Author: John Tan

Implementation of SB 75 Health for All Children

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DHCS has issued a letter to inform counties about the expansion of Medi-Cal to individuals under age 19 without satisfactory immigration status but who are otherwise eligible for the program.  CalHEERS changes should be effective no sooner than May 15, 2016, with eligibility effective as of May 1, 2016 (assuming implementation of system changes occurs in May; effective eligibility will be pushed back according to when CalHEERS changes).

SB 75 does not implement new aid codes (the DHCS letter includes a crosswalk of aid codes as a reference), nor does it change any requirements to verify citizenship under federal regulations or state law.  Counties, however, must not request verification from children who do not claim satisfactory immigration status.  The SB 75 determination and transition does not reset a beneficiary’s annual redetermination date.

Individuals under 19 who do not have satisfactory immigration status are eligible for full-scope Medi-Cal under SB 75.  Individuals who turn 19 on or before May 1, 2016, will not be considered eligible for full-scope benefits through the transition of current restricted-scope beneficiaries.  The transition population is supposed to receive three notices: a general information notice, a notice of action, and a managed care plan enrollment notice.

New applicants will be able to submit an application through all current application pathways.  Prior to SB 75 implementation, new applicants will be determined eligible for restricted scope eligibility and can then be considered part of the transition population for full-scope eligibility.  Retroactive coverage is available for only those months when SB 75 is available; restricted scope retroactivity will be available in appropriate cases.  New enrollees will receive a notice of action and a Health Care Options enrollment packet (in non-COHS counties).

The transition period is expected to begin no sooner than May 15, 2016.  Once both CalHEERS and SAWS are ready, SAWS will identify eligible restricted scope individuals under age 19 and process the transition into full scope through CalHEERS and/or SAWS, then generate and send an appropriate NOA.  New enrollees and transition population beneficiaries will be enrolled in managed care depending on whether the beneficiary resides in a COHS or non-COHS county, whether the beneficiary will be aging out within six months, and whether the beneficiary has a share of cost or other health coverage.

When SB 75 eligible individuals age out of the program, Counties must redetermine eligibility.  A timely NOA is always required in these situations; if a beneficiary does not receive timely notice, counties will restore eligibility manually in SAWS until a proper and timely notice is issued.

DHCS ACWDL 16-12 (May 4, 2016).

Manual Workaround to Preserve Covered California Coverage for Pregnant Women

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DHCS issued a letter to the counties about a workaround for women enrolled in a Covered California plan with premium tax credits to remain in their health plans and not transition to Medi-Cal when they report a pregnancy.

The State expanded full-scope Medi-Cal for pregnant women from 60% FPL to 138% FPL.  Pregnancy-related Medi-Cal, covering women between 138% and 213% FPL, has been considered minimum essential coverage (MEC), which would normally disqualify them from Covered California plans with APTCs.

There is an exception for women who are enrolled in APTCs and then become pregnant, making them eligible for MEC Medi-Cal.  This workaround allows these pregnant women to keep their Covered California plan rather than being transitioned to Medi-Cal, if they choose.  While a change request has been submitted to CalHEERS to fix this, it is tentatively scheduled to take effect in October 2016.

The M9 manual workaround involves informing affected women who have been impacted by the transition about their option to remain in Covered California.  Pregnant women can either contact a County eligibility worker or Covered California to exercise this option.  These women will be discontinued from Medi-Cal, and the pregnancy record will be removed from the CalHEERS account.

DHCS MEDIL I-16-03 (April 14, 2016).

Clarifying the Inter-county Transfer Process

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DHCS has issued this letter to update information about how to process an ICT and how that affects managed care enrollment.

A beneficiary needs to report a change in county address within ten days of the change in residence either to the county welfare office or through CalHEERS.  After this, the Sending County must assist the beneficiary with transitioning benefits to the Receiving County.  The Sending County initiates the ICT and may only discontinue benefits during the ICT once a new effective date is confirmed with the Receiving County.  The Sending County is allowed seven days to initiate an electronic ICT to the Receiving County, and the Receiving County is required to complete and process the eICT within 30 days.

If a beneficiary contacts the Receiving County to request an ICT, the Receiving County will submit a request to the Sending County within three days of the beneficiary’s notification.  Once the Sending County is notified of an ICT request, the Sending County will initiate the eICT within seven days.

If a beneficiary contacts a Medi-Cal managed care plan, the plan will contact the county offices to provide updated beneficiary contact information.  When the plan indicates that it has received permission from the beneficiary to provide updated contact information to the Sending County, counties must incorporate this information into the case record.  The County may fill out a request to deal with managed care enrollment issues.

DHCS ACWDL 16-10 (4/21/16).

Transitioning from APTCs to Medi-Cal

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CMS has recently issued guidance to DHCS about how to help those enrolled in Covered California plans with APTCs who are later determined eligible for Medi-Cal.  DHCS has issued this letter to explain that those who transition from APTCs to Medi-Cal may have retroactive Medi-Cal coverage that can be used for unpaid medical expenses received up to three months prior to the month of transition, where the QHP will be the primary payor and Medi-Cal the secondary payor.

Those enrolled in QHPs with APTCs who later become eligible for Medi-Cal are not disqualified from receiving tax credits until the month following the Medi-Cal approval, even if Medi-Cal eligibility is retroactive.  Changes to enrollment are to be made prospectively and there would be no retroactive termination of enrollment from a QHP or termination from APTC.

Individuals do not lose eligibility for APTC until the first day of the month following the approval.  An individual can claim the tax credits for these months, if otherwise eligible.  Meanwhile, there is no requirement to be refunded premiums paid of QHP coverage.

DHCS ACWDL 16-08 (4/21/16).

Guidance on COLAs and Health Insurance Costs

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DHCS has issued guidance about the effect of this year’s lack of a Social Security COLA on Medicare premiums and costs, along with other programs such as the Pickle program.

The Medicare Part A premium increased to $411 for those who do not receive free Part A; the reduced Part A premium is $226.  Part B premiums will stay at $104.90 for current Medicare beneficiaries who have the premium deducted from Social Security; those new to Medicare this year, or those who do not have Part B deducted from their Social Security check, will pay $121.90.  Those with higher incomes will pay higher premiums.

Medi-Cal resource limits remain at $2000 for an individual and $3000 for a couple.  DHCS ACWDL 16-05 (4/15/16).

Medicare Savings Program property limits remain unchanged: $7280 for an individual and $10930 for a couple.  DHCS ACWDL 16-07 (4/21/16).