Santa Clara County Social Services Agency page 1 Date: 09/16/15 References: ACWDL 15-01 & ACWDL 15-05 Cross-References: N/A Clerical: No Handbook Revision: No Update 2015-25: Medi-Cal Transitioning from Covered California Coverage to Medi-Cal Background The Department of Health Care Services (DHCS) has coordinated an interim transition process with Covered California for individuals that are found potentially eligible for the Medi-Cal (MC) program as a result of the Covered California annual redetermination process that began in early October 2014. These batches continue to occur monthly for individuals transitioning from Covered California programs to MC when there is a reported change of circumstance, such as income, until the implementation of an automated process to transition cases from Covered California to MC. Policy Covered CA redetermined the eligibility of qualified individuals enrolled in Covered CA programs during the annual redetermination period or a reported change in circumstance. As a result of this process, individuals may become eligible for MC and their case must be evaluated. Covered CA Annual Redetermination Process For the 2015 benefit year, Covered CA started processing their clients’ redeterminations in early October 2014. Clients had 34 days from the date of their annual redetermination notice (NOD12) to actively complete their annual redetermination through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). If clients did not actively complete their annual redetermination by the 34th day after their redetermination notice date, Covered CA automatically re-enrolled clients into their current plan for the 2015 benefit year. If clients do not want the plan they were automatically enrolled in by Covered CA, then they have the ability to change their plan during Open Enrollment.
Transcript
Santa Clara County Social Services Agency page 1
Date: 09/16/15
References: ACWDL 15-01 & ACWDL 15-05
Cross-References: N/A
Clerical: No
Handbook Revision: No
Update 2015-25: Medi-CalTransitioning from Covered California Coverage to Medi-Cal
Background The Department of Health Care Services (DHCS) has coordinated an interim transition process with Covered California for individuals that are found potentially eligible for the Medi-Cal (MC) program as a result of the Covered California annual redetermination process that began in early October 2014. These batches continue to occur monthly for individuals transitioning from Covered California programs to MC when there is a reported change of circumstance, such as income, until the implementation of an automated process to transition cases from Covered California to MC.
Policy Covered CA redetermined the eligibility of qualified individuals enrolled in Covered CA programs during the annual redetermination period or a reported change in circumstance. As a result of this process, individuals may become eligible for MC and their case must be evaluated.
Covered CA Annual Redetermination Process
For the 2015 benefit year, Covered CA started processing their clients’ redeterminations in early October 2014. Clients had 34 days from the date of their annual redetermination notice (NOD12) to actively complete their annual redetermination through the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS).
If clients did not actively complete their annual redetermination by the 34th day after their redetermination notice date, Covered CA automatically re-enrolled clients into their current plan for the 2015 benefit year. If clients do not want the plan they were automatically enrolled in by Covered CA, then they have the ability to change their plan during Open Enrollment.
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Covered CA to MC Referral Process
Covered CA benefits will always end December 31st of the current year and clients will need to reestablish eligibility for January 1st of the following year. During the Covered CA annual redetermination process, the Covered CA client may have been determined potentially eligible for the MC program. This occurs when the client actively completes the redetermination process or during the ex-parte review conducted by Covered CA.
When a Covered CA client is determined potentially eligible for MC, the case is referred to the appropriate county of residence for a final determination of MC eligibility. The case is sent to the county using the CalHEERS e-HIT process. Once the county receives the case, the county must complete a MC eligibility determination and provide adequate notice to approve, discontinue, or deny MC benefits.
Incorrect Dual Coverage
While DHCS recognizes there are current system challenges with eligibility determination when these cases are referred to the counties with the individuals’ original application date, DHCS also recognizes that there may be health coverage benefits calculation which could result in dual coverage (i.e. MC or Covered CA eligibility) being reported to the Medi-Cal Eligibility Data System (MEDS) from the initial application date.
Premium Reimburse-ment and MC Retroactive Coverage
For purposes of premium reimbursement and MC retroactive coverage, these clients are not able to request refunds of premiums paid to Covered CA plans nor are they entitled to receive retroactive MC to pay their medical expenses because they received Covered CA benefits from a Qualified Health Plan.
Notification Covered CA mails a notice informing clients that they no longer qualify for an Advanced Premium Tax Credit under Covered CA and now qualify for MC. If clients disagree with their MC determination effective date, they may file an appeal.
Potential MC Eligibility
For Covered CA clients that appear to be eligible for MC, the counties will receive, via e-HIT, one of three e-HIT eligibility determination results from CalHEERS: Eligible, Conditionally Eligible, or Pending Eligible.
Note:For Covered CA renewal cases, case information sent by CalHEERS to the counties will reflect the initial application date from the last open or special enrollment period.
Eligible If CalHEERS can electronically verify that the Covered CA client now meets MC eligibility criteria, the case will be referred to the county of residence for the Eligibility Worker (EW) to confirm that the information is correct.
Update 2015-25: Medi-Cal page 3
The EW must not request any additional information from the client unless the EW has reason to believe that the information used to determine MC eligibility is not correct. If the determination appears to be correct, the EW must approve the case thru CalWIN. If the determination appears to be incorrect, the EW must work the case as described below in the “Pending Eligible” section.
Conditionally Eligible
An individual will be determined “conditionally eligible” if CalHEERS can electronically verify MC eligibility and the individual attests to having satisfactory citizenship/immigration status or a Social Security Number (SSN) but the status cannot be verified. If the determination appears to be correct, the EW must approve the case thru CalWIN. If the determination appears to be incorrect, the EW must work the case as described below in the “Pending Eligible” section.
Citizenship or Immigration Status
If MC is approved, the client has 90 days to provide verification of his/her citizenship/immigration status. If, after 90 days, the individual has not provided satisfactory proof of citizenship/immigration status, the individual must be moved to restricted scope MC benefits.
Social Security Number (SSN)
If approved, the individual has 60 days to provide verification of his/her SSN status. EWs must follow the current MC policies and procedures for SSN verification for approval or discontinuance.
Pending Eligible
If CalHEERS cannot electronically verify that the Covered CA client now meets MC eligibility criteria, but the attested income is within the MC limit, the case will be referred to the county of residence in a pending status. A pending status means the county must verify program eligibility for whatever data element(s) could not be electronically verified by CalHEERS.
Since a Covered CA client is not an existing MC client, the Covered CA referral is treated as a new application for MC purposes. This means that the county has 45 days from the date when the referral is sent to work the cases. All information must be requested using the two contact requirement (10-day request(s) for information and/or verification).
Information Provided
Once the applicant provides the needed information or the verification issue is otherwise resolved, a MC eligibility determination must be made in CalWIN.
MAGI Eligible If the individual is determined eligible for MAGI MC, he/she must have his/her eligibility established for a new 12-month period and a Notice of Action (NOA) must be mailed.
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A client’s previous Covered CA health plan doctor may or may not be in his/her new MC health plan. If required, the client will need to select a new plan and plan selection information will be provided separately. The client may be able to keep their current plan and continue seeing his/her current doctor if treatment is being provided for certain health conditions or if this is a plan offered by MC. Clients should be referred to their doctor, the Health Care Options (HCO) Representative at 1-800-430-4263, or if applicable, their new MC health plan.
Covered CA Eligible
If the individual is determined eligible for Covered CA coverage, the EW must accept the Covered CA eligibility determination and assist the individual with plan selection/enrollment.
Not Enough Information
If the EW makes the necessary two-contacts and the individual does not respond, the case must be denied. If the individual does provide additional information, but it is not enough information to determine ongoing eligibility, the EW must continue to work with the client to collect the necessary information.
The EW must attempt to work with the client in the client’s preferred method of contact and language, to the extent possible. If the client is not making a good faith effort to provide the requested information, and the 45 days to provide the information has passed, the EW must deny the case for failure to respond. A timely and adequate denial NOA explaining the basis for denial must be mailed to the client.
Managed Care Process
DHCS transferred clients to a health plan using one of two methods.
• Clients with a health plan in Covered CA that also matches a Santa Clara County MC health plan will be assigned to the same health plan.
• Clients with a health plan in Covered CA that does not match a Santa Clara County MC health plan will be assigned to a new health plan.
For any questions regarding health and/or dental plan(s), clients can contact a HCO Representative at 1-800-430-4263.
DHCS will also mail a notice to clients informing them of the plan they are enrolled in, the effective date, and information on contacting HCO to change their plan. Additionally, all new MC clients will receive a Welcome to MC packet.
Clients will also receive a MC Benefit Identification Card (BIC). For clients who already have a BIC and are going through this process, their old card will be deactivated and a new BIC will be issued.
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Process The following outlines our process for the DHCS interim transition process of Covered CA cases to MC.
STEP WHO ACTION
1. DHCS Sends a secure listing of transitioning Covered CA cases to Santa Clara County.
2. CATS Emails secure listing to MC Program Coordinator.
3. MC Program Coordinator
4. District office SSPMs
5. EW
Implementation The information in this update is effective immediately.
EW Supervisors
Eligibility Work Supervisors must review this update with their respective units at their next unit meeting and ensure that the correct procedures are being followed.
Data Systems
MEDS For the Covered CA to MC Cases batch, the MEDS Case Name is “ACA Renewal Rush.”
These individuals are in MEDS with the existing Express Lane aid codes 7W (individuals under 19 years old) and 7S (individuals 19 years old and over). Assignment of the aid codes was based on the age of the Covered CA client at the time of the batch run.
• Emails listing to Management Analyst for CalWIN data matching.
• Emails listing titled “APTC to MAGI MC” with instructions to district office SSPMs.
• Assigns listing to EW staff.
• Returns listing to MC Program Coordinator once listing has been completed.
• Follows emailed instructions and takes appropriate actions.
• Documents actions in all appropriate systems and listing spreadsheet.
• Returns completed listing to SSPM.
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Reference Documents
Attached are reference documents EW staff can review and use to respond to client questions on the transition and referral process from Covered CA to MC:
• Talking Points: Transitioning from Covered California Coverage to Medi-Cal Process When Eligibility Changes.
• Sample Medi-Cal Program Consumer Correspondence: Medi-Cal Health Plan Enrollment Confirmation Letter.
• Sample Covered California to Medi-Cal Transition Notice.
Other Programs
The information contained in this update only affects the MC program.
DENISE BOLAND, DIRECTOR, Department of Employment and Benefit Services
