Author: John Tan

Updated Specialty Thresholds for Medi-Cal Programs in 2018-2019

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Effective July 1, 2018, through June 30, 2019, the FMBA amount for a family member living with the community spouse of an institutionalized spouse is $2,058 (compared to last year’s $2,030). DHCS ACWDL 18-13 (July 3, 2018); DHCS ACWDL 18-13E (November 20, 2018).

As a result of the 2.8% COLA for 2019 Social Security benefits, DHCS has updated various threshold documents, including Pickle and SSI/SSP payment levels. This change does not affect MAGI eligibility. DHCS ACWDL 18-27 (December 7, 2018).

Effective January 1, 2019, the community spouse resource allowance is $126,420.  The maximum spousal income allocation/minimum monthly maintenance needs allowance is $3,161. DHCS ACWDL 18-28 (January 14, 2019).

Processing Medi-Cal cases with no potential MAGI eligibility

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DHCS has issue guidance on not running CalHEERS business rules for certain household with no potential MAGI Medi-Cal eligibility.  These include Mega-Mandatory beneficiaries in programs required by federal law or categorical programs (e.g., foster care, Pickle, SSI/SSP) and cases where the entire household is potentially non-MAGI eligible (aged/disabled, receiving Medicare, no dependent children or pregnant persons).

Currently, if an applicant is Mega Mandatory and CalHEERS returns a MAGI eligibility result, counties must not accept the MAGI result and must retain or establish eligibility under the Mega Mandatory aid code.  In some cases, the county is unable to grant Mega Mandatory eligibility without running the case through CalHEERS rules, which requires information that is unnecessary for aged or Mega Mandatory individuals.  SAWS will be making changes to address these workarounds for Mega Mandatory and non-mixed MAGI/Non-MAGI households.  Otherwise, counties must run the CalHEERS rules for other individuals.

DHCS ACWDL 18-16 (July 11, 2018).

Medi-Cal for Unaccompanied Refugee Minors (URMs)

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DHCS issued a letter with information and guidance to counties regarding cases for Unaccompanied Refugee Minors (URMs)  URMs who are otherwise eligible get no share of cost full scope Medi-Cal benefits, and are to be treated like foster care children for Medi-Cal eligibility purposes.

Three state-designated URM program service providers should submit applications to the county of residence on behalf of URMs placed with the agency.  Social workers will provide verification letters as proof of eligibility for refugees.  County welfare departments must not delay or deny services for failure to provide the SSN or verification of immigration status, though counties should work to verify status in order to maximize federal financial participation.

URM individuals are eligible for full scope Medi-Cal regardless of immigration status.  Those who meet former foster youth (FFY) eligibility requirements are eligible to continue receiving full scope Medi-Cal under the FFY program.  Counties must follow the appropriate rules on annual redetermination and inter-county transfers.

DHCS ACWDL 18-14 (July 3, 2018).

Non-MAGI Denial and Termination Notices for Non-Linkage

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The State has revised Notices for individuals who are not eligible for Non-MAGI Medi-Cal due to lack of linkage.  Counties will manually issue these NOAs until SAWS is updated.

Counties are to send denial notices to applicants who are not eligible for MAGI Medi-Cal and are found to have no Non-MAGI linkage after a full Medi-Cal determination.  Additionally, those who lose MAGI Medi-Cal and are found to have no Non-MAGI Medi-Cal linkage will receive a denial notice.  These applicants and beneficiaries should immediately be assessed for Covered California subsidy eligibility.

Counties will send discontinuance notices after annual renewal or change in circumstances reporting when beneficiaries no longer have linkage to Non-MAGI Medi-Cal and cannot establish eligibility on any other basis.

DHCS ACWDL 18-12 (July 2, 2018)

Medi-Cal Denial Notices for Retroactive MAGI Eligibility Determinations

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Counties are required to send Notices of Action when an individual is denied MAGI Medi-Cal as a result of being over MAGI income limits (138% FPL) during any of the three retroactive months prior to the application month.  In most cases, SAWS will generate the relevant notice.  CalHEERS will generate an over income denial NOA when there’s a tax subsidy approval.

Counties are encouraged to avoid sending multiple NOAs. When individuals who are not eligible for MAGI Medi-Cal are approved for Non-MAGI Medi-Cal in a retroactive coverage month, counties must send only the NOA that provides the final Non-MAGI eligibility determination for that month.  If an individual is not eligible for either MAGI or Non-MAGI Medi-Cal, the county must send both MAGI and Non-MAGI denial NOAs for the retroactive month.

DHCS ACWDL 18-11 (June 29, 2018)