IHSS licensed health care professional certification

CDSS has issued instructions and forms to counties about certification from a licensed health care professional as a condition of eligibility for In Home Supportive Services (IHSS) benefits.  Counties are required to provide applicants with the SOC 873 certification form and SOC 874 instructions.  Applicants must submit the completed form within 45 days of receiving it from the county.  Applicants can submit alternative documentation if it contains the same information as the SOC 873 form.  The application will be denied if certification is not submitted within 45 days of the county providing the forms.

The health care certification is not the only factor in determining the need for IHSS services, but should be considered as one indicator of the need for services.  However, the IHSS application must be denied if the first two questions on the SOC 873 form are not answered yes by the licensed health care professional.  If the county believes the applicant should be eligible for IHSS despite not receiving yes answers to those questions, the form must be returned to the health care professional to be reconsidered.

Services cannot be authorized until the county has received certification from a licensed health care professional unless services are being requested on behalf of an applicant who is returning to the community from a hospital or nursing home and needs services to remain safely in the community or the applicant is at imminent risk of out-of-home placement.  ACL 16-78 (September 28, 2016).

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).