DHCS has issued this letter to guide SAWS and counties on implemented annual redeterminations for 2015 for MAGI Medi-Cal beneficiaries.

First, counties are to review any ex parte information available to the county about the beneficiary or beneficiary’s immediate family members, including cases that are either open or closed within the last 90 days.  If the ex parte review is sufficient to confirm eligibility, a redetermination form is not required.  This information is entered into SAWS and sent to CalHEERS for a MAGI eligibility determination.  For pre-ACA beneficiaries, counties will attempt to obtain RFTHI information ex parte.  If CalHEERS confirms MAGI eligibility, SAWS will receive the result back with a NOA confirming eligibility.

If a beneficiary is found ineligible through ex parte review, the county will send a pre-populated redetermination form (MC 0216) from SAWS and given at least 60 days to complete and return it.  Beneficiaries may complete this through many methods.  Counties are to contact the beneficiary if they have not yet received the form.  If the beneficiary fails to provide the requested information, county will issue a discontinuance NOA with a 90-day cure period.

When information from MC 0216 is received and entered into SAWS, CalHEERS will determine Medi-Cal eligibility.  MAGI eligible will be sent a NOA for a new 12-month eligibility period.  Those who are not MAGI eligible will go through the process described here.  Where there isn’t enough information, counties will work with beneficiaries to gather the necessary information.

DHCS issued this letter about implementing Medi-Cal annual redeterminations in 2014, a process meant to convert some beneficiaries from pre-ACA Medi-Cal to MAGI Medi-Cal.

At the 2014 annual redetermination, counties will try to convert beneficiaries to MAGI by sending a RFTHI form at least 60 days prior to the redetermination date.  If a beneficiary reports certain changes (e.g., size of household, categorical eligibility), counties will complete the annual redetermination process per previous guidance.  If there are no such cases, the county will just renew without a CalHEERS transaction.  Counties must also review Share of Cost cases for MAGI Medi-Cal.  Those ineligible will be granted APTC eligibility per Covered California requirements for special enrollment periods.

For MAGI populations, RFTHI information must be provided but not necessarily in paper form.  The information will be entered into SAWS for the next renewal.  If a beneficiary fails to respond to the RFTHI, counties must try to contact the beneficiary to get this information.  If after these attempts the beneficiary still does not respond, and if the information is not available ex parte, then the county shall send a timely NOA to discontinue benefits.  There is a 90 day cure period.

DHCS issued guidelines for counties to proceed on discontinuing Optional Targeted Low-Income Children Program cases on the basis of non-payment of premiums (NPP).  The counties have experienced a backlog of NPPs that should have been terminated.  DHCS has determined that premium payment status is an eligibility condition, so there are no redetermination requirements unless there’s a reported change in circumstances.

For those on aid codes H3 and H5, NPPs will be sent a timely NOA and terminated accordingly.  Beneficiaries must pay past-due premiums before termination to preserve eligibility.  If a beneficiary pays past-due premiums after discontinuance but within 30 days, coverage can be reinstated without a break in coverage.  After 30 days, the beneficiary will need to reapply.  Those on aid code 5D will proceed similarly.

The letter includes sample discontinuance language for NOAs.

DHCS has issued this letter to explain that those individuals granted deferred action status through DACA are eligible for full-scope state-funded Medi-Cal as PRUCOLs.  Individuals must meet all other Medi-Cal eligibility requirements.  DACA status will be verified through the federal data hub, SAVE, or by the applicant.  Counties will need to grant full scope through an eligibility workaround.

DHCS provided this updated information on processing state residency verifications for pending and current applications through SAWS and CalHEERS.  Previously, the paper verification of state residency status had been suspended until 8/1/14.  That suspension is now extended until further notice.  Attestation by verbal contact or listing of California address is sufficient.

DHCS issued this letter to the counties about the implementation of the new Full-scope Medi-Cal coverage and affordability benefits program for low-income women and non-qualifying immigrants, to be operational no sooner than 1/1/15.

Currently, Medi-Cal limits full-scope benefits to pregnant women under 60% FPL and pregnancy-only Medi-Cal to those between 60%-208% FPL.  Recent legislation established an affordability wrap between Medi-Cal and QHPs purchased through Covered California where pregnant women and non-qualifying (5 year bar) immigrants in a Covered California plan could have out-of-pocket expenses (including copays, premiums and deductibles) paid for by Medi-Cal.

Once these programs are fully implemented, pregnant women under 138% FPL will qualify for full-scope Medi-Cal.  Pregnant women between 138-213% FPL who are enrolled in a Covered California QHP will have the option to enroll in the wrap.  NQIs who would have been eligible for Medi-Cal due to MAGI expansion rules would enroll in a QHP with automatic enrollment in the wrap.

The letter also discusses the implementation process to be followed leading up to January 2015.