SAWS Soft Pause Removal

Currently, the Soft Pause feature of SAWS protects consumers from losing MAGI-based Medi-Cal eligibility when personal circumstances change.  The soft pause allows the county to run eligibility determinations for other programs while keeping the beneficiary on a MAGI aid code.  This generally happens when a MAGI beneficiary becomes eligible for APTCs, premium-based Medi-Cal, or limited scope/restricted/pregnancy-related Medi-Cal, or if the beneficiary becomes ineligible for MAGI Medi-Cal.

The county worker must screen the beneficiary for Non-MAGI programs before removing the soft pause or before sending the case for APTC evaluation.  If the individual is eligible for Non-MAGI Medi-Cal, the county can remove the soft pause to place the beneficiary into an appropriate aid code.  The same 90-day cure period applies to restore a beneficiary to a proper non-MAGI aid code if the individual did not respond to the Non-MAGI evaluation request.

County workers have the ability to remove the soft pause directly.  If an individual has been determined eligible for APTCs, the county worker can help the beneficiary complete plan enrollment in CalHEERS after removing the soft pause.

DHCS ACWDL 17-35 (October 5, 2017)

Extension of Presumptive Eligibility Period for Pregnant Women

DHCS has reminded counties that women on Presumptive Eligibility for Pregnant Women should have their PE period extended when they submit the required application.  Currently, PE benefits last for up to two months beginning on the day of the PE determination.  Individuals must submit a Medi-Cal application to continue receiving benefits beyond the PE period.  The MEDS system automatically terminates PE benefits unless it notes a pending application.  Counties must ensure that such transactions are posted to MEDS to continue PE benefits until they make a final eligibility determinatio.

MEDIL I 17-17 (October 3, 2017).

Medi-Cal Applications and Services for Disaster-Affected Individuals

In the wake of recent hurricanes and fires, counties have been reminded that they may accept written attestations from applicants to prove California residency.  DHCS has issued talking points to help applicants and providers navigate issues of eligibility, enrollment, and billing for relocated (permanently or temporarily) Medi-Cal or Medicaid beneficiaries.

DHCS MEDIL I 17-16 (October 2, 2017).

Hearing representative responsibilities and privileges process

The California Department of Social Services (CDSS) has issued clarification about county hearing representative responsibilities before a hearing.  The county hearing representative initially impartially reviews the hearing request.  After the review, the hearings representative either orders the county to take corrective action or defends the action at hearing.  The county hearings representative also provides claimants with information about the hearing process, including preparing a position statement.

The county hearings representative ensues that aid paid pending is paid when appropriate, identifies the issues raised in the hearing request, reviewed the disputed action(s) based on available evidence and regulations, and determines whether the case can be resolved or should proceed to hearing.

The county hearings representative also must provide reasonable accommodations for claimant’s disabilities, and services for limited English proficient claimants, including using forms that have been translated and using an interpreter for communication with the claimant at no cost to the claimant.

If the hearings representative cannot identify the issues from the hearing request, the hearings representative should attempt to contact the claimant to discuss the case.  If the hearings representative cannot reach the claimant, the hearings representative should review the case file for 90 days prior to the hearing request to determine issues.  If the hearings representative still cannot determine the issues, the hearings representative should write a limited position statement for the hearing. If the issues are identified on the day of the hearing and the hearings representative and claimant cannot reach a resolution, the hearings representative can request postponement of the hearing.

If the hearings representative determines the county action is correct, the county hearings representative should contact the claimant to explain the basis for the county action.  The hearings representative cannot imply that the claimant cannot or should not proceed with the hearing.  The hearings representative can explain the claimant’s right to withdraw if the claimant states they do not want to proceed with the hearing, but the county hearings representative cannot request a withdrawal.

If the hearings representative determines the county action is incorrect, the county representative must contact the case worker to take corrective action.  The county hearings representative must also contact the claimant to resolve the case without a hearing.  If that resolution is a conditional withdrawal, the language of the conditional withdrawal must be specific regarding the duties of the county and claimant for the action to be corrected.  A conditional withdrawal that states the county will re-review its action is insufficient. Conditional withdrawals should be in writing.  The county must ensure that corrective action is completed within 30 days.  If the claimant still chooses to attend the hearing, the hearings representative must be prepared for the hearing.

The hearings representative should inform the claimant of their right to review the case file and provide that access in two business days.  If the hearings representative withholds documents from the claimant pursuant to a claim of privilege, the hearings representative must prepare and give to the claimant a form identifying the withheld documents and the basis of the claim of privilege or confidentiality.  Welfare fraud investigation information from an active investigation is confidential unless that information has been used or relied on by the county in making its decision to take administrative action.  When the claimant challenges a county claim of privilege or confidentiality, the administrative law judge will convene an in camera proceeding to adjudicate that claim.

Finally, CDSS has issued guidelines for the content and format of county position statements for hearings.  (ACL 17-102, September 29, 2017.)

Medi-Cal System Treatment of New Medicare Beneficiary Identifiers

The Centers for Medicare and Medicaid Services (CMS) is planning to phase in Medicare Beneficiary Identifiers (MBIs) between April 2018 and April 2019 to replace the current Medicare Health Insurance Claim Number (HICN) based on beneficiary Social Security Numbers.  The MBI and HICN will be linked and used, with SSA generating HICNs and CMS generating MBIs.

Starting April 2018, the SAWS and MEDS systems, along with other statewide systems, are expected to be able to receive MBI information.  The transition period will run through December 2019.  During this time, when beneficiaries will only receive an MBI, Counties are not to share MBI with anyone.  County workers will continue to enter Medicare information as they receive it.  A new field for MBI has been added to MEDS.

DHCS MEDIL I 17-15 (September 18, 2017).

Blind FPL Medi-Cal Income Threshold/Disregards Update

Effective April 1, 2017, the Blind Federal Poverty Level income limits are as follows:

  • For a blind individual, the monthly income threshold is $1235, the same as the Aged and Disabled FPL threshold.
  • For a couple where both individuals are blind, the monthly income threshold is $1751
  • For a couple where one individual is blind and the other is aged or disabled, the monthly income threshold is $1666

DHCS ACWDL 17-33 (September 14, 2017)