DHCS issued new guidance on the requirements for issuing Notices of Action to individuals discontinued from Medi-Cal due to being over income for MAGI programs, not being eligible for Consumer Protection Programs, and not being eligible for any non-MAGI programs.  SAWS now has been programmed to automatically generate the Over Income NOA for the appropriate scenario.  The NOA provides more detail related to the income, household size, and income limit for the individual losing eligibility.

All counties must ensure that timely and adequate NOAs are issued to all discontinued individuals.  For those also found ineligible for non-MAGI programs, those individuals would also be issued the appropriate non-MAGI NOA.  These individuals should be immediately evaluated through CalHEERS for Covered California eligiblity.

Those losing Medi-Cal are not subject to the 15-day rule to pick a plan.  They may pick a Covered California plan by the end of the month in which they lose coverage and have Covered California coverage start at the beginning of the next month as long as they pay the first month’s premium on time.  The county shall assist individuals in completing the enrollment process into Covered California, including helping with plan selection should an individual request such assistance.  A beneficiary may have less than ten days to prevent a gap in coverage, but affected beneficiaries would still have the full 60 days to pick a plan through Covered California.

DHCS ACWDL 16-14 (June 15, 2016).

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).

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).

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).