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Medi-CalMedi-Cal 8. Transitions (MAGI/Non-MAGI/APTC)

8. Transitions (MAGI/Non-MAGI/APTC)

This chapter provides information about the following:

• Transitioning from Pre-Affordable Care Act (ACA) Medi-Cal (MC) to ACA MC

• Consumer Protection Programs

• Transitioning from Modified Adjusted Gross Income (MAGI) MC to Non-MAGI MC or Advanced Premium Tax Credit (APTC)

• Transitioning from Covered California (CA) to MC

8.1 Transitioning from Pre-ACA MC to ACA MC

There are steps that must be taken before transitioning from a Pre-ACA MC Case to an ACA MC Case. These steps are as follows:

• Pre-Transition Review

• Identify if the case needs to be Merged or Linked

• Merging - The CalWIN Pre-ACA MC case has a companion CalWIN ACA MC case that needs to be combined into one CalWIN case. Refer to CalWIN Announcement (CA) 317 - Merging Pre-ACA MC ONLY Cases and ACA MC ONLY Cases for detailed step-by-step instructions.

• Linking - The CalWIN case has a CalHEERS case for some or all of the CalWIN case members and it needs to be linked or connected to each other. Refer to CA 312.2 - Linking CalHEERS Cases to CalWIN Cases and Adding-a-Person for detailed step-by-step instructions.

• Transitioning

• Required Data to Call the CalHEERS Business Rules Engine (BRE)

Update #20-07Page 8-1

http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_searchable/calwin_announcements/ca_317.pdf


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/calwin_searchable/calwin_announcements/ca_317.pdf






2Medi-Cal 8. Transitions (MAGI/Non-MAGI/APTC)

8.1.1 Pre-Transition Review

Before transitioning a case, identify if the case has one of the following aid codes, and then follow the steps in the action box:

Table 38: Pre-Transition Review

Aid Codes Action

39, 3T, 59, 5T For the Transitional MC (TMC) population, the EW must:

• Review the case to determine if the case is entitled to additional TMC.

23, 63, 64, 67 (Not limited to these aid codes)

For Disability-based MC, review MEDS to determine if the client is also receiving Medicare.

If the client is... Then...

Receiving Medicare

Determine if the individual is also a parent/caretaker relative with income under 114% FPL.

If the individual is... Then...

Both a parent/caretaker relative and receiving Medicare,

Proceed with the transition process for a MAGI MC eligibility determination.

Not a parent/caretaker relative, • DO NOT transition the case.

• Ensure all Medicare-related fields and windows are correctly entered.

Not receiving Medicare,

Proceed with the transition process for a MAGI MC eligibility determination.

8.1.2 Identifying If the Case Needs to be Merged

1a. In CalWIN, from the Display Individual Eligibility Summary window, click on the [Companion Cases] button.

Note:

This step must be completed for each individual in the case.

• If the case is still TMC eligible, continue to follow the current TMC process. [Refer to “Transitional Medi-Cal/Four-Month Continuing,” page 31-1]

• If the case is no longer TMC eligible, proceed with the transition process.



1b. On the Display Companion Cases window see if a companion case exists.

Table 39: Companion Case Review

If a companion case… Then...

Does NOT exist, Proceed to “Identifying If the Case Needs to be Linked”.



8.1.3 Identifying If the Case Needs to be Linked

In CalWIN, from the Inquiry function, select Case Inquiry.

2a. Click on Search on Case Information.

2b. Click on the [Open] button.

Exists, • Compare the Open/Active household members of the companion case(s) with the case to be transitioned.

• Determine if the companion case(s) are part of the tax household of the case to be transitioned.

• Review IDM for all cases (compare the RFTHI forms)

• Review Search Case Comments window for all cases.

• Call the client if unable to determine tax household.

• If determined that this case needs to be merged with another CalWIN case refer to CalWIN Announcement (CA) 317 - Merging Pre-ACA MC ONLY Cases and ACA MC ONLY Cases

Table 39: Companion Case Review

If a companion case… Then...




2c. On the Search on Case Information window, review the Search Results to see if there is a case number in the CalHEERS Case ID column.

EXAMPLE ONE



EXAMPLE TWO



Table 40: CalHEERS Case ID

If the CalHEERS Case ID column… Then...

Has a case number, • The CalWIN case is already linked to a CalHEERS case. This case does not need to be linked.

• This case may still need to be transitioned.

If the MC application date is…

Then...

1/1/2014 or after, • The CalWIN case is an ACA case.

• Ensure all individuals eligible for MAGI MC have a MAGI aid code.

Before 1/1/2014, Review the Transitioned field on the [Programs Requested] tab of the Collect Case Summary Detail window.

• If the Transitioned field is disabled in the case, make sure the case is correctly transitioned. (i.e. correct MAGI aid codes for eligible individuals, CalHEERS case was created, etc.)

• If the field is not disabled, the case needs to be transitioned. Refer to Step 3 of CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC).

Does not have a case number,

Proceed to Step 2d directly below.

2d. In CalHEERS, on the Search Individual window:

• Select Combo in the Search By field.• Enter the individual's name in the Last Name and First Name fields.• Enter the individual's Date of Birth.• Click on the [Search] button.

If no record is found with Combo search, select SSN in the Search By field to search by the individual's SSN.

• Repeat Step 2d for each individual in the CalWIN MC case.

• If they do have MAGI aid codes, no further action is needed.

• If they do not have MAGI aid codes, proceed to Step 3 of CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC).

• If the case is correctly transitioned, no further action is needed.

• If the case is not yet correctly transitioned, proceed to Step 3 of CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC).








Table 41: CalHEERS Case Search

If there is... Then...

At least one CalWIN case member with a record in CalHEERS,

This case needs to be linked. [Refer to CA 312.2 - Linking CalHEERS Cases to CalWIN Cases and Adding-a-Person].

NO CalWIN case members with a record in CalHEERS,

• This case DOES NOT need to be linked.

• Refer to CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC).

8.1.4 Transitioning

Pre-ACA cases must be transitioned three months prior to their MC Redetermination (RD) due month in order for cases to have their MC RD completed through the CalHEERS automated BRE eHIT. Pre-ACA cases must be transitioned to ACA cases for the following reasons:

• Current share-of-cost (SOC) individuals who are potentially MAGI eligible can be evaluated for MAGI MC and, if determined eligible, they will meet Minimum Essential Coverage (MEC) for tax purposes,

• Provide continued MC eligibility to aged-out children,

Update #20-07-8








• Prevent children turning 21 years old from being erroneously discontinued from their MC case,

• Grant MAGI MC eligibility to otherwise eligible property-waiver case parent(s) (individuals not Pre-ACA MC eligible),

• Avoid “splitting” MC cases in order to add a person,

• Continue zero-SOC MC coverage on MAGI MC for eligible individuals,

• Some Pre-ACA aid codes will become obsolete in the near future (i.e. 3N/3V), and/or

• Avoid manual MC RD process.

Pre-ACA cases not transitioned prior to the CalHEERS automated BRE eHIT will have to have their MC RD processed manually. Refer to CA 316 - Manual Medi-Cal Redetermination Process for the entire manual MC RD process which includes manually generating NOAs.

Once it has been determined that the Pre-ACA case does not require Merging or Linking an ex-parte review of all available information (in CalWIN, IDM, CalHEERS, MEDS, and any other state and/or federal system and/or report) must be completed. All “Request for Tax Household Information” (RFTHI) forms previously submitted via SCD 2350, MC 01-2014, CSC 91 or provided verbally must be entered into CalWIN.

The review also includes the review of information in companion cases and/or other programs (i.e. CalWORKs, CalFresh and/or General Assistance). Information from closed companion cases and other closed programs may be used if the case and/or program was closed within the last 90 days.

If for any reason the RFTHI was not provided, is incomplete, is unclear, or there are differences in the various systems, the EW must call the client and attempt to obtain the missing information. Refer to the table (EW Phone Call Process) directly below.

Reminder:

The RFTHI data does not need to be obtained in writing. The client may verbally provide this information.






Table 42: EW Phone Call Process

If the EW is... Then...

Unable to reach the client by telephone, Mail an SCD 50 requesting the missing information and allow 30 days.

If the requested information is...

Then...

Provided, • Update the information in CalWIN.

• Evaluate the case for MAGI MC.

• Mail appropriate NOAs.

• Check MEDS in 2 days.

• Make sure CalWIN, CalHEERS, and MEDS match.

• Document actions in Search Case Comments window.

Not provided, • Discontinue MC in the case.

• Mail discontinuance NOA.




Able to reach the client by telephone, • Obtain the missing information.

• Update the information in CalWIN.

• Evaluate the case for MAGI MC.





In order to ensure that all eligible cases are sent through the CalHEERS BRE for the electronic verification process, all the essential and very important fields must be correctly entered in CalWIN. [Refer to MC Scoop - Issue 6: Preparing a Case for the Medi-Cal RD]

Refer to CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC) for detailed step-by step instructions.


http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_ref_materials/mcscoop_volume1_issue6.pdf

https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/reference_materials/mcscoop_volume1_issue6.pdf#search=medi%2Dcal%20scoop



8.2 Essential and Very Important Fields

The following Data Elements are required in CalWIN for all cases and clients to generate a successful CalHEERS BRE call. These essential and very important fields must be completed for anyone who has or will interface with CalHEERS, this includes clients who are not in the home and/or not requesting aid.

Table 43: Essential and Very Important Fields

Essential and Very Important Fields CalWIN Window

Financial Assist for Healthcare [Y/N]Note:

Staff is instructed to enter Yes during Application Registration.

Collect Applicant Information

Transitioned [Y/N] - Select Yes Collect Case Summary Detail - [Programs Requested] tab for the Medi-Cal program



Marital Information Status Note:

Select appropriate status from drop-down list for everyone in the case.

Collect Individual Demographics Detail - [Demographics Detail] tab

• Previously on Foster Care [Y/N]

• In the Foster Care System on their 18th Birthday [Y/N]

• Same Home Address as Case [Y/N]

• Same Mailing Address as Case [Y/N]

Verify correct CINNote:

When completing Index Clearance, ensure new/existing CIN is selected correctly.





Verification (Received) and Source (select appropriate source from drop-down)

Collect Individual Address Detail - [Individual Address] button from the Collect Individual Demographics Detail window.

Expiration Date

• Alien #

(Alien # must total an “A” plus 9 numbers. If there are less than 9 numbers, add zeroes directly after the "A" to total 9 numbers for the Alient #.) [Ex: A001234567]

• Card # (also called receipt #)

(Must be exactly 13 alphanumeric characters. If there is no document number, enter 3 “As followed by 10 “0”s (Ex: AAA0000000000)

• “Name On Document” group box (Complete all fields)

Refer to Program Directive 2014-22: Federal Data Services Hub (FDSH) - Verify Lawful Presence (VLP) and Chewable Bytes 2015-01: Valid Immigrant Information for Successful eHIT.

Display Citizen/Non-Citizen Document Detail - [Documents] button from the Collect Individual Demographics Detail window.




http://intranet.ssa.co.santa-clara.ca.us/calwin/handbooks/program_directives/2014/14-22.pgd.pdf

http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_ref_materials/cats_cb_2015_01.pdf

http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_ref_materials/cats_cb_2015_01.pdf


Social Security Number (SSN) or Reason for no SSN Note:

If no SSN or field is blank - select appropriate reason from drop-down list for Reason for no SSN field.

Collect Individual Demographics Detail - [SSN Detail] tab

Remote Identification Process Verification Complete [Y/N]NOTE: Everyone in the home should have Yes for this field even if not requesting aid. ONLY individuals not in the home and not requesting aid should be blank or No.

Collect Individual Demographics Detail - [DRA Detail] tab





Preferred Communication Method (always select Mail from drop-down) Collect Communication Detail

Evaluate for Non-MAGI [Y/N] (select No for everyone requiring MAGI determination)

Collect Case Individual Detail





For LIHP individuals - under CMSP/LIHP Program Type, update Requesting Assistance [Y/N] (Yes) and Reason (CMSP Benefits Requested)

Collect Case Summary Detail - [Case Information] tab





Does this person need help with Long Term Care or Home and Community Based services (HCBS) Waiver Services [Y/N] (Select Yes or No from drop-down menu as appropriate.)

Collect Individual Attributes Detail - [Health Care Information] tab





• Offer a Health Plan that meets the Minimum Standard Value [Y/N]

• Employer Making Changes to Health Plan [Y/N]

Note:Complete for everyone with a job.

Important:ALL jobs that are terminated MUST be ended correctly.

• Enter the last paycheck received with Income Terminated [Y/N] (Yes) in the Collect Income Received Detail window

• Update the Effective End Date under Collect Earned Income Detail window

• Complete “Employment Termination” group box in the Collect Employment History Detail window.

Display Employment Health Coverage Detail - [Employment Health Coverage] button from the Display Employment History Summary window





Complete all relationships within the household correctly (unrelated if adults are not married, stepson, stepbrother, half-brother, half-sister, etc.)

Collect Household Relationship Detail - [Household Relationship] tab





Eligible Immigration Status [Y/N]

• Select Yes for all individuals who have Satisfactory Immigration Status (SIS) [LPR/eligible for full-scope benefits].

• Select No for all individuals who do NOT have SIS [undocumented/eligible for restricted benefits only].

Important:Some Non-citizens with legal temporary status will have APTC eligibility, but only be eligible for Restricted MC (i.e. Student Visa or Work Visa). [Refer to Chapter 9, "Immigration”] of the Common-Place Handbook.

Collect Non-Citizen Detail window

• In the “Five Year Bar” section, select the appropriate drop-down values for the Verification and Verification Source fields.

• In the “Qualified Non-Citizen” section, select Yes or No from the drop-down menu for the Attested [Y/N] field and select the appropriate drop-down values for the Verification and Verification Source fields.




http://intranet.ssa.co.santa-clara.ca.us/calwin/handbooks/cp/cpchap10.pdf


• Enter Yes/No for Primary Tax Filer [Y/N] field.

• Enter Yes/No for Expected to be Required to File Taxes this Year [Y/N] field.

• Enter Yes/No for Filed Taxes Last Year [Y/N] field.

• Select filing status from drop-down menu for This Year's Filing Status field.

• Select previous filing status from drop-down menu for Last year's Filing Status field.

• Enter Yes/No for Planning to File Taxes this Year [Y/N] field.

• Enter Yes/No for Claimed as a Dependent this Year [Y/N] field.

[Refer to MC Scoop - Issue 2: CalWIN Window - Display Tax Filer Detail, Case Scenarios]

Display Tax Filer Detail Reminders:

• Only ONE primary tax filer per case.

• Make an entry for EACH individual in the case including children on the Display Tax Filer Detail window.

• Complete Dependents window for each tax filer claiming dependents.

Important:For couples with tax filing status Married Filing Jointly, tax dependents are recorded under primary tax filer only.




http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_ref_materials/mcscoop_volume1_issue2.pdf




Dependent Name

• Make one entry for each dependent.

• Select each dependent from the Dependent Name drop-down menu.

• Click the [Save] button and close the window.

NOTE:

• Spouses who are Married Filing Jointly are NOT dependents of each other.

• Verify that any individual claimed as a dependent on the Display Tax Dependent Detail window is only claimed by one individual.

• The Primary Tax Filer field must be No for a dependent on the Display Tax Filer Detail window.

• This Year's Filing Status must be left blank on the Display Tax Filer Detail window.

Display Tax Dependent Detail - Click [Dependent] button from the Display Tax Filer Detail window.Reminders:

• Add dependents in the Display Tax Dependent Detail window under the case member claiming the dependent.

• For couples with tax filing status Married Filing Jointly, tax dependents are recorded under primary tax filer only.

End date ALL Batch AU Exception-MC Special Indicators Collect Case Special Indicators





Client Agrees to Consent to Verification [Y/N] (must select Yes even if blank or consent not given)

Perform Data Collection Wrap-up windowNote:

MC clients do not have the option not to consent; must renew information yearly at RD.

Renewal Period (select the number of years the client indicated on his/her application. If blank or no consent given, select 5 Years)





These fields must be completed before the EW runs EDBC to determine eligibility. However, after running EBDC, any required fields that are not completed will be displayed on the Display Reasons window under the Display Eligibility Summary window or in the Search for CalHEERS Results window.

Therefore, it is critical that the EW reviews these windows each time after EDBC is run to ensure all the required fields are completed in CalWIN. Otherwise, the case will remain pending, never call the CalHEERS BRE, or receive data in the Search for CalHEERS Results window.

8.3 Consumer Protection Programs

If a change in circumstance (CIC) RD results in consumer protection program eligibility (Continuous Eligibility for Children (CEC), Transitional MC (TMC), Continuous Eligibility for Pregnant Woman (CE)), the RD due date is not reset; the client will be placed in the appropriate consumer protection program (CPP). At the end of the client's consumer protection period, the entire case must be reevaluated for eligibility resulting in a determination and prompting the RD due date to be reset to a year from that determination. The RD due date is reset by the EW in the Collect Case Summary Detail screen in CalWIN to a year from the date of the eligibility redetermination.





When a CIC results in the reset of the RD due date, the client must be notified if there is a change in MC eligibility and/or level of benefits.

When Soft Pause individuals are eligible for a CPP, they should be removed immediately from Soft Pause and put on the CPP. However, CalHEERS and CalWIN currently lack functionality to automatically place some eligible clients on a CPP when they are discontinued from MAGI MC. Therefore, EWs must leave clients who are eligible for a CPP on Soft Pause. [Refer to Chapter 8, Section 8.5.3 "Soft Pause Lifting Process,” page-44]

Exception:Exception:

There is a workaround for individuals eligible for TMC. Follow Systems Announcement 335 for instructions on approving TMC. Individuals eligible for TMC should no longer be left on Soft Pause.

8.4 Transitioning from MAGI MC to Non-MAGI MC or APTC

When a client reports a change during or outside of their MC RD that requires a redetermination of eligibility, the result may require the case to be transitioned from MAGI MC to Non-MAGI MC and/or APTC. This process, known as CIC, requires the MC RD due date to be reset to a year from the reported change(s) via the Collect Case Summary Detail window. When a change of circumstance results in the reset of the MC RD due date, the client must be notified by his/her preferred method of contact. EWs also need to mail the MC 219 to the client and document that it was mailed in the Search Case Comments window.

After changes have been updated in CalWIN, prior to running EDBC, the MC RD due date is reset by selecting Yes in the Reset RRR [Y/N] field of the [Case Information] tab of the Collect Case Summary Detail window.



.

8.4.1 MAGI MC Ineligibility

When a client is determined to be ineligible for MAGI MC, the EW must complete an ex-parte review (all income and property verification must be within 90 days) and/or send out the Non-MAGI MC Screening Packet. An eligibility determination for a Covered CA healthcare program will happen automatically at the same time in CalWIN. The client may or may not be placed into Soft Pause. The table below shows the process to follow for the Non-MAGI MC Screening Packet.

The client does not have to return the actual Non-MAGI MC Screening Packet. The client only needs to provide the information from the packet along with paper verifications (i.e. pay stubs, bank statements, car registration, etc.).


https://ssaconnect.sccgov.org/ssaforms/Pages/DEBS-Medi-Cal-Forms.aspx#nonmagimcscreening




Note:

For a Non-MAGI MC eligibility determination, the e-verification of income by the Federal Hub cannot be used; paper verification of income must be obtained from the client.

Clients can have SOC Non-MAGI MC eligibility and APTC simultaneously. The EW must assist the client with their Covered CA health plan selection to the fullest extent possible.

Table 44: MAGI MC Ineligibility

If the client is... EW must...

Placed into Soft Pause, Complete an ex-parte review (all income and property verification must be within 90 days) and/or mail the Non-MAGI MC Screening Packet and allow 30 days.

If the necessary information and verifications are...

Then...

Provided, • Lift Soft Pause. [Refer to Chapter 8, Section 8.5.3 "Soft Pause Lifting Process,” page-44]

• Evaluate the case for Non-MAGI MC.


• Check MEDS in 2 business days.



Not Provided, • Lift Soft Pause. [Refer to Chapter 8, Section 8.5.3 "Soft Pause Lifting Process,” page-44]

• Discontinue the individual(s).

• Mail appropriate MAGI MC discontinuance NOA. [Refer to Program Directive 2015-18: MAGI Medi-Cal Discontinuance Notice of Action]

• Check MEDS in 2 business days.







Non-MAGI MC Screening Packet

This packet includes:

• “Non-MAGI Informing Letter” (CSC 99) [Print from CalWIN]

• “Evaluation for Non-MAGI Medi-Cal” (MC 604 IPS) [Print from CalWIN]

• “Non-MAGI Medi-Cal Brochure” (SCD 2447)

• “APTC and CSR Brochure” (SCD 2448)

Not placed into Soft Pause but automatically approved for Covered CA and CalWIN case closes,

Complete an ex-parte review (all income and property verification must be within 90 days) and/or mail the Non-MAGI MC Screening Packet and allow 30 days.

If the necessary information and verifications are...

Then...

Provided, • Rescind the CalWIN case.

• Evaluate the case for Non-MAGI MC.




Not Provided, • Mail appropriate MAGI MC discontinuance NOA. [Refer to Program Directive 2015-18: MAGI Medi-Cal Discontinuance Notice of Action]




Form Number

Form Name Description/Purpose

CSC 99 The Non-MAGI Informing Letter

The Non-MAGI Informing Letter has multiple objectives:

• Informs the beneficiary that he/she does not or no longer qualifies for MAGI MC.

• Informs the beneficiary that he/she may still qualify for Non-MAGI MC.

• Provides a brief overview of Non-MAGI MC and APTC/CSR.

• Informs the beneficiary that he/she may still be eligible for either free MC or SOC MC if found eligible when the requested information is returned to the county.

Table 44: MAGI MC Ineligibility

If the client is... EW must...




https://ssaconnect.sccgov.org/ssaforms/Documents/SCD_2447_en.pdf#search=SCD%202447

https://ssaconnect.sccgov.org/ssaforms/Documents/SCD_2448_en.pdf#search=SCD%202448


Mixed MC Cases (MAGI MC/Non-MAGI MC)

The information provided above still applies to mixed MC cases. However, if a client has reported a change, the EW must be in receipt of all current necessary verifications prior to redetermining MC eligibility and resetting the MC RD due date. This includes current property and income information (i.e. paper verifications) for all individuals in the case, including individuals already active with Non-MAGI MC eligibility.

Children turning 19 years old

Children who turn 19 years old and age out of the MAGI MC OTLIC program, may still be eligible for the adult, parent/caretaker relative, or pregnancy MAGI MC coverage group or Non-MAGI MC.

Table 45: Children turning 19 years old

If the child turns 19 years old and income is... Then...

Under 138% FPL, • Run EDBC to evaluate for other MAGI MC (i.e. adult, parent/caretaker relative, or pregnancy).




Above 138% FPL, Follow same process from the MAGI MC Ineligibility section. [Refer to “MAGI MC Ineligibility,” page 19-27]

Individuals turning 65 years old

Each month there is a population of Modified Adjusted Gross Income (MAGI) Medi-Cal (MC) NON-parent/caretaker relative and/or NON-pregnant individuals who will be turning 65 years old and, as a result, they will no longer be eligible for MAGI MC due to their age.

Note:

Parent/caretaker relative and/or pregnant individuals who are or turn 65 years old are still eligible for MAGI MC.

MC 604 IPS Evaluation for Non-MAGI MC

The MC 604 IPS requests the necessary Non-MAGI MC asset, income, and deduction information to evaluate an individual for Non-MAGI MC eligibility when such information has not been obtained through the ex-parte review process.

Form Number

Form Name Description/Purpose



Monthly Mass Mailing

Each month for this specific population turning 65 years old, Central Support Services (CSS) will complete a mass mailing of a cover letter (SCD 2453) and the Non-MAGI MC Screening packets; therefore, Eligibility Workers (EWs) do not need to mail the Non-MAGI MC Screening packets for this specific population only.

An automatic case comment stating Non-MAGI MC Screening Packet Mailed will be entered in the Search Case Comment window.

Any Non-MAGI MC Screening Packet that is received for this specific population by CSS will be scanned into the Integrated Document Management (IDM) and a CalWIN case comment stating Non-MAGI MC Screening Packet Received will be entered in the Search Case Comment window using case comment Type - Turning 65/Soft Pause.

This will automatically create a Task Management Tool (TMT) ticket with category Docprocessing.CaseUpdate.Over65_SoftPause for EWs to process.

The case comment type (Turning 65/Soft Pause) will mostly be used by CSS and clerical. EWs must not use this case comment type except when a client calls to provide the information over the phone or an actual physical copy of the Non-MAGI MC Screening Packet is received from a client who is turning 65 and a Turning 65/Soft Pause case comment was not entered.

If the Non-MAGI MC Screening packet or the necessary information from that packet has not been received in the month an individual turns 65 years old, then TMT tickets with category Docprocessing.CaseUpdate.NotReceivedOver65 will be automatically created for EWs in the following month. This will occur on a monthly basis.


https://ssaconnect.sccgov.org/ssaforms/_layouts/15/WopiFrame.aspx?sourcedoc=/ssaforms/Documents/SCD_2453_en_sp_vi.docx&action=default&DefaultItemOpen=1


EWs must follow the same process from the MAGI MC Ineligibility table. [Refer to “MAGI MC Ineligibility,” page 19-27]

EW Phone/Walk-In Process

The following outlines the EW process when a client calls to provide the information over the phone for a Non-MAGI MC determination or an actual physical copy of the Non-MAGI MC Screening Packet is received from a client who is turning 65 and a Turning 65/Soft Pause case comment has not been entered.

Table 46: EW Phone/Walk-In Process

Step Who Action

1 Client Walks-in or calls to provide information on the Non-MAGI MC Screening packet.

2 EW • Goes to Search Case Comments window.

• Documents Non-MAGI MC Screening Packet Received using case comment Type - Turning 65/Soft Pause.

IMPORTANT: This case comment must be entered on the same day as the MC 604 IPS is updated to Received in the Maintain Periodic Report Details window; otherwise, an MC RD TMT ticket will be created instead of a Docprocessing.CaseUpdate.Over65_SoftPause TMT ticket.

3 EW • Goes to the Search for Periodic Reports window.

• Updates the MC 604 IPS form as Received in the Maintain Periodic Report Details window.

• Updates any other appropriate CalWIN windows based on information provided by the client

If income and property verification are...

Then...

Provided, • Updates appropriate CalWIN windows.

• Goes to Step 4.

Not provided, • Mails an SCD 50 requesting missing verification and allow 10 calendar days.

• If missing verification is received, then updates CalWIN and goes to Step 4.

• If missing verification is not received after 10 days:

• Follows lifting Soft Pause process. [Refer to Chapter 8, Section 8.5.3 "Soft Pause Lifting Process,” page-44]

• Discontinues the individual.

• Mails timely discontinuance MAGI MC Notice of Action (NOA). [Refer to Program Directive 2015-18]





Medicare

If clients receiving aid code M1 report they have been approved for Medicare and they have started receiving it, then they are no longer eligible for aid code M1. The EW must review the case and determine if the client is still eligible for MAGI MC through the parent/caretaker relative and/or pregnancy coverage group. If the client is not eligible, then follow the same process from the MAGI MC Ineligibility section. [Refer to Chapter 8, Section 8.4.1 "MAGI MC Ineligibility,” page-32]

8.4.2 MAGI MC to APTC

Whenever there is a change and MAGI MC is reevaluated which results in all family members becoming eligible for APTC ONLY, the CalWIN case will close automatically. However, the APTC ONLY case will remain open in CalHEERS. For these cases, Covered CA is responsible for case maintenance; however, if an APTC ONLY household reports a change to the county, then an EW must update the information into CalHEERS.

Note:

For an APTC household with CCHIP, the information directly above still applies. The no “wrong door” policy applies to CCHIP.

8.5 Soft Pause

Soft Pause protection is applied to prevent clients from being discontinued from MAGI MC or moving to a premium aid code when a CIC is reported by clients, or via an annual renewal, or other review that results in certain adverse actions and clients are not eligible for one of the CPP implemented by CalHEERS (currently only Deemed Infant). Soft Pause protection is only applied by CalHEERS. CalHEERS can send Soft Pause via a change DER or a solicited DER.

When an individual is placed on Soft Pause protection by CalHEERS, the EW must determine if the individual is potentially eligible for Non-MAGI MC. Clients must maintain their prior eligibility until the EW has reevaluated the case based on an ex-parte review (all income and property verifications must

4 EW • Follows lifting Soft Pause process. [Refer to Chapter 8, Section 8.5.3 "Soft Pause Lifting Process,” page-44]

• Documents actions in Search Case Comments window.

• Mails timely NOA.

• Checks MEDS after 2 business days.

Table 46: EW Phone/Walk-In Process

Step Who Action



be within 90 days) and/or a response to the Non-MAGI MC Screening Packet. [Refer to Chapter 8, Section 8.4.1 "MAGI MC Ineligibility,” page-32]

When more than one individual is placed on Soft Pause at the same time in a case, only one (1) Non-MAGI MC Screening Packet must be sent to the household if the case cannot be reevaluated for MC eligibility based on the ex-parte review process.

Soft Pause protection has been applied to Intake cases when the initial eligibility assigned by CalHEERS changes during the application process. For example, when the income verified by the EW changes the initial aid code from a non-premium to a premium aid code. EWs will be able to lift Soft Pause if this occurs.

Example:

An Intake EW receives a CalHEERS External Referral Data (ERD) application which has already been approved for MAGI MC. After reviewing the application, the Intake EW discovers the client entered incorrect income information. Once the Intake EW verifies and updates the correct income in CalWIN, the client is placed on Soft Pause because the client’s income is over the MAGI MC income limit. The Intake EW lifts the Soft Pause and dispositions the MC application as appropriate.

The negative actions for MAGI MC that will trigger a Soft Pause protection are:

• Moving from MAGI MC eligibility to Advanced Premium Tax Credits/Cost Sharing Reductions (APTC/CSR)

• Losing MAGI MC eligibility (e.g. a 64-year-old individual (aid code M1) turning 65 years old).

• Changing from Non-Premium MAGI MC (i.e. aid code T2) to Premium MAGI MC (i.e. aid code T1).

• Changing from full scope MAGI MC to limited or restricted scope MAGI MC.

• Changing from full scope MAGI MC to pregnancy-related MC.

Soft Pause can apply to the following populations:

• Children under 21,

• Aged, Blind, and Disabled (ABD) persons,

• Parent/Caretaker Relative of a child under 21, and/or

• Pregnant women or women in the 60-day postpartum period.



8.5.1 Soft Pause Functionality

The CalWIN Project has created functionality to lift Soft Pause in CalWIN and send the information to CalHEERS. EWs are now able to lift (release) Soft Pause using the radio button on the Collect Case Individual Detail window, and CalWIN will send the Soft Pause Lift via an Eligibility Determination Request (EDR) when an Eligibility Determination and Benefits Calculation (EDBC) is run.

CalWIN will continue to send the Soft Pause Lift to CalHEERS until the case is authorized.

Note:

Soft Pause protection can be manually lifted in CalWIN. It currently cannot be lifted directly from within the CalHEERS portal.

The “Soft Pause” action box is located on the [Program Requested] tab of the Collect Case Individual Detail window in CalWIN.



When Soft Pause is lifted, the change will take effect in the future month. Once the case is authorized, CalWIN will set the Soft Pause indicator to No Change.

Example:

If an EW lifts Soft Pause in May and authorizes the case, then the change will be effective in June to allow for a timely 10-day Notice of Action (NOA). However, if the Soft Pause lift is completed after May NOA cutoff, then the change will be effective in July.

CalHEERS will reapply Soft Pause again after it has been lifted and the case is run back at a later time.



Example:

Soft Pause is applied on May 5th but it is lifted by an EW for June. It is now July and the client had reported another change on May 15th but no action was taken at that time. The EW makes the change now in CalWIN and reevaluates the case for May and future months. CalHEERS reapplies Soft Pause effective May, June, and July. The EW will need to lift Soft Pause again and run EDBC for those months (i.e. May, June, and July). Once the DER is received, the EW will run EDBC again and authorize the case.

Example:

Single non-disabled 28-year-old (aid code M1) receiving MAGI MC reports a change in income over 266% FPL on May 4th. The client is put on Soft Pause and is eligible for APTC. The EW mails the Non-MAGI MC Screening Packet and allows 30 calendar days. The client fails to respond with the necessary information and verifications within 30 calendar days. The EW mails an SCD 50 requesting missing information and verifications, and allows another 10 calendar days. The client still fails to respond with the necessary information and verifications after 10 calendar days. The EW lifts the Soft Pause in June that will take effect in July. The EW runs EDBC, authorizes the case, and CalWIN automatically closes the case.

8.5.2 Soft Pause CalWIN Display Reasons

The Soft Pause and Soft Pause Lift reasons display at the individual level. CalWIN will display the new reasons for Soft Pause and Soft Pause Lift under the [Reason] button in the Display Individual Eligibility Summary window of Wrap Up.

Soft Pause Display Reason

When an individual has been placed on Soft Pause or if Soft Pause has not been lifted, the display reason will read: Individual has been placed in Soft Pause protection mode due to reporting a change.



Soft Pause Lift Display Reason

When Soft Pause has been lifted (e.g. an individual has been removed from Soft Pause), the display reason will read: Soft Pause protection mode has been lifted for this individual.



8.5.3 Soft Pause Lifting Process

Follow the steps below to lift Soft Pause for an individual:

Table 47: Soft Pause Lifting Process

Step Action

1 • Determine if the client is eligible for a CPP (i.e. CEC, CE, etc.).

If the Soft Pause client is...

Then...

Eligible for a CPP, Leave the client on Soft Pause.

NOTE: If at RD and client has CEC, then reevaluate for MAGI MC. If the client is not eligible for MAGI MC, then go to Step 2.

Not eligible for a CPP, Follow Steps 2 - 6.

Reminder: Individuals eligible for TMC can be granted the correct eligibility via the workaround outlined in Systems Announcement 335.

2 • Determine if the client(s) is potentially eligible for Non-MAGI MC.

• Complete an ex-parte review (all income and property verifications must be within 90 days) and/or send a Non-MAGI MC Screening Packet.

Note:Allow 30 days for the client to provide the necessary information and verifications for a Non-MAGI MC determination. The Non-MAGI MC Screening Packet does not have to be returned.

If the necessary information and verification are...

Then...

Provided, • Update the information in CalWIN.

• For the client in Soft Pause, select Yes from the drop-down menu for the Evaluate for Non-MAGI [Y/N] field.

• Go to Step 3.

Partially provided, • Mails an SCD 50 requesting missing verification and allow 10 calendar days.

• If missing verification is received, then:

• Update the information in CalWIN.

• For the client in Soft Pause, select Yes from the drop-down menu for the Evaluate for Non-MAGI [Y/N] field.

• Go to Step 3.

• If missing verification is not received after 10 days:

• For the client in Soft Pause, select No from the drop-down menu for the Evaluate for Non-MAGI [Y/N] field.

• Go to Step 3.



8.6 Transitioning from Medi-Cal to Covered CA during Special Enrollment Periods

The discontinuance of MAGI MC is considered a loss of Minimum Essential Coverage (MEC) which is a Qualifying Life Event (QLE) in Covered CA that creates a Special Enrollment Period (SEP), and

Not provided, • For the client in Soft Pause, select No from the drop-down menu for the Evaluate for Non-MAGI [Y/N] field.

• Go to Step 3.

3 • Go to Collect Case Individual Detail window.

• Select the Soft Pause client from the Name drop-down.

• Change the Effective Begin Date to today’s date.

• Click the Release radio button in the “Soft Pause/APTC” action box.

• Click the Save button.

4 • Run EDBC (an EDR is sent to CalHEERS).

• Once a DER is received in the Search for CalHEERS Results window, run EDBC again.

• Authorize the case.

Note:CalWIN will continue to send the Soft Pause Lift to CalHEERS until the case is authorized. Once case is authorized, CalWIN will set the “Soft Pause/APTC” action box to No Change.

5 • Go to Display Individual Eligibility Summary window.

• Click on the [Reason] button.

• If Soft Pause has been lifted, the display reason will read: Soft Pause protection mode has been lifted for this individual.

• If Soft Pause has not been lifted, the display reason will read: Individual has been placed in Soft Pause protection mode due to reporting a change.

6 • Mail appropriate Non-MAGI MC approval NOA, APTC NOA, or MAGI MC discontinuance NOA.

Note:Refer to Program Directive 2015-18 for MAGI MC discontinuance NOAs.


• Check MEDS after 2 business days.

Table 47: Soft Pause Lifting Process

Step Action




coverage can begin the month following the final MC eligibility determination if the client picks a Qualified Health Plan (QHP) and pays his/her APTC premium timely.

8.6.1 Qualifying Life Events

The following life events or situations qualify clients for SEPs in Covered CA and allow a client to enroll or change plans outside of Covered CA’s Open Enrollment periods:

• Lost or will soon lose their MC eligibility or other health insurance (also known as loss of MEC).

• Permanently moved to/within CA.

• Had a baby or adopted a child.

• Got married or entered into a domestic partnership.

• Domestic violence survivors. (If married, abuser’s income not counted if survivor lives apart and is unable to file joint tax return.)

• Returned from active military duty service.

• Released from jail or prison.

• Gained citizenship/lawful presence.

• Federally recognized American Indian/Alaskan Native.

• Loss of Medically Needy SOC Coverage (only once per calendar year).

• Other qualifying events as identified in CalHEERS.

Clients have up to 60 days after the QLE to enroll in or change their Covered CA plan. Most of these SEPs are subject to the 15th day of the month rule in determining the start date of coverage. The 15th day of the month rule pertains to the deadline in which clients eligible for Covered CA must select a QHP to have coverage become effective on the first day of the following month. However, there are some exceptions.

The following situations qualify as exceptions to the 15th day of the month rule for Covered CA enrollment and can start coverage on an earlier date:

Lose of Minimum Essential Coverage

If a client loses full-scope or pregnancy MC coverage, job-based coverage or other MEC such as Medi-Cal Access Program (MCAP) or Children’s California Health Insurance Program (CCHIP), and they are otherwise eligible for Covered CA, the start date of the Covered CA health plan coverage can



be as early as the first of the month following the month in which a client’s MC or other MEC is discontinued. However, the client must select a plan and make the premium payment timely for this immediate coverage start date to happen.

CalHEERS is already programmed with the functionality to bypass the 15th day of the month rule for loss of MEC as well as to add the correct effective begin date when this QLE is identified in CalHEERS and/or CalWIN. A loss of MEC can be reported up to 60 days before or after the life event date. Refer to the following Covered CA Job Aids: Special Enrollment Administrative Review and Special Enrollment for instructions on how to process a SEP case with a loss of MEC in CalHEERS.

Marriage or Entry into Domestic Partnership

If an individual gets married or enters into a domestic partnership, the Covered CA health plan coverage can start on the first day of the next month following plan selection and premium payment regardless of when the individual makes the plan selection during that month. A life event of marriage or domestic partnership can only be reported the day of, or any day after but not exceeding 60 days from the life event date.

Birth or Adoption or Foster Care

If a child is born or a client adopts a child or a foster care child is placed in the client’s custody, the Covered CA health plan coverage can start on the date of the birth of the child, adoption, or the placement of the foster care child or the first of the month following the event based on the client’s choice.

8.6.2 Avoiding a Gap in Coverage

When a client transitions from MC (or other CPPs) to Covered CA and the client requests assistance with Covered CA enrollment process and plan selection, then the EW must assist the client with their Covered CA health plan selection to the fullest extent possible. EWs should also inform the client to make a timely premium payment to avoid a gap in coverage. Transitioning clients must select a QHP in the same month as the MC discontinuance date to have their Covered CA health plan start the following month and avoid a gap in coverage.

Outside of the Covered CA Open Enrollment periods, when clients have a loss of MEC or other QLE, they have up to 60 days before and after the date of the QLE to enroll in a Covered CA health plan or change their existing Covered CA coverage.

Example:

A client reports an increase in income on June 17, 2016. After being reviewed for the appropriate MC programs, this results in ineligibility for MEC MC, with an end date of coverage effective June 30, 2016 (the QLE date) and a transition to Covered CA. The client is allowed until August 29, 2016 to choose a Covered CA health plan and pay the first month’s premium. If


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/job_aid_special_enrollment_administrative_review.pdf#search=special%20Enrollment

https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/job_aid_special_enrollment_administrative_review.pdf#search=special%20Enrollment

https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/job_aid_special_enrollment_processing.pdf#search=special%20Enrollment


60 days pass after the end of the MC coverage and the client does not complete his/her Covered CA enrollment by selecting a health plan and paying the monthly premium timely, the client will have to wait until the next annual Covered CA Open Enrollment period to enroll in coverage.

In the example directly above, if the client selects a Covered CA health plan on or before June 30, 2016 and then pays the premium timely, his/her healthcare coverage will begin on July 1, 2016 and the client will not have a gap in coverage. However, if the client does not pick a plan until after June 30, 2016, the Covered CA health plan coverage will not begin until August 1 or later (depending on when the plan is picked and the payment is made). For example, if the client does not pick a plan until after July 31, 2016 but before August 29, 2016, and then pays before the billing due date, the Covered CA health plan will not begin until September 1, 2016. Covered CA does not offer retroactive start dates of coverage when a client has a loss of MEC.

8.6.3 Loss of Medically Needy Share of Cost Coverage

Clients with SOC MC and no other healthcare coverage can meet the requirements for an SEP if they meet their MC SOC in at least one of the two previous months. These clients are entitled to this SEP once per calendar year. Clients who meet their SOC in a particular month can be evaluated for eligibility through Covered CA (including APTC/CSR) based on an SEP in the following two months. Clients meeting their MC SOC in one month and having to meet it again the following month is considered loss of medically needy SOC coverage at the end of that month.

When clients contact Covered CA through the Service Center, Service Center Representatives (SCRs) will direct current MC clients to the county for assistance. If the client is currently eligible for SOC MC and wants to enroll in an APTC plan outside the open enrollment period, an EW must determine whether or not the client meets the requirements for any possible SEP reason (including the loss of medically needy SOC coverage). If the client has met his/her SOC in at least one of the two previous months, he/she is eligible for an SEP for the loss of medically needy SOC coverage.

EWs should make every reasonable effort to verify that the client has certified his/her SOC or has lost eligibility for a medically needy SOC program. Clients “certify” or meet their SOC when they either incur necessary medical expenses or pay medical costs that meet or exceed their SOC amount. If the MEDS Online Provider Inquiry or SOC Case Make-up Inquiry Request show the SOC was certified in one of the two previous months, the EW can evaluate the client for APTC eligibility.

If these electronic sources show that the SOC was not certified in one of the two previous months, the EW can accept the client’s attestation that the SOC was certified in one of the two previous months, and document it in the Search Case Comments window in CalWIN before evaluating for APTC eligibility. When processing the SEP in CalWIN, the SEP reason would be “loss of MEC” and the date of the “loss of MEC” is the last day of the most recent month in which the client’s SOC was certified and medically needy SOC coverage was lost.

If the client is eligible for APTC, he/she will have up to 60 days from the date of loss of medically needy coverage to choose and enroll in a QHP. If the client requests assistance with plan selection, then the EW should assist the client to the fullest extent possible. The Covered CA health plan coverage will be



effective as of the first of the month following plan selection and timely premium payment. The EW should also inform the client that he/she has the option to keep both SOC MC and QHP coverage.

8.7 Transitioning from Covered CA to Medi-Cal

Covered CA clients are transitioned to MC coverage due to the result of the completion of their Covered CA annual renewal or changes reported outside of the renewal period. Covered CA begins processing renewals in October of each year. The completion of the renewal evaluates the household for APTC subsidies for the following benefit year.

Covered CA clients are required to complete their renewal within 34 days of the date of their annual renewal notice. If clients do not complete their renewal by the 34th day, Covered CA re-enrolls clients into the last health plan they selected for coverage in the past (or current) benefit year, or a close or equivalent plan if last year's health plan is unavailable.

When the changes the client reports during their Covered CA renewal period result in the termination of their APTC subsidized health plan, an ERD is sent to the county for processing. If the change happened in the current month, the client has the option of choosing to keep their APTC until the end of the year, or being evaluated for MAGI immediately. Follow the table below to process ERDs with 2019 MAGI eligibility resulting from APTC renewals:

Table 48: ERDs with 2019 MAGI Eligibility

If... Then...

The client is MAGI eligible in the month of renewal (i.e. their income decreased in the current month)

Contact the client to confirm if they want to be evaluated for MAGI immediately, or if they want to keep APTC until the new year.

If... Then...

The client wants to keep their APTC through the end of the year,

The EW must wait to process until January eligibility is showing in CalWIN (after November NOA cutoff).Note:

Program is aware this may result in the case appearing on the Rivera listing, but this population is expected to be small.

The client wants to be evaluated for MAGI immediately,

Process the ERD and evaluate MAGI eligibility for future month forward.



8.8 Carry Forward (APTC/QHP to MAGI)

When an Advanced Premium Tax Credit (APTC)/Cost Sharing Reduction (CSR)/ Qualified Health Plan (QHP) client reports a change that result in termination of APTC/CSR/QHP health coverage, the client(s) are placed into a Carry Forward Hold. During the Carry Forward Hold the Covered California health plan will continue, if the client continues to pay their portion of the premium, until a full MC evaluation is completed by an EW and the Carry Forward status is lifted.

Example:

An active APTC client reports a decrease of income to Covered CA that results in MAGI MC eligibility. The client's APTC and Covered CA subsidized plan enrollment would terminate at the end of the month, however, the client and their impacted case members will be placed into a Carry Forward Hold and will continue receiving their Covered California health plan until a county EW makes a final eligibility determination and approves a MC aid code.

During this process, the EW may have to request additional information from the client if it is necessary to make a final MC eligibility determination. Clients may also submit additional verification if they feel it would impact their determination.

All clients have the option of keeping their Covered CA health plan if they do not want MC; however, they will have to pay the full premium out of pocket cost for the Covered CA plan. No APTC will be provided. To keep coverage with their Covered CA health plan, clients can call their Covered CA health plan directly. This is considered a QHP and in CalWIN appears as an X7 aid code.

8.8.1 Covered CA to Medi-Cal Referral Process

Covered CA benefits (APTC/CSR/QHP) 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 be 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.

The client is not MAGI eligible until the following year (i.e. their income is expected to increase beginning the following year)

The EW must wait to process until January eligibility is showing in CalWIN (after November NOA cutoff).Note:

Program is aware this may result in the case appearing on the Rivera listing, but this population is expected to be small.

Table 48: ERDs with 2019 MAGI Eligibility

If... Then...



A client may also be determined to be potentially eligible for MC following a Report a Change (RAC) in CalHEERS or if income changes outside of their renewal period including:

• Decreased earnings,

• An increase/addition of tax dependents, and/or

• Updates to the Federal Poverty Limits (FPLs).

When a Covered CA client is determined potentially eligible for MC, the client is referred to the Social Services Agency for a final determination. CalHEERS sends the case to CalWIN using the e-HIT process and creates a Determination Eligibility Response (DER) in the Search for External Referral Data window (if no CalWIN case is open) or Search for Case Updates window (if there is already an open CalWIN case, i.e. children on OTLIC and parents are APTC) in CalWIN. Case information received in the DER will reflect the initial application date from the last Covered CA open enrollment or special enrollment period or the date of the RAC. An EW must complete an MC eligibility determination and provide adequate notice for approval, discontinuance, or denial of MC benefits.

Carry Forward cases and clients may have Eligible, Pending Eligible, or Conditionally Eligible MC status.

CARRY FORWARD HOLD REFERRALS ARE HIGH PRIORITY.

Notification

Covered CA mails an NOD64 "Covered California Carry Forward" notice.

Following the MC determination the regular MC NOA requirements apply.

Premium Reimbursement

If a change is processed and the client is now eligible for MC, clients are not able to request refunds of premiums paid to Covered CA plans. However, the client may be able to request retroactive MC coverage to pay unpaid medical expenses during the Carry Forward period.

Dual Coverage

A person, who is enrolled in a QHP with APTC and later becomes eligible for MC, is not disqualified from receiving APTC until the month following the MC approval, even if MC coverage is retroactive. For tax related questions clients can be referred to the Internal Revenue Service.


www.IRS.gov


8.8.2 District Office Process

The following outlines the process for Carry Forward applications.

Table 49: New Application Carry Forward Process

Stage Who Action

1 Clerical • Receive and prioritize the Carry Forward Application through the External Referral Subsystem.

• Complete application registration using Carry Forward as the application Type.

• Send to Eligibility staff.

2 Intake EW • Prioritize Carry Forward Applications.

• Refer to “EW Instructions,” page 8-52"

Table 50: Existing CalWIN Case Carry Forward Process

Stage Who Action

1 EW • Receive and prioritize External Change DER TMT with Carry Forward Change Type.

OR

• When the client calls, comes in to the office or provides information that inititates Carry Forward Hold (i.e. income decreased, change in tax filing household, etc.) for individual clients or the entire case.

• Complete all data entries required for the case (i.e. complete the Change DER queue).

• Refer to “EW Instructions,” page 8-52"

EW Instructions

Carry forward cases may be received by TMT for continuing MC cases or by regular Intake Case distribution if there is no existing MC case. The EW must review CalWIN, MEDS, and CalHEERS for each Carry Forward individual and take all appropriate actions to make sure that the same information is reflected in all three systems.



Table 51: EW Actions for Covered CA to MC Cases

If an individual is... Then...

Not active but eligible for MC, 1. Identify which client(s) is/are in Carry Forward Hold.

2. Determine if the client is eligible for MC.

In Collect Case Individual Detail:

3. Select the Carry Forward client from the Name drop-down.

4. Change the Effective Begin Date to today’s date.

5. Click the Remove radio button in the “Carry Forward” action box.

6. Click save.

7. Run EDBC for future month.

8. Once a DER is received in the Search for CalHEERS Results window, Run EDBC again and authorize the case.

9. Once Carry Forward is lifted, EDBC can be run back to the month the change was reported.

10. Review CalWIN, MEDS, and CalHEERS to make sure the correct MC aid code is in all three systems.

11. Send the appropriate Notice of Action.

12. Case comment all actions taken on the case.

Already active on MC, • Review CalWIN, MEDS, and CalHEERS to make sure the correct MC aid code is in all three systems.

• If applicable, make any necessary corrections.

Ineligible for MC, • Deny the case in CalWIN.

• Send an adequate denial NOA.

• Evaluate all other programs the client may be eligible for (i.e. MCAP, CCHIP, APTC, etc.)

If the case is APTC ONLY, then the case should automatically close in CalWIN once authorized

Important:This is a two step process if MC is requested for the current or prior months, at Intake EDBC will always need to be run TWICE for Carry Forward applications.

Note:



8.8.3 Potential Medi-Cal Eligibility

One of three MC eligibility results will be established for the client in CalHEERS and transmitted via e-HIT:

• 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.

If there is no MC case (i.e. all household members were receiving APTC, QHP or not active) the DER that is received is considered a new application and must be processed within 45 days from the date the DER was sent to the county. This also includes the two contact requirement (10-day request(s) for information and/or verification).

Eligible

An Eligible status indicates CalHEERS electronically verified that the client(s) meets all MC eligibility criteria. CalHEERS has electronically verified the following for a client(s):

• Citizenship or immigration status (or the person is a U.S. national),• Social Security Number,• Reported income is reasonably compatible,• Residency,• Not incarcerated, and• Not deceased or the date of death has been given and is not in a month prior to the month being

assessed.

After the DER is processed in CalWIN and a case is opened, the EW must confirm all information is correct and approve MC.

An 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 through CalWIN. If the determination appears to be incorrect, the EW must process the case as described in the Pending Eligible section.



Conditionally Eligible

When transitioning from Covered CA to MC, a Conditionally Eligible status indicates that CalHEERS electronically verified that the client(s) meets MC eligibility criteria. [Refer to Chapter 8, "Eligible,” page-54], except for citizenship/immigration status or SSN. The client attests to having satisfactory citizenship/immigration status and/or a SSN but the status of either of the two cannot be electronically verified.

After the DER is processed in CalWIN and a case is opened, the EW must review the case to determine if the citizenship/immigration status and/or the SSN status are correct or require follow up. If the MC eligibility is correct and no additional verification is needed, the EW must approve MC. If the determination appears to be incorrect, the EW must:

• (Citizenship or Immigration Status) Approve MC, allow the client 90 days to provide verification of his/her citizenship/immigration status. If, after 90 days, the client has not provided satisfactory proof of citizenship/immigration status, the client must be moved to the restricted scope aid code for the appropriate MC program depending on his/her coverage group (i.e. M2, M4, etc.).

• (Social Security Number) MC is approved, the client 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

A Pending Eligible status indicates that CalHEERS cannot electronically verify that the client(s) meets all MC eligibility criteria, but that the client's attested income is within the MC income limits. A pending status means an EW must verify MC eligibility for whatever data element(s) could not be electronically verified by CalHEERS.

After the DER is processed in CalWIN and a case is opened, the EW must review and determine what information is needed to make an eligibility determination for the Pending Eligible case. 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 CalWIN to process the application. All information must be requested using the two contact requirement (10-day request(s) for information and/or verification).

Missing 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.



The client(s) will be required to select a MC Managed Care Health Plan that may be different than the plan they had in Covered CA. A client's previous Covered CA health plan doctor may or may not be in his/her new MC health plan. Clients may be able to keep their current plan and continue seeing their 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 Managed Care Health Plan.

Covered CA Eligible

If the client(s) is determined to be eligible for Covered CA, the EW must accept the eligibility determination and assist the client with plan selection and enrollment to the greatest extent possible. If the EW is unable to resolve clients’ concerns or questions to complete plan selection and enrollment, the EW must refer them to speak to a Covered CA Client Service Representative.

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 through the client's preferred method of contact and language to the greatest 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 have 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.

8.9 Transitioning from CalWORKs to Medi-Cal

Individuals discontinued from CalWORKs must be evaluated for ongoing MC eligibility by following the "Ex Parte Process”.

8.10 Ex Parte Process

Senate Bill 87 (Ex Parte Process) requires a Medi-Cal (MC) case review and potentially client contact when:

• A CalWORKs case discontinues, • A Refugee Cash Assistance case discontinues, • An SSI/SSP individual is discontinued from SSI (Craig v. Bonta),• An MC client is no longer eligible for their current aid code, or



• In Home Support Services (IHSS) discontinuance.• An individual is placed into aid code 38. • An individual is placed into Soft Pause.

Note:

Aid Code 38 and Soft Pause provide temporary eligibility for individuals while determining their ongoing MC eligibility under SB 87 regulations.

The Ex Parte Process requires three steps:

Step Action

Case Review

1. Ex Parte ReviewThe Eligibility Worker (EW) must use information available from all sources to establish ongoing MC eligibility without client contact, including IDM, MEDS, Federal Hub, CalHEERS, companion cases open or closed within the past 45 days etc. If there is not sufficient information and verifications available, then continue to Step 2.

Direct Contact

2. The EW must contact the client by telephone to request information/verification that is not available during the ex parte review. EWs must document the reason and attempts made on the [Maintain Case Comments] window in CalWIN. If the client cannot be reached or there is not enough information to establish eligibility, then continue to Step 3.

Medi-Cal Request for Information

3. The EW must send a request for information (MC 355, SCD 50, etc) to the client to request needed infor-mation/verification if the ex parte review and the telephone contact have been unsuccessful. Update the Verification Checklist due date in Wrap Up to allow 30 days.After 30 days, if there is not enough information or verifications provided to continue eligibility, then take appropriate action. Note: The Verification Due Date may need to be updated to allow for the 30 day time limit.

8.10.1 No Ex Parte Process Required

The Ex Parte Process is not required when an individual is discontinued from CalWORKs or MC for the following reasons:

• Death• Recipient’s written request to discontinue Medi-Cal benefits• Loss of California Residency• The individual is being transferred to another Public Assistance program that provides

Medi-Cal benefits. (Note: Other family members in the case must be reviewed for ongoing Medi-Cal eligibility.)



8.11 Eligibility Determination Procedures

Follow the procedures below for evaluating discontinued cases (CalWORKs or Medi-Cal Only) for ongoing Medi-Cal eligibility:

REASON FOR DISCONTINUANCE REQUIRED ACTION

Failure to complete the annual CalWORKs RRR, Send the appropriate MC RD packet to request the neces-sary information.Note: If the CalWORKs RRR packet was returned but the RRR process was not complete, the information on the RRR packet can be used for MC, a new packet is not required.

Incomplete MC RD, Follow the Ex Parte process to obtain missing information/verification and complete the eligibility review.

Income exceeds CalWORKs standards, Evaluate for MAGI MC, TMC, etc.

Ineligibility for current aid code, Follow the Ex Parte process to determine ongoing eligibil-ity.

8.12 CalWORKs Denials

If a CalWORKs application is denied, ongoing MC must be explored.

Table 8-1: MC Action Following CalWORKs Denial

If... Then...

The applicant is not eligible for CalWORKs, Follow the Ex Parte process to determine MC eligibility.

The applicant fails to comply with the application process or provide information or verifications,

Follow the Ex Parte process to obtain missing information/verification and complete the eligibility review.

The applicant fails to complete the SAWS 2 PLUS, Follow the Ex Parte process to determine MC eligibility.
