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).

DHCS is reminding county workers to assist MAGI Medi-Cal beneficiaries to get immediate health coverage when they are being discontinued from Medi-Cal and transitioning into Covered California during a special enrollment period.  Workers must assess individuals for non-MAGI programs first.  If the beneficiary chooses not to be evaluated or selects something else, that beneficiary will get a MAGI termination notice.

Discontinuance of MAGI Medi-Cal is a qualifying life event for a Covered California SEP, after which individuals can enroll into Covered California for up to 60 days.  While most SEPs are subject to the 15th day of the month rule to determine start date of coverage, there are exceptions:

• Loss of MEC: Can be reported up to 60 days before and after the life event date.  The start date of Covered California coverage can be as early as the first of the month following the month in which MEC is discontinued as long as the beneficiary selects a plan and pays the premium timely.
• Marriage/domestic partnership: Plan coverage can start on the first day of the next month after plan selection and payment regardless of when the individual makes the plan selection during that month.
• Birth/adoption/foster care: Plan coverage can start on the date of birth of the child, adoption, or placement of foster care child, or the first of the month following the event.
• Other less common exceptions as listed in 10 CCR 6504(h)

County workers shall assist beneficiaries with the Covered California enrollment process and advise on the need for timely health plan selection and premium payment to avoid a gap in coverage.  For Medi-Cal beneficiaries, this means selecting a plan in the same month as Medi-Cal discontinuance to have their plan start the following month.  Workers may also direct individuals to certified enrollment counselors if they are unready to select a plan.

Those with Medi-Cal share of cost coverage may qualify for an SEP if they meet their share of cost in one of the past two months and have not received an SOC SEP consideration in the calendar year.  The county must determine whether the beneficiary has met the criteria for any SEP reason, including loss of medically needy coverage.

DHCS ACWDL 16-18 (7/22/16) also includes a service center task guide on SEPs.

DHCS issued two all-plan letters about billing for inpatient services at both designated public hospitals (DPH) and private or non-designated public hospitals for CCS-eligible conditions of managed care Medi-Cal beneficiaries.  Generally, CCS services are paid through fee-for-service Medi-Cal, and most CCS services are carved out of managed care plans.  However, some plans carve in these services.

For services provided to a Medi-Cal beneficiary with a CCS-eligible condition enrolled in a managed care plan with a CCS carve out:

• A hospital stay for a CCS-eligible condition must be billed entirely to Medi-Cal FFS (DPH will get a per diem, while other hospitals will get a single payment based on the diagnosis related group), with no billing to the managed care plan.
• A hospital stay for a non-CCS eligible condition with subsequent services during the stay for a CCS-eligible condition is billed entirely to Medi-Cal FFS (again with applicable per diem or DRG), with no billing to the managed care plan.
• A stay that includes delivery and well-baby coverage is billed entirely to the health plan.  If the baby develops a CCS-eligible condition, the baby’s entire stay will be billed to Medi-Cal FFS and not the health plan.

For services and hospital stays for a Medi-Cal beneficiary with a CCS-eligible condition enrolled in a managed care plan that covers CCS services, a beneficiary hospital stay (regardless of reasons) must be billed entirely to the managed care plan.

DHCS APL 16-007, DHCS APL 16-008 (7/18/16)

DHCS recently released information about making sure that individuals determined Medi-Cal eligibility by CalHEERS should be considered eligible even when other members of the household are pending eligibility.  CalHEERS should determine the lowest potential eligibility for an individual and electronically verify eligibility and/or ask for relevant verification before placing in the appropriate program.  Counties must ensure that individuals with eligibility get authorized through SAWS without delay.  Counties must not hold the eligible

The State notes in this letter that children granted AE are to be provided eligibility immediately.  Children also are protected through continuous eligibility for children (CEC) if there is a change that would disadvantage the child or if there is loss of contact with the family.  Upon verification of an income change or loss of contact, affected children are placed in a CEC aid code until their next redetermination period.  Affected adults would be denied.

When the county recognizes a data entry error, the county should edit and rerun the CalHEERS determination.  If the county determines that an individual already receives full-scope Medi-Cal, the county can discontinue the new MAGI eligibility as long as the existing eligibility remains in MEDS.

DHCS ACWDL 16-16 (7/5/16)