELE eligibility.

5.21.7 Retroactive Coverage

Individuals enrolled in MC by means of ELE may be entitled to three months of retroactive coverage in the appropriate ELE aid code back to February 2014 when ELE was initiated by DHCS. The individuals must have had active CF benefits for the month in which retroactive coverage is requested.

Any request for retroactive coverage for a month before February 1, 2014, a MC application must be completed to do a full determination of benefits.

5.21.8 Redeterminations

For MAGI MC determinations before the 12th month of ELE eligibility. MEDS will send the standard renewal worker alerts during the individual’s 10th month of ELE eligibility. In the event eligibility is not determined before the 12th month, the record will be placed in a Burman hold and EWs will continue to receive MEDS alerts. The MC renewal data may not align with the CF recertification date.

5.21.9 Undocumented Individuals

ELE is only for documented individuals. Undocumented clients would need to complete an RFTHI and have a full determination of eligibility; however, documented members of the same family are eligible for ELE.

5.21.10 Inter County Transfers

Sending county should use an EW12 MEDS online transaction to update the address and county of residency. Receiving county should use an EW5 MEDS online transaction to update the county of responsibility



5.21.11 Notices of Action

No denial NOA is needed when an individual is already active under another MC program.

If clients do not qualify for ELE, or CF is terminated, we need to do a determination of eligibility and send the appropriate NOA based on that determination.

5.21.12 Frequently Asked Questions

Question 1: What is the process for verifying citizenship and identity for enrolled individuals?

Answer 1: For the most part, ELE individuals have undergone citizenship verifications related to their CF enrollment. In some cases, additional verification will be needed. For example, if an individual does not have a valid SSN, they will need to provide a valid SSN before enrollment into MC.

Question 2: How do we provide undocumented individuals ELE?

Answer 2: ELE is only for individuals with satisfactory citizenship and immigration statuses. If an individual with unsatisfactory status asks for ELE, the individual must complete an SCD 2350 and the EW must determine him/her for MAGI MC eligibility.

Question 3: If a CF application has documented children and undocumented parents, can we provide the children ELE and send the parents an SCD 2350?

Answer 3: Yes, the children can go on ELE as long as they meet the program requirements. The parents would need to complete the SCD 2350 and the EW must determine the parents for MAGI MC eligibility.

Question 4: After a 12-month period of ELE, if an individual is no longer eligible for MC (i.e. through a MAGI MC determination), will this trigger a special enrollment period for purchasing a qualified health plan (QHP) through Covered California?

Answer 4: A MAGI MC determination will be done after 12 months. Individuals will be eligible for a special enrollment period for purchasing a QHP offered by Covered California if they are determined not eligible for MC.

Question 5: If an individual is approved for ELE in the middle of the month, will they be on Fee-for-Service MC for that first month or enrolled in a MC Managed Care Plan?

Answer 5: They will be on Fee-for-Service the first month and Managed Care will start the following month.



5.22 Clients’ Right to be Evaluated for Non-MAGI

Although the MC Hierarchy shows that MAGI must be granted before Non-MAGI, clients do have a right to request a Non-MAGI evaluation.

Table 21: Process for Evaluating MAGI clients for Non-MAGI

If. . . Then. . .

A MAGI eligible client requests a Non-MAGI evaluation at intake (verbally or on an application)

Intake:

1. Approve MAGI per normal business process.

2. Send the client the Non-MAGI Screening Packet.

3. Transfer the case to Continuing.

Continuing:

If the client... Then...

Provides partial information, Request the missing information, allowing an additional 10 days. If the client still does not provide the missing verification, they will remain on the MAGI aid code.

Provides all information and the client is determined to be Non-MAGI eligible,

• Contact the client to inform them of their new eligibility.

• Mail appropriate NOA if there is a Share of Cost (SOC).

• Enter “Client Chose Non-MAGI” Special Indicator.• Check MEDS in two business days.• Make sure CalWIN, CalHEERS, and MEDS match.• Document actions in Search for Case Comments

window.

Provides all information and the client is determined not to be Non-MAGI eligible,

Contact the client to inform them they are ineligible to Non-MAGI and will remain eligible for the MAGI aid code.

Does not provide any information or attempt to contact the county,

The client will remain eligible for the MAGI aid code.

(Chart page 1 of 2)



A continuing MAGI eligible client requests a Non-MAGI evaluation,

Continuing:

1. Send the Non-MAGI Screening Packet.

2. Allow 30 days to Provide.


Provides partial information, Request the missing information, allowing an additional 10 days. If the client still does not provide the missing verification, they will remain on the MAGI aid code.

Provides all information and the client is determined to be Non-MAGI eligible,

• Contact the client to inform them of their new eligibility.

• Mail appropriate NOA if there is a SOC.• Enter “Client Chose Non-MAGI” Special Indicator.• Check MEDS in two business days.• Make sure CalWIN, CalHEERS, and MEDS match.• Document actions in Search for Case Comments

window.

Provides all information and the client is determined not to be Non-MAGI eligible,

Contact the client to inform them they are ineligible to Non-MAGI and will remain eligible for the MAGI aid code.

Does not provide any information or attempt to contact the county,

The client will remain eligible for the MAGI aid code.

A client who previously chose Non-MAGI is now requesting MAGI.

1. Evaluate the client’s eligibility for MAGI.


Is no longer eligible for MAGI, Inform the client that they are only eligible for the Non-MAGI aid code.

Is eligible for MAGI, • Approve the MAGI aid code. Contact the client to inform them of their new eligibility.

• End date the “Client Chose Non-MAGI” Special Indicator.

• Check MEDS in two business days.• Make sure CalWIN, CalHEERS, and MEDS match.• Document actions in Search for Case Comments

window.

Table 21: Process for Evaluating MAGI clients for Non-MAGI

If. . . Then. . .

(Chart page 2 of 2)



5.23 Medi-Cal Access Program

The Medi-Cal Access Program (MCAP) provides health care coverage to uninsured pregnant women and their newborns who have income between 213% - 322% FPL. There is no specific application for MCAP; any application that can be used to determine MC eligibility is sufficient to determine MCAP eligibility.

MCAP is determined by CalHEERS, if a client's income increases or decreases out of the MCAP eligibility range, they will be evaluated for other healthcare programs, or may be referred to the CalWIN ERD if there is no current CalWIN MC case for the client.

5.23.1 Processing MCAP Applications

Follow the procedures below for processing MCAP applications:

To apply for MCAP, a client can submit the SSApp, call and complete the application over the phone, go online to MyBCW or go directly to www.coveredca.com.

Table 5-25: MCAP Application Procedures

If... Then...

The application is incomplete (does not include all information required to process the application for eligibility and enroll the client),

• The client is notified that she has 17 calendar days to submit all required information, after which MCAP has 3 days to process and enroll.

• Do not forward the packet back to the provider.

• Contact the applicant to obtain any needed information or verification that is missing from the MCAP application packet.

The application is complete (includes all information required to process the application for eligibility and enroll the client),

• MCAP has 3 calendar days to process and enroll the applicant plus another 10 calendar days to notify the client's health plan.

• The client will receive a notice that she is enrolled in MCAP. The letter will provide the date health coverage starts. Coverage starts 10 calendar days after the date the application is approved.

• Once enrolled the client will receive an Evidence of Coverage (EOC) booklet and an insurance card from the health plan.

Income verification submitted is last year’s income tax records,

It may be used if the client states that his/her income remains the same; otherwise, request more recent information.

Updated information is not available, Document in the case file, but do not take any negative action or deny the application.

Updated information reflects an increase in the eligible pregnant woman’s income during her pregnancy or postpartum period, or a change in family status which would otherwise give the woman a SOC MC,

Do not take any negative action. The applicant is protected under Continued Eligibility (CE). The information may be compared against future income information obtained as part of the redetermination.



Continuing EWs are to follow the same procedures if any of the above forms are received on an active MC case.

[Refer to “MC Access Program (MCAP),” page 35-1] for additional information about MCAP.

5.24 Additional Children's Programs

For telephone numbers and location addresses, [Refer to “Inquiries and Resources,” page 4-1].

Healthy Kids

If a child under 19 years old is ineligible for no cost MC, EWs must explore eligibility for the Healthy Kids program. The net non-exempt family income must be at or below 300% FPL, and the child does not qualify for zero SOC, full-scope MC, including OTLIC (i.e. Undocumented children 267% - 300% FPL).

Valley Kids

If a child under 19 years old is ineligible for no cost MC, EWs must explore eligibility for the Valley Kids Program. The net non-exempt family income must be between 300% - 400% FPL, and the child does not qualify for zero SOC, full-scope MC, including OTLIC.

County Children’s Health Initiative Program

If a child under 19 years old is ineligible for no cost MC, EWs must explore eligibility for the County Children’s Health Initiative Program (CCHIP). The net non-exempt family income must be between

Updated information reflects a decrease in income from that shown on the previous year’s tax return,

No immediate action needs to be taken to calculate the woman’s income eligibility, as she already has no SOC.

The MCAP application is received incomplete,

• Do not forward the packet back to the provider.

• Contact the applicant to obtain any needed information or verification that is missing from the MCAP application packet.

The applicant is found ineligible for no SOC MC due to excess income,

• Make a note on the denial NOA that the application will be sent back to MCAP.

• Include a copy of the denial NOA with the reason why the applicant was determined ineligible for no SOC pregnancy-related MC with the referral to MCAP.

Table 5-25: MCAP Application Procedures

If... Then...



267% - 322% FPL, and the child CANNOT be eligible for zero SOC, full-scope MC, including OTLIC. (Undocumented children are not eligible for CCHIP.)

5.25 Children's Health Initiative

The Santa Clara County CHI is a local effort to make sure access to no cost or low cost comprehensive health, dental and vision coverage to all uninsured children in Santa Clara County whose net non-exempt family income does not exceed 322% FPL.

CHI was established through a collaborative partnership with SSA, Santa Clara Valley Health and Hospital Systems, Santa Clara Family Health Plan, Health Trust, Working Partnerships, PACT, Alum Rock School District, and others.

The goal of the CHI is that 100% of the children residing in Santa Clara County will have access to quality health care through comprehensive health insurance and that no uninsured child who is a resident of Santa Clara County, and whose parents have income at or below 322% FPL, will be turned away from receiving health coverage.

5.25.1 CHI Objectives

To make sure that our county's CHI goal is achieved, the application process has been simplified for families to expedite the enrollment of children into the appropriate health insurance plans.

Fast-Track Enrollment of Kids

Intake district offices must have procedures in place to make sure that families with children who are applying for MC only, are seen by an EW on the same day the application is filed.

Single-Point-of-Service

SSA district offices are a single-point-of-service for children's healthcare coverage. EWs are to determine what program is most advantageous to the child(ren). Determine eligibility for all programs, in the following order:

1. MC (Family's income at or below 266% of FPL)

2. CCHIP (family income between 266% to 322% of FPL) (citizen, nationals, and legal permanent residents only)

3. Healthy Kids (Family's income at or below 300% of FPL and child(ren) are not eligible for zero SOC MC.)



EWs are to assist the client with the application, as needed.

5.25.2 Role of the Intake EW

An Intake EW can assist applicants with both programs (CCHIP and Healthy Kids), by:

• Screening applicants for the appropriate programs based on the family's net non-exempt incomes.

• Assisting applicants, as needed, with the completion of the SSApp.

• Gathering verifications, if applicable.

• Determining the health insurance premium for Healthy Kids and/or CCHIP.

• Reviewing the application packet for completion and signatures.

AND

• Assembling the application packet and ensuring it is forwarded to the appropriate location for an eligibility determination for Healthy Kids (Santa Clara Family Health Plan).

OR

• Completing the application in CalWIN to determine CCHIP eligibility (2C aid code) through Covered California (Children's Health Initiative in Santa Clara County).

5.25.3 Application Forms and Verifications

CHI Release of Information Form

The SCD 115 form must be included in every MC intake packet. Both the EW and the client must sign it. This form enables EWs to share specific eligibility information with Santa Clara Valley Health and Hospital Systems for MC and Santa Clara Family Health Plan regarding the Healthy Kids application. It must be completed annually.

Other Forms and Verifications

• Verification of income

• Verification of income deductions

• Verification of California residency



• Verification of Immigration Status (allow up to 90 days)

• Social Security Number (allow up to 60 days)

• Pregnancy verification

• Assist the client with completion of the application process. The Healthy Kids application must NOT be mailed to applicants to complete on their own.

5.25.4 Adding Other Family Members

Any verbal or written request for MC is considered to be an application, therefore:

• Obtain all required forms and verifications

• Issue all mandated informing notices

• Issue an approval or denial notice for the applicable program.

5.25.5 Healthy Kids

Healthy Kids is a public-private partnership that is locally funded. EWs must explore eligibility for Healthy Kids AFTER a child has been determined to be ineligible for MC. Adults are not eligible for Healthy Kids.

Children who only qualify for restricted MC benefits may qualify for Healthy Kids; however, children who receive full-scope MC with a SOC are ineligible.

Eligibility Criteria

Eligibility for Healthy Kids depends on the child's age, residency status, family size and income, which must meet the following criteria:

• Child resides in Santa Clara County

• Child is under 19 years old.

• Net non-exempt family income is at or below 300% FPL.

• Child is NOT eligible for Zero SOC, full-scope MC.

• Child is NOT eligible for CCHIP.



Note:

There is no property requirement for this program.

Benefits

Children enrolled in Healthy Kids are members of Santa Clara Family Health Plan, and receive their health care services through the plan's network of doctors, clinics, and hospitals.

Healthy Kids insurance provides full medical coverage including prescriptions, inpatient care, office visits, preventive services, well-baby care, dental care, vision services, mental health, and alcohol/substance abuse care.

Premiums and co-payments apply.

EW Requirements

EWs are required to:

• Screen and assess eligibility for the appropriate program(s).

• Assist the client with completion of the application process. The Healthy Kids application must NOT be mailed to applicants to complete on their own.

• Forward the application to SCFHP for Healthy Kids if family income is between 250% - 300% FPL and consent is given.

Note:Note:The client or EW can contact SCFHP at 1-877-688-7234 to schedule an appointment for the client to meet with a Certified Application Assistor to complete an application or renewal.

• Make sure that the application is complete and signed by the applicant and the EW.

• Assist the client with obtaining required documents, i.e. proof of income and residency, as needed.

• Provide information about coverage, co-payments, premium payments, incentives for paying premiums on a quarterly or annual basis, and that premium assistance is available to some families. The family's share of the monthly premium is $4-6 per child, with a maximum of $12-18 per family.

• Assist in the selection of a provider.



• Inform the client that it is important to maintain health insurance. Address and phone number changes must be reported to Santa Clara Family Health Plan and an annual redetermination form will be required.

5.25.6 Healthy Kids Process

EWs must follow the process below after a MC eligibility determination is completed (in Intake or Continuing) and a child under 19 years old is found to be:

• Ineligible for MC

• Eligible for MC with a share of cost (SOC)

Table 5-26: Healthy Kids Procedures

Step Action

1. Compare the countable household income to the FPL income limits for Healthy Kids program.

2. If the child is potentially eligible for Healthy Kids based on income and age factors, then explain this to the applicant and offer application assistance.

3. Assist the applicant to:

• Complete the appropriate application form (SSApp), if not previously completed.

• Select a health plan provider.

• Understand the premium requirements and amounts (including the Healthy Kids Hardship Fund, if appropriate).

• Understand the Healthy Kids Wait List implications for children over 5 years old.

4. Print any documents/verifications from IDM that will be required by the Healthy Kids programs.

5. Review the application for completeness and make sure that the application is signed by both the applicant and the EW.

6. • Instruct the applicant to mail the application to the appropriate program.

Note:If working with a mail-in application or a redetermination by mail, this step may occur by phone and an appointment scheduled for the application assistance.

Note:Healthy Kids applications do not require that premium payments be included with the application due to the wait list. Healthy Kids will bill the family for the appropriate amount.



5.26 Express Enrollment for Children in the National School Lunch Program

5.26.1 Overview

National School Lunch Program (NSLP) allows children who are approved for free school lunches to apply for MC using the information on the NSLP application.

A modified NSLP application along with a supplemental form can be used to determine eligibility for MC. Our agency must accept and process NSLP applications from schools who wish to participate.

The Santa Clara County Social Services Agency has an agreement with the Campbell and East Side Union High School Districts to process the modified NSLP applications for MC eligibility and complete Express Enrollment for qualified children.

At this time, no other school districts in Santa Clara County are participating in this program. Since MC enrollment through the NSLP application is time-limited, EWs at the Medi-Cal Benefits Assistance (MBA) office process these applications.

5.26.2 Express Enrollment Definition

Express Enrollment is temporary, expedited full-scope healthcare coverage for children up to 19 years old, who qualify to receive free meals through the NSLP. Express Enrollment continues until a determination of eligibility for regular MC is made.

5.26.3 NSLP Application Process

The NSLP provides either free or reduced price meals based on household size and family income. Income is self-declared and no income verification is required. Alum Rock School District Child Nutrition Services (CNS) will inform the family of the child's eligibility for the NSLP or denial within 10 calendar days of receipt of the application.

The Alum Rock School District (ARSD) Child Nutrition Services (CNS) mails an NSLP application to all families a few weeks before the start of the school year. Families must complete, sign and return the NSLP application for an eligibility determination. In order for children to be considered for Express Enrollment, a parent/caretaker relative must consent to the sharing of personal and financial information contained in the modified NSLP application by signing the optional MC benefits section of the application.

• Families with household income at or below 130% FPL qualify for free school lunches.



• Families with household income at or below 185% FPL qualify for reduced-priced lunches.

5.26.4 Modified NSLP Application Form

The NSLP application has been modified to include information needed for a determination of MC eligibility:

• The child's birth date

• The child's income

• The relationship of all household members to the child for MFBU determination

• The income and family size of CF and Food Distribution Program on Indian Reservation (FDPIR) clients

• A signature line for the parent/caretaker relative to provide signed consent to sharing of information on the NSLP form for a MC determination

• A signature under penalty of perjury statement

5.26.5 Income Verification for Express Enrollment

The modified NSLP application serves as income verification for determining MC eligibility of a child enrolled through the Express Enrollment process. Income is self-declared and no income verification is required. However, IEVS information must be used to verify income when a Social Security Number is available.

Verification of income is required only when the EW determines there is a discrepancy in the reported income, including when:

• A change is reported during or after the MC determination,

• IEVS discrepancies need clarification,

• Retroactive MC coverage is requested,

• Income was not reported on the NSLP application, or

• Other family members are requesting MC.

Parents are not required to provide Social Security Numbers unless they are requesting MC for themselves.



5.26.6 Express Enrollment Process

The school has sole authority to certify a child for Express Enrollment using the information provided on the modified NSLP application. Once the certification is made, the school notifies the parent/caretaker relative that the child is certified for temporary MC and forwards the application to Social Services Agency for a MC determination.

Activation on MEDS

WITHIN 5 DAYS of receipt of the NSLP application, Social Services Agency must:

• Complete CalWIN and MEDS file clearance procedures,

• Complete an AP 18 transaction to report the application information and school determination date to MEDS, and

• Activate aid code 7T on MEDS.

Date of Application/Enrollment

• The Express Enrollment date is the date the school determined eligibility.

• The application date is the date the application is received at Social Services Agency.

Ineligible Children

Children in the following categories are not eligible for Express Enrollment:

• Children who are already receiving MC benefits through an active CW or MC case, or through SSI.

• Children whose NSLP applications lack sufficient information for the school to make a determination for Express Enrollment.

• Children with family income exceeding the income limit.

Note:

These applications are to be processed for other MC programs.



Required Supplemental Forms/Notices

When a modified NSLP application is received by SSA, the following informing notices and request for information must be sent to the family:

• “Notice and Supplemental Form for Express Enrollment Applicants” (MC 368) - The MC 368 includes a check box indicating the child's Express Enrollment status and is also a request for additional information necessary to complete the MC eligibility determination.

• “Important Information for MC Applicants” (MC 368 Attachment) - The MC 368 A includes the applicant's Rights, Responsibilities and Declarations, the MC Confidentiality Notice, and the MC Privacy Notice.

• MC 003

• Health Care Options Flyer

• CHDP Brochure

• WIC 2

• Other forms as applicable

Information NOT Required

• MC 13

• MC 219

• CW 2.1 (Q) and CW 2.1 Notice and Agreement

Note:Note:Medical Support forms are given to the parent(s) for completion; however, if only the child(ren) are active, no action is taken if they are not completed and returned. Cooperation with medical support enforcement is required if the parent(s) want MC.

• Proof of California Residency

• Verification of Income

• Verification of Allowable Income Deductions



Note:

Income deductions are not allowed unless verification is provided; therefore, income deductions may be requested to bring the family income within the FPL limit (if applicable).

Fair Hearing Rights

There are no fair hearing rights or NOA requirements during the Express Enrollment period. However, once an eligibility determination is made for regular MC, the appropriate NOA must be sent to either approve or deny the application, and fair hearing rights apply.

5.26.7 MC Eligibility Determination

The MC eligibility determination requirements (including timeframes for providing forms and verifications) have not changed. EWs must first evaluate the child for eligibility under the applicable FPL program.

Express Enrollment (7T) continues until a MC eligibility determination is completed by the EW. Since MC applications must be processed within 45 days, it is expected that Express Enrollment will not exceed two months.

Since the Express Enrollment period is temporary and is NOT considered a MC determination, children in aid code 7T must have an eligibility determination for zero SOC MC before CEC applies.

Other Family Members Requesting MC

When other family members request MC they are NOT required to complete the SSApp. However, the necessary information must be requested for the other family members. Once sufficient information is provided to determine eligibility under all MC programs, all necessary verifications and requirements must be met.

Request for Retroactive Benefits

The requirement to complete a “Supplement to Statement of Facts Request for Retroactive MC Eligibility” (MC 210 A) has not changed. Income verification is required for all requested retroactive months (if appropriate). Eligibility for retroactive months is based on the date the NSLP application is date-stamped as received by a Social Services Agency district office.



Required Actions

EWs must take the following steps upon assignment of an NSLP application:

Table 5-27: NSLP Application Procedures

Step Action

1. Complete one MC 368 for each child listed on the NSLP for whom MC is requested.

2. Mail the request for information forms (MC 368, MC 368A) and applicable informing notices (MC 003, Managed Care Flyer, CHDP Brochure, WIC 2) to the parent/caretaker relative.

When the MC 368 is returned, EWs must:

1. Determine immigration status of each child to determine scope of coverage.

2. Determine eligibility for MC, using the information on the NSLP application.

3. Complete the appropriate CalWIN windows.

4. Mail the appropriate NOAs. If the child does not qualify for full-scope, zero SOC MC, send a referral flyer to the Alum Rock School District Health Care Outreach Program Coordinator.

5. Review MEDS to make sure the appropriate aid codes are active.• If approved, MC is active and aid code 7T is terminated. • If denied, MC is not active and aid code 7T is terminated.

6. Follow up with the family if Retro MC is requested or if the MC 368 indicates that other family members wish to apply for MC.Collect the required supplemental forms and verifications and determine eligibility based on current rules and processes.

7. Document actions in the Search Case Comments window and make sure all documents are scanned into IDM appropriately.

When the MC 368 is NOT returned, EWs must:

1. Conduct follow-up activity (i.e. phone or written contact to the family). Allow a minimum of 10 additional days for the family to submit the required information.

2. Send NOA and a referral flyer to the Alum Rock School District Health Care Outreach Coordinator.

3. Document actions in the Search Case Comments window and make sure all documents are scanned into IDM appropriately before submitting case to the EW Supervisor for transfer to closed files.

Note:Follow-up action may be required if the MC 368 is returned incomplete.

Note:If the family indicates that they are working to meet the requirements as requested by the EW, additional time must be allowed.



5.27 Public Guardian Cases

If it is discovered that the applicant is under conservatorship, the conservator must be contacted to inform them that the client has attempted to apply.

5.27.1 General Information

The Public Administrator/Guardian/Conservator office makes applications for MC (and possibly GA) for persons who have been “conserved” by the county court system.

The court names the Public Guardian as the “guardian” or conservator of these clients because they are unable to conduct their own legal affairs.

The Public Guardian's office is located at:

333 W. Julian St. - 4th Floor San Jose, CA 95110 Phone: (408) 755 - 7610

Mailing Address: P.O. Box 760 San Jose, CA 95106

5.27.2 EW Procedures

1. The EW determines eligibility from the information contained in the packet and from verifications supplied by PAG/C. A face to face interview is not required. The application is held in pending status until all verifications are received. For RDs, completed forms must be returned by the end of the indicated redetermination month, or eligibility will be discontinued.

2. Completion of the “Responsibilities of Public Guardian/Conservators or Applicant/Beneficiary Representative” (DHCS 7068) form is required when an applicant has a public guardian, conservator or a representative acting on his/her behalf, due to the incompetence of the client.

3. Eligibility Reminders:

a. The county of residence for application procedures is the county where conservatorship is assigned by the court.

b. Property owned by the applicant or client is treated or counted the same as for any other applicant or client.

c. Parental responsibility is not considered when a conservatorship exists.



4. All required informational notices must be sent to each Public Guardian to keep them informed of their reporting responsibilities, changes and additional information about MC eligibility.

5. When the client is determined to be eligible, the EW sets up the payee as “Public Guardian for (client's name)”.

5.27.3 Referrals to Public Guardian

The laws governing referrals to the Public Guardian's Office are very complex and require a number of forms to be completed. A “Capacity Declaration” from a medical doctor or psychiatrist declaring the person to be in need of a conservator and a request for a court hearing to determine capacity is required. Due to the complexity of the referral process, the social workers at the hospitals initiate these referrals. EWs do not refer individuals to the Public Guardian's Office for conservatorship.

When there is a valid reason to believe a client is being abused or neglected, the EW must complete an “Adult Protective Services” (APS) referral.

5.27.4 Guardian and Conservator Fees

Fees paid to a court-appointed guardian or conservator are allowable deductions from unearned income when computing the SOC of an aged, blind, or disabled medically needy individual if certain conditions are met.

Note:

Paper verification of fees is required before allowing deductions.

[Refer to “MN/MI and Non-MAGI MC MFBU,” page 19-1]

5.28 Presumptive SSI and Extended MC

Presumptive SSI clients are able to receive zero SOC MC benefits for up to six months from the date Presumptive Disability is approved while the Social Security Administration (SSA) makes a formal disability determination.

When an SSI/SSP applicant is approved for Presumptive Disability and then denied (after a formal disability determination), and a timely appeal is requested, SSI-based MC MUST be extended throughout the entire Social Security Administration appeal process.

A presumptive SSI client who is found NOT to be disabled during the formal disability determination process is terminated on MEDS with a denial code, instead of a discontinuance code (N07 Cessation of Disability).



When a denial code is used, MEDS cannot automatically identify and track these individuals for extended zero SOC MC eligibility, as it does for N07 individuals.

5.28.1 Identification of Presumptive SSI Individuals

Presumptive SSI clients are identified by the following information on MEDS:

Table 22: MEDS Screens for SSI Individuals

Screen Field Description

INQM AID-CODE Aid code “60” will appear (with a time period of one to six months.)

INQX DISABL-PAYMENT-CD A letter “P” will appear if the client was approved for Presumptive Disability by Social Security Administration.

INQP APPEAL-LEVEL Should show a recent denial date and the denial reason. The appeal date for these clients should be a date that is after the date of the denial.Example: If there is a denial code of “N32” and a denial date of 08/02/07, then if the client had requested an appeal with Social Security Administration, the appeal date should usually be within 65 days of the denial date.

5.28.2 Referrals to the DHCS

Individuals meeting the criteria listed below must be referred to the DHCS for potential extended zero SOC MC eligibility:

• Self-identified individuals as a presumptive SSI client who was found NOT to be disabled during the formal disability determination, OR

• A MC applicant whose MEDS record indicates a short period of SSI eligibility (six months or less) AND an SSI denial code (not a discontinuance code).

The following actions occur when an individual meeting the criteria listed above is referred to DHCS:

Table 5-28: Referrals to DHCS

Step Who Action

1. EW Refers the client (name and SSN) to the district office MC Liaison, noting “Presumptive Disability approval/denial, appeal pending with Social Security Administration.”

2. MC Liaison Forwards the information to the MC Program Coordinator.

3. MC Program Coordinator

Forwards the information to DHCS by contacting the MC Disability Unit.



5.28.3 DHCS Responsibility

DHCS must manually issue extended zero SOC MC to these clients. DHCS also sends a notice informing the clients that their SSI-based MC eligibility has been restored.

During the period that the SSI appeal is pending with SSA, MC eligibility will be under State control.

4. DHCS Confirms with SSA that:

• The individual received presumptive SSI, and

• The individual was found NOT to be disabled in the formal disability determination process.

• The disability determination is not yet “final.”

If the information is... Then DHCS...

Confirmed, • Activates extended zero SOC MC, and

• Tracks the client’s SSA appeal status on MEDS until the disability decision becomes “final.”

Not Confirmed, Does not activate extended zero SOC MC or track the appeal status.

• Informs the MC Program Coordinator of the action taken.

5. MC Program Coordinator

Forwards the information from DHCS to the MC Liaison.

6. MC Liaison Forwards DHCS information to the EW.

7. EW Takes the appropriate action to approve/deny MC.

If DHCS... Then the EW must...

Activates the extended zero SOC MC,

Deny MC.

Does not activate extended zero SOC MC,

• Process the application to determine MC eligibility.

• Approve/deny as appropriate.

Reminder: Social Security Administration disability decisions are binding for MC. A MC applicant who has been denied SSI within the last 12 months must be screened to determine if a DDSD referral should be completed.

Table 5-28: Referrals to DHCS

Step Who Action



5.29 Foster Care Program, Former Foster Youth and Adoption Assistance Program

[Refer to Chapter 34, "Medi-Cal”] of the Foster Care Handbook.

5.30 Medically Indigent Adult in Long Term Care

Individuals who qualify for MC under aid code 53, must be:

• In an acute care hospital,

• Otherwise ineligible for MC,

• Expected to remain in long term care (LTC) for more than 30 days, and

• Ready to be transferred to an LTC facility.

[Refer to “Medically Indigent Adults,” page 24-9]

5.30.1 MIA LTC - Intake

The following must occur for an Medically Indigent Adult (MIA) LTC (aid code 53) application:

Table 5-29: Intake MIA LTC

Who Action

Hospital Case Manager Contacts Intake Information Supervisor to inquire if the client has an application pending.

Intake Information Supervisor • Explains that an application must be on file if one is not already pending.

• Requests SCD 41 and SAWS 1 from Hospital Case Manager.

• Explains the process will take a minimum of 24 hours before a card can be issued.

• Refers information to Screener.

Screener • Meets patient in hospital.

• Gathers necessary paperwork.

• Returns paperwork to clerical at MBA.



5.30.2 MIA LTC - Continuing

When the case has already been set up at Intake and is pending a DDSD decision from Los Angeles, the following procedures apply:

Clerical • Receives paperwork.

• Completes application registration in CalWIN.

• Assigns case to an EW.

EW • Receives case assignment.

• Initiates Intake workflow window in CalWIN.

• Runs EDBC and authorizes aid code 53.

• Completes SCD 1296 to initiate immediate need MC card.

• Submits case to supervisor for immediate review.

EW Supervisor • Receives and reviews case.

• Forwards case to clerical or returns to EW for corrections, as appropriate.

Clerical • Receives case.

• Performs all clerical functions to transfer case.

• Scans into IDM.

Table 5-30: Continuing MIA LTC

Who Action

Hospital Case Manager Contacts Continuing Information Supervisor to inquire if a card may be issued.

Continuing Information Supervisor • Requests the Hospital Case Manager fax verification to 793 - 1875.

• Forwards request to BSC LTC unit.

• Notifies Continuing EW that an aid code 53 is going to be necessary.

Case Manager • Completes necessary paperwork.

• Makes arrangements with LTC facility to transport patient to facility and reserves bed.

• Faxes verification to district office.

Clerical • Receives fax.

• Forwards verification to Continuing EW.

Table 5-29: Intake MIA LTC

Who Action



5.31 San Andreas Regional Center

Home Community Based Services (HCBS) are referrals from San Andreas Regional Center (SARC). SARC is a state waiver program. The majority of the applicants are disabled children. Although the children are disabled, they are typically treated as Medically Indigent Children (MIC) and set up on a 6V aid code.

The parents must list their property and income on the application because the EW must screen for no SOC MC first. If the child is ineligible for no SOC MC, the SARC waiver applies.

Note:

OTLIC MC with premiums are considered no SOC MC (i.e. T1, T3, etc.).

5.31.1 SARC Special Treatment

SARC applications are treated differently than other MC applications as follows:

• The income and resources of the parents are not considered.

• The other family members should NOT be pended in the SARC case.

• If other family members are requesting aid, then separate cases are required.

• IEVS should only be requested for the child, not the parents.

• The parents must list their property and income on the application because a determination must be made that the client would not be eligible for a no SOC MC without deeming.

Continuing EW • Receives case assignment.

• Verifies the client is expected to stay at least 30 days in the LTC facility.

• Receives verification.

• Updates CalWIN.

• Runs EDBC and authorizes aid code 53.

• Completes SCD 1296 to initiate immediate need MC card.

Table 5-30: Continuing MIA LTC

Who Action



5.31.2 SARC Aid Codes

Children are in their own separate case. Aid codes are as follows:

• 6V (no SOC), or

• 6W (SOC).

Note:

If there is more than one referred child in the family, each one is in a separate case.

[Refer to “Model IHO Waiver,” page 36-8] for more information.

5.31.3 Medi-Cal Benefits Assistance Application Process

The “Department of Developmental Services Waiver Referral” (DHCS 7096) form will be attached to the appropriate CalWIN and MEDS screens, along with an informational notice that must be sent to the clients.

The following must occur with SARC applications:

Table 23: MBA SARC Application Procedures

Who Action

Designated SARC Employee Sends the DHCS 7096 form to MBA district office email.

Clerical Staff • Retrieves the DHCS 7096.

• Sends the informational notice to the parents along with application packet.

• If parents return the packet, completes application registration in CalWIN.

• Creates and assigns TMT to EW for processing.

• If packet is not returned, then sends 2nd notice.

EW • Initiates Intake workflow window in CalWIN and evaluates for MAGI MC first, before the special waiver program.

• Mails NOA(s).



Note:

All SARC cases are to be transferred to BSC.



5.32 Tuberculosis Clinic Applications

The following procedures apply when a client is referred to the Tuberculosis (TB) Clinic:

Table 5-31: TB Application Procedures

Who Action

Client • Receives TB services from the Park/Alameda Clinic.

• Meets with the Financial Counselor to complete MC 274 TB, SCD 41, and MC packet.

Financial Counselor • Meets with the client to complete the MC 274 TB, SCD 41, and MC packet.

• Prepares the packet and delivers to 650 S. Bascom Ave. to process.

Clerical • Receives MC packet including MC 274 TB and SCD 41.

• IDs case and completes application registration in CalWIN.

• Creates and assigns TMT to EW for processing.

EW • Receives TB application.


• Approves or denies application.

• Mails NOA(s).



[Refer to “Tuberculosis Program,” page 37-8] for complete details on the TB program.

5.33 Therapeutic Abortions

Therapeutic Abortions (TABs) applications are considered priority one emergency applications and are processed as follows:

Table 5-32: TAB Application Procedures

Who Action

Client Applies for MC and indicates an abortion is needed.

Clerical • Provides client with an SCD 41 and SAWS 1.

• Explains client must complete paperwork in office.



5.34 Partners in AIDS Care and Education

SSA has made special arrangements with the Partners in AIDS/HIV Care and Education (PACE) Clinic. When patients are seen at PACE and the patient is diagnosed with AIDS/HIV, the Medical Admitting Clerk will:

• Complete an SCD 41 and SAWS 1.

• Page the Screener and coordinate the appointment with the Screener to make sure the client is seen immediately.

The Screener will meet the patient at the clinic and complete a BCW application.

Client • Receives paperwork.

• Completes forms indicating that an abortion is needed.

• Submits paperwork to clerical.

Clerical • Receives SCD 41 and SAWS 1.

• Performs application registration in CalWIN.

• Performs case assignment in CalWIN.

• Provides assigned EW with necessary paperwork and screens.

EW • Receives application.

• Processes application as immediate need.


• Runs EDBC and approves/denies MC, as appropriate.

• Sends appropriate forms to IDM.

• Submits to Supervisor for review.

EW Supervisor • Receives and reviews case.

• Submits to clerical for transfer or returns to EW for corrections, as appropriate.

Clerical • Receives case.

• Scans into IDM.

• Makes necessary entries in CalWIN to transfer case.

Table 5-32: TAB Application Procedures

Who Action



5.35 Renal Dialysis

Renal Dialysis applications are to be treated as priority one applications. Patients receiving Renal Dialysis need immediate attention, as their lives depend on renal dialysis for survival. When patients are seen for Renal Dialysis, the Medical Social Worker will:

• Complete an SCD 41 and SAWS 1.

• Fax the paperwork to MBA.

• The paperwork is processed by clerical staff and handed off to the Screener.

The Screener will meet the patient at the clinic and complete a BCW application.

5.36 Organ Transplant Anti-Rejection Medication Program

Assembly Bill (AB) 2352, Chapter 676, Statutes of 2010 added section 14132.70 to the Welfare and Institutions Code to allow MC recipients to remain eligible to receive coverage for anti-rejection medications for up to two years after a transplant, unless the he/she becomes eligible for Medicare or private health insurance that covers the anti-rejection medications.

5.36.1 Eligibility Requirements

In order to be eligible for this program, the client must meet at least one of the following criteria:

• Had an organ transplant within two years and is losing MC and/or California Children’s Services (CCS) AND does not have Medicare or private health insurance that covers anti-rejection medications, OR

• Had an organ transplant within two years and is only eligible for restricted scope MC, is not on CCS, AND does not have Medicare or private health insurance that covers anti-rejection medications.

Note:Note:No verification is required as to who paid for the organ transplant, as the payer is not relevant to eligibility for this program.

• There are no income, property, or residency/citizenship requirements for this program regardless of their living arrangements or with whom they reside.



• An annual redetermination and/or Midyear Status Report is not required. Clients will remain on this program for up to two years from the most recent organ transplant, unless they obtain Medicare or private health insurance that includes the anti-rejection medication.

Note:

A Redetermination due to change in circumstances (i.e., Medicare, private health insurance, move out of state, eligibility for another MC program or death) is still required.

Identifying Eligible Beneficiaries

The Department of Health Care Services (DHCS) will research the claims data and identify the beneficiaries who have had an organ transplant paid by MC and will send an informing notice to advise them of the new program.

DHCS will send a list of organ transplant beneficiaries to each county. These cases must be flagged to determine eligibility for this program before the client is discontinued by entering a Special Indicator.

If the client is not on the DHCS list, but indicates on the MC 210 RV or states verbally that he/she received an organ transplant, the EW must request a note from the treating physician on letterhead with the National Provider Identifier (NPI) stating that the individual had an organ transplant and the date of the transplant.

Eligibility Determination

• When a client is no longer eligible for MC, the SB 87 process must be completed to determine if eligibility exists for another MC program. If the individual is not eligible and has had an organ transplant, he/she must be placed in this program. A ten-day NOA is required.

• Undocumented children who are eligible for the California Childrens Services (CCS) program may be eligible for the anti-rejection medications program if they meet all the criteria (within two years of transplant). CCS only pays for the organ transplant and anti-rejection medication until the child ages out of CCS.

• There may be other exceptions where a individual on restricted MC has received a transplant and MC does not pay for the anti-rejection medication. These beneficiaries should be placed in this program.

• If the client has private health insurance, the EW must determine whether the insurance covers the medication. If the client states that the medication is not covered, verification must be provided. Verification can include the following:

• Summary of benefits showing anti-rejection medications are not covered.• Letter from the insurance company stating the medications are not covered.• Documentation that the transplant and/or related benefits are in a period of exclusion.



• Documentation showing the client has exhausted his/her lifetime limit on all benefits under the plan.

• Documentation showing the client’s coverage or his/her annual benefits for treatment of the organ transplant have been exhausted.

• Any other documentation that states anti-rejections medications are not covered.

5.36.2 Notices of Action

The Following Notices of Action (NOAs) are used for this program:

1. “Approval For Organ Transplant Anti-Rejection Medication Program” (MC 378). The NOA must include the time period for which the individual is eligible.

2. “Discontinuance For Organ Transplant Anti-Rejection Medication Program” (MC 379).

5.36.3 MEDS Transactions

Aid Code 77 provides State-only restricted scope MC coverage with no share of cost (SOC) for organ transplant anti-rejection medications, for up to two years following an organ transplant, to individuals who have lost regular full scope MC or are on restricted scope MC. Aid Code 77 does not cover physicians’ office visits.

An online MEDS Transaction is required to place the individual in Aid Code 77. A termination date is required. The termination date will be two years from the most recent transplant date, regardless of when they become eligible for the program.

Example:

individual had an organ transplant on April 1, 2010 and found eligible for Aid Code 77 on March 1, 2011. The termination date is March 31, 2012.

Note:

An EW 20 transaction with an ESAC for closed eligibility must be sent to limit the services up to 24 months. If the transaction covers more than 24 months, a MED Alert 1094 [Displayed Data Elements Contain Conflicting Information Pre-Rej*] will be generated.

MEDS Alerts

There are two MEDS alerts that will be generated when Medicare or other health insurance is obtained by the individual:



1. ALERT 9061 - MEDICARE ELIGIBLE – COUNTY AID CODE TERMINATION NEEDED - URGENT The criteria for generating this alert will be any establishment of pending eligibility in the Medicare status Part A/B and any pending eligibility in the Medicare Status – Part D.

2. ALERT 9062 - POSITIVE OHC REPORTED – COUNTY AID REEVALUATION NEEDED - URGENT The criteria for generating this alert will be the establishment of other health coverage on the MEDS record in the current OHC field.

5.37 SSI/SSP Denial Applications

Effective July 1, 2009, Supplemental Security Income/State Supplemental Payment (SSI/SSP) applicants who were denied by Social Security Administration (SSA) due to excess income are referred to the county via Daily MEDS Alert 9043 to complete Medi-Cal eligibility determination, including Medicare Savings Programs. These referrals are considered new Medi-Cal applications which will be processed back to the date of the SSI/SSP application.

For SSI/SSP Denials application procedures, refer to Common Place Handbook Chapter 57, section 57.1.11.

5.37.1 Date of Application

The date of application for Medi-Cal is:

• The original SSI/SSP application date,• The denial date when the application date is a future date(e.g. applicant applies as aged but is

64 years 9 months of age), • The date California residency began if later than the SSI/SSP application date, or• The initial Medi-Cal application date when the case is currently pending.

Note:

When the residency date is a later date, the EW must clarify with the client the actual residency date. The client’s statement is acceptable.

SSI/SSP Denials Medi-Cal Packet

The following forms must be sent to the SSI Denials individual:


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/cp/cpchap57.pdf


• MC 219 - Important Information for Persons Requesting Medi-Cal,• MC 210 PS - Property Supplement,• MC 007 - Medi-Cal General Property Limitations,• MC 003 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Brochure,• SCD 2350 - Request for Tax Household Information (RFTHI),• SCD 1264 - Language Survey• SCD 508 - Would You Like to Register to Vote?• DHS 7077 - Notice Regarding Standards for Medi-Cal Eligibility,• DHS 7077-A - Notice Regarding Transfer of a Home for Both a Married and an Unmarried

Applicant/Beneficiary, and• Pub 68 - Medi-Cal “What It Means To You” Brochure.

5.37.2 MEDS Screens

The EW can access the following [ISDX] MEDS screens and use the SSI/SSP applicant’s information, on these screens to determine eligibility. When the information found in MEDS is incomplete, unclear, inconsistent or contradictory, the EW should request further information and verification from the applicant.

• [SDX1] - SDX Inquiry - Client Data From MEDS• [SDX2] - SDX Inquiry - Client Address Data From MEDS• [SDX3] - SDX Inquiry - Client Information (displaying the SSI Application Date)• [SDX4] - SDX Inquiry - Client Income/Status Data • [SDX5] - SDX Inquiry - Household Information

To access above screens, log in to MEDS, clear the screen and type, ISDX.

[Refer to MEDS Handbook Chapter 1 for more information on ISDX screens.]



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