Equitable relief for people with Medicare and Marketplace coverage

Individuals who have Medicare Part A coverage are considered to meet minimum coverage requirements under the Affordable Care Act and are therefore ineligible to receive premium and cost-sharing assistance for Marketplace health insurance plans.  Individuals who have Medicare Part B coverage are eligible to receive premium and cost-sharing assistance for Marketplace health insurance plans.  The Social Security Administration states that individuals may not have known they were not eligible for premium and cost-sharing assistance for Marketplace health insurance plans if they had Medicare Part A coverage.  This may have caused individuals to not enroll in Medicare Part B, drop Part B or enroll late in Part B and be assessed a penalty.

The Social Security Administration allows individuals to request equitable relief from their failure to have Medicare Part B.  The Social Security Administration is phasing out this relief but has extended it until June 30, 2020.

To be eligible for equitable relief, individuals must have enrollment in premium-free Medicare Part A and meets one or more of the following: Part A entitlement date between July 2013 and June 2020; notified of retroactive Part A entitlement between October 1, 2013 and June 30, 2020 or special enrollment period ended between October 1, 2013 and June 30, 2020.  The beneficiary must also request Part B enrollment or premium surcharge rollback or removal, mention equitable relief or being enrolled in both a Marketplace plan Medicare Part A, and present proof of Marketplace enrollment for any period between January, 2014 and June 30, 2020.  (EM-16033 REV 7, October 25, 2019.)

Recent DHCS Clarifications on Verifications and Paperwork

Annual Redetermination Signature Requirements

DHCS is clarifying the signature requirements for the MAGI and Non-MAGI renewal forms, as well as the property supplement form.  The renewal form may be signed by handwriting,  electronic signature, or telephonic recorded signature. Beneficiaries may respond via the Internet, mail, phone, in person, or other electronic means.  Counties must accept electronic signatures. DHCS MEDIL I 18-13 (September 14, 2018).

Supplemental Income Verification

  • October 12, 2018 ACWDL 18-21

CDSS administers a commercial income verification service on behalf of counties for the CalFresh and CalWORKs programs.  Any recent reports from this service should be used to determine Medi-Cal eligibility as part of ex parte review. DHCS ACWDL 18-21 (October 12, 2018).

Social Security Number in MEDS for Children in the Child Welfare System

  • October 16, 2018 ACWDL 18-23

As a condition of eligibility, a Medi-Cal applicant must provide a Social Security Number to receive full-scope Medi-Cal.  Because of post-adoptive records, counties have inconsistencies in entry and maintenance of records.  DHCS directs counties to use the child’s existing SSN (if available) and CIN in MEDS throughout the child’s history in the child welfare system.  If the adoptive parents change the child’s SSN, the county should use the new SSN in MEDS. DHCS ACWDL 18-23 (October 16, 2018).

Expanding Guidance on Medi-Cal Spousal Impoverishment Rules

The Affordable Care Act broadened the definition of an “institutionalized spouse” to include HCBS recipients and persons who have requested HCBS and generally reside at home or in the community. DHCS ACWDL 17-25 (July 19, 2018) initially extended spousal impoverishment rules from institutionalized spouses in long term care settings to applicants and recipients of other HCBS and waiver programs.  DHCS has clarified that the spousal impoverishment provisions apply to registered domestic partners.

Spousal impoverishment rules apply to the first month when a request for HCBS or IHSS has been made and the individual meets a nursing facility level care.  These rules must be applied to HCBS spouses who request IHSS and provide a verification form.  These provisions should be applied retroactively; DHCS provides examples of how to apply these rules.

The Letter walks through the process of applying spousal impoverishment rules to the HCBS spouse and community spouse.  First, the county needs to characterize property and apply any CSRA protections. Next, the county would calculate income. An eligible individual would be placed in a budget unit separate from the community spouse once the couple’s property meets the CSRA limit plus $2000.

The HCBS spouse will remain eligible (short of change in circumstance) unless and until the county denies the HCBS request.  At annual renewal, the HCBS spouse only needs to confirm continued HCBS participation. Continuous eligibility ends when the HCBS spouse or institutionalized spouse does not receive HCBS waiver services or inpatient care for a full calendar month.

If the community spouse applies for Medi-Cal, that spouse will need to spend down non-exempt countable property before the end of the month of application.  A spousal income allocation is still permitted.  However, if the community spouse requests HCBS, there is no longer a community spouse.  The letter also goes through applying these rules retroactively, including reimbursement through the Conlan process.

DHCS ACWDL 18-19 (August 21, 2018)

Recent Changes to Medi-Cal Notice of Action Requirements

Revised NOA for 250% Working Disabled Program Approval

DHCS has revised NOAs for Working Disabled Program approvals to clarify that couples do not need to pay separate premiums as a couple.  DHCS has also revised its EFT premium payment flyer for county use. DHCS ACWDL 18-18 (August 9, 2018).

NOAs for Beneficiaries Who Do Not Complete Non-MAGI Evaluation at Annual Renewal/Change in Circumstance

DHCS updated guidance to counties regarding MAGI discontinuance NOAs when the beneficiary is ineligible for MAGI, is potentially eligible for Non-MAGI, and the beneficiary does not complete the Non-MAGI evaluation when ex parte review is not successful.  The discontinuance NOA must indicate both why a beneficiary is not eligible for MAGI and why the county could not complete the Non-MAGI evaluation.  This guidance provide required language for such notices. DHCS ACWDL 18-24 (October 29, 2018).

Information Regarding Reporting Requirements on NOAs

DHCS is providing guidance about the requirement to include information about an applicant’s or beneficiary’s responsibility to report changes in circumstances on all MAGI and Non-MAGI NOAs that approve, change, or continue Medi-Cal eligibility.  The letter includes sample NOA snippets for various situations. DHCS ACWDL 19-02 (January 9, 2019).

NOA Requirements at Annual Renewal or Change in Circumstance Resulting in Resetting Annual Renewal Date

DHCS has issued updated requirements for NOAs for continuing eligibility at annual renewal and change in circumstances.  Federal regulations require counties to send NOAs when there are no changes to eligibility at annual renewal or following a change in circumstances resulting in resetting of the annual renewal date.  DHCS has provided sample language for these circumstances. DHCS ACWDL 19-03 (January 9, 2019).

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

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).