Access to Medi-Cal Services for Transgender Beneficiaries

DHCS updated its guidance to managed care plans regarding covered services for transgender beneficiaries.  Under the state Insurance Gender Nondiscrimination Act and the federal Affordable Care Act, plans cannot discriminate in its health care benefits against individuals based on gender, including gender identity and expression.  Services that are available based on gender should not be denied or limited based on a beneficiary’s gender assigned at birth.  Federal regulations also prohibit categorical exclusions or limitations for services related to gender transition.

The DHCS All Plan Letter reminded plans that they must cover medically necessary services (services which are reasonable and necessary to protect life, to prevent significant illess or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury) and reconstructive surgery (surgery performed to correct or repair abnormal structures of the body . . . to create a normal appearance to the extent possible).  Plans do not have to cover cosmetic surgery (surgery that is performed to alter or reshape normal structures of the body in order to improve appearance).

The letter prescribes the use of nationally recognized guidelines to review requested services, specifically naming the WPATH Standards of Care for the treatment of gender dysphoria.  Identified core services for the treatment of gender dysphoria include behavioral health services, hormone therapy, psychotherapy, and a variety of surgical procedures to conform primary and secondary gender characteristics with a person’s gender identity.

Evaluation of requested services must be made by a qualified and licensed mental health professional and the treating provider in collaboration with a primary care provider.  Plans must provide in a timely manner all medically necessary services that are otherwise available to non-transgender beneficiaries.  Plan decisions are subject to review through the plan appeal and grievance process, the State Fair Hearing process, and/or the DMHC IMR process.

DHCS APL 16-013 (October 6, 2016).

Certain IHSS/HCB caregiver wages are MAGI exempt

DHCS clarified its MAGI Income and Deductions chart to account for recent IRS clarification about live-in caregiver wages.  Caregiver wages paid under certain IHSS and Home and Community Based Waivers are not counted for MAGI determinations when paid to a provider who lives with the Medi-Cal beneficiary receiving personal care services.

This exemption applies to:

  • In-Home Operations Waiver
  • Nursing Facility/Acute Hospital Waiver
  • Personal Care Services Program
  • In-Home Supportive Services Plus Option
  • Community First Choice Option
  • In-Home Supportive Services – Residual Program

DHCS MEDIL I 16-17 (September 21, 2016).

Changes to Medi-Cal estate recovery

Effective January 1, 2017, SB 833 changes rules regarding Medi-Cal estate recovery.  DHCS will be limited to recovering for nursing facility services, home and community-based services, and related hospital and prescription drug services when beneficiaries receive nursing facility and/or home and community-based services.

Other important changes include:

  • An additional hardship waiver if DHCS determines that enforcement of the claim would result in substantial hardship to other dependents, heirs, or survivors of the decedent.  Subject to federal approval, “substantial hardship” can include consideration of a homestead of modest value, defined as “a home whose fair market value is 50 percent or less of the average price of homes in the county.”
  • Prohibition of recovery from the estate of a deceased beneficiary who is survived by a spouse or registered domestic partner.
  • Setting how a voluntary post death lien accrues interest
  • Allowing eligible Medi-Cal beneficiaries to request a copy of the amount of recoverable Medi-Cal expenses once per calendar year for $5.

The estates of Medi-Cal beneficiaries who pass on or before December 31, 2016, will be subject to existing estate recovery rules.

DHCS MEDIL I 16-16 (September 21, 2016).

Changes to CalHEERS and determination of immigration status

Recently, DHCS updated CalHEERS and how the system determines program eligibility based on immigration status.  The update removed a question asking applicants whether they are an “eligible immigrant” and added a drop-down option for those who do not have a specifically identified document or status.  Instead, the updated CalHEERS asks applicants to select from a list of statuses.  Counties should only follow up with an MC 13 when necessary to determine status or when an applicant selects “Document or status not listed” for both document and status choices.

This update should not change how CalHEERS determines Medi-Cal eligibility, which will be conditional for up to 90 days to verify status unless “Document or status not listed” is selected.  Those applicants must get an MC 13 from the county, and the county cannot delay or deny the application if an applicant fails to respond to the MC 13.

This update will not be implemented in SAWS, so county workers will need to be able to address some of the issues that will come up when a status is not verified by the Federal Hub.  DHCS’s county letter describes these situations.

DHCS ACWDL 16-21 (September 14, 2016).

CalFresh Student Eligibility

CDSS issued instructions to counties about CalFresh eligibility for students.  The general rule is students age 18-49 are ineligible for CalFresh.  However, there are several exceptions.  Eligibility workers must evaluate whether a student meets one of the exceptions.  The exceptions are when the student is:

  • Employed average of 20 hours per week for the month
  • Has parental control of a child under age 6
  • Has parental control of a child 6-12 but do not have child care to allow attending class and working 20 hours per week
  • Approved for Work Study and anticipate getting a work study job. Exception applies even if no work study jobs are available as long as will take Work Study job if it is offered
  • Receives CalWORKs
  • Enrolled full time and single parent with responsibility to care for a child under age 12
  • Participating in an education and training program and placed in education for that program. Placements with Workforce Investment Opportunity Act, CalFresh Employment and Training, JOBS, Section 236 of Trade Act or state or local government education and training program can qualify.

ACIN I-89-15 (December 1, 2015).

CalWORKs supportive services and verification for education and training

CDSS has issued instructions to counties about supportive services and verification when a recipient’s welfare-to-work (WTW) activity is education or training.  The WTW plan should include all classes or equivalents required to meet the goal of the education or training program.  This includes concurrent or prerequisite classes.  The specific classes for the education program may not be available prior to enrollment.  In that instance, the county must have procedures to update or revise the WTW Plan to reflect the classes that are actually being taken.  Classes that are not required by the client’s program or education provider are not required to be included in the WTW plan.

Clients are entitled to supportive services for all classes included in the WTW plan.  Clients can request and receive advance payment for supportive services, including books, transporation, or fees and other ancillary expenses.

Participation hours in education or training must be supported by documentation in the case file.  Documentation can include classroom time sheets, attendance records, or enrollment verification from the provider.  Clients are not required to seek additional verification if such verification would require disclosure of confidential information, including disclosure of the fact that an individual is a CalWORKs recipient.  Prohibited verification includes requiring a client to provide teacher or instructor verification of attendance.  Instead, counties can seek verification through other resources offered by the educational institution such as CalWORKs Community College Counselors.

Counties are also reminded that the requirement of daily supervision of WTW activities does not require daily in-person contact.  The supervision requirement is that the responsible party has daily responsibility for oversight of participation.  This responsibility can be achieved by telephone or electronic means.  ACIN I-57-16 (September 8, 2016).

Requiring use of the “Here’s Why” section of CalFresh overissuance notices

CDSS has issued instructions to counties about the content of CalFresh overissuance notices.  Counties must complete the free-form “Here’s Why” section of the overissuance notice.  The drop-down menu explanations in the “Here’s Why” section of the overissuance notice do not provide sufficient detail about the reason for the overissuance and must be accompanied by additional information that is specific to the case.  The free-form “Here’s Why” section must be completed even if the county consortia computer system allows the notice to be issued without completing the free-form section in order to meet state and federal due process requirements.

At a minimum, the free-form “Here’s Why” section must include: 1) the amount of benefits the household received, 2) the amount of benefits the household should have received, 3) the time period of the overissuance, 4) the specific reason that caused the overissuance, 5) the amount of benefits to be repaid, and 6) how the household can pay the claim.  ACL 16-71 (September 12, 2016).

CalWORKs Time Limit Exemption for Indian Country Residents

CalWORKs has a time limit exemption for Indian Country residents where at least 50 percent of adults are not employed.  The California Department of Social Services did a survey to determine which Indian Country areas qualify for this time limit exemption.  Based on the survey, CDSS identified and listed 25 Indian Country areas where at least 50 percent of adults are not employed.

If a CalWORKs recipient lives in an Indian Country area not identified by CDSS as having at least 50 percent of adults not employed, the recipient, county or Tribal-TANF program can get a written certification from a federally-recognized tribe that the recipient lived in where at least 50 percent of adults are unemployed to qualify for the time limit exemption. ACL 16-68 (August 26, 2016).

Preserving Medi-Cal eligibility for Foster Youth who run away from placements

DHCS has issued a letter to clarify eligibility guidelines for foster care youth who leave court-ordered placements.  While loss of contact with the youth may discontinue foster care payments, that youth may be in other Medi-Cal aid codes and must not be discontinued simply due to loss of contact.

During ex parte review of Medi-Cal cases, workers should determine if the foster care youth is still under jurisdiction of the court; if so, the youth should be placed in the appropriate Medi-Cal only aid code not associated with a foster care payment.  If the foster care youth is still under the court’s jurisdiction, that youth should stay in the appropriate aid code regardless of whether the youth is located.  Foster care youth are not required to enroll into managed care unless in a COHS county.

The letter runs down scenarios about whether a foster care youth is located, where that youth is located, and whether the youth is under jurisdiction of the court.

DHCS ACWDL 16-20 (September 1, 2016).

Adult Immunizations as a Medi-Cal Pharmacy Benefit

DHCS has issued a letter to Medi-Cal managed care plans to instruct plans to include adult immunizations on plan formularies.  A pharmacist may administer immunizations according to plan protocols as long as the pharmacist completes an immunization training, is certified in basic life support, and comply with all state and federal recordkeeping and reporting requirements.

DHCS APL 16-009 (August 31, 2016).