Medi-Cal

Position Statements in CDSS hearings

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CDSS has issued instructions implementing AB 2346 about position statements.  Previously, public and private agencies other than the Department of Health Care Services were required to make paper copies of their position statements available to claimants at least two business days prior to the hearing.  AB 2346 extends this requirement to the Department of Health Care Services.  This means that position statements in Medi-Cal cases must now be made available two business days before the hearing.

In addition, position statements can now be provided to the claimant in one of three ways: 1) secure electronic transmission at least two business days before the hearing, with the claimant’s permission, and if the agency can comply with state and federal electronic privacy laws, 2) first class mail with mailing early enough for the claimant to receive the position statement two business days before the hearing, or 3) paper copy available at the appropriate office of the county welfare department two business days before the hearing, with public or private agencies that are not part of the county welfare department mailing a paper copy of the position statement to the county early enough for the county welfare department to make it available at least two business days before the hearing.

If electronic transmission does not apply, the county can choose whether to mail the position statement or make it available at the county welfare department office, but the county should discuss with the claimant how the claimant would prefer to receive the position statement.

If the position statement is not made available to the claimant two business days before the hearing or the agency modifies the position statement after providing it to the claimant, the claimant will have good cause to postpone the hearing.  The claimant must waive the 90 day deadline for a decision to get this postponement.  Because the postponement was caused by the county’s failure to provide the position statement as required, this postponement will be considered the claimant first postponement for purposes of evaluating subsequent postponement requests.

(ACL 17-21, February 16, 2017.)

DHCS 2017 FPL Charts

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DHCS has updated its annual eligibility charts to reflect the 2017 federal poverty level ceilings for Medi-Cal and other health programs.  The new FPLS are effective 1/1/17 for MAGI programs, 1/1/17 for MSP applicants and recipients without Title II income, 3/1/17 for MSP applicants and recipients with Title II income, and 4/1/17 for ABD FPL programs.

Note that the new monthly ABD FPL thresholds will be $1235 for an individual and $1663 for a couple.

DHCS ACWDL 17-10 (March 3, 2017).

Transitioning from MAGI Medi-Cal to Medicare

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As of 8/1/16, CalHEERS has been able to verify Part A entitlement through the Federal Data Hub.  Medicare entitlement precludes MAGI New Adult group eligibility, though it does not preclude eligibility through the MAGI Parent/Caretaker Relative or pregnancy coverage groups when eligible.

New Medi-Cal applicants who are eligible for Medicare will be evaluated for Non-MAGI Medi-Cal programs.  For New Adult MAGI beneficiaries who are become eligible for Medicare, the county shall evaluate for other MAGI programs.  Beneficiaries shall be placed on a Soft Pause until a Non-MAGI Medi-Cal eligibility determination can be made.

DHCS ACWDL 17-08 (February 24, 2017).

Carry Forward Status for Transitioning from Covered California to Medi-Cal

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As of 9/26/16, CalHEERS implemented a change to introduce the Carry Forward Status to reduce gaps in coverage while consumers transition between Covered California and Medi-Cal pending county eligibility determinations.  The flag in CalHEERS triggers a new notice to inform individuals of CFS.

Previously, DHCS and counties used Express Lane aid codes in a batch process pending county final eligibility determinations during the Covered California annual redetermination or change in circumstances reporting.  This, however, could result in a gap in coverage when, during the final eligibility determination, a person was found not to be eligible for Medi-Cal and was referred back to Covered California without retroactive coverage.  This process has been discontinued.

Now, CalHEERS will automatically place individuals into CFS when redetermination of eligibility results in potential MAGI Medi-Cal eligibility.  The individual will continue with Covered California coverage until the county completes a full Medi-Cal determination.  CFS will apply when a consumer reports a change that results in MAGI eligibility, when a consumer is determined MAGI eligible during the renewal period, when a consumer reports a change after the renewal is complete, and when a consumer reports a change after Covered CA eligibility has gone into effect.

During the CFS process, counties must treat cases as a new application for benefits.  Counties are required to send notices to affected beneficiaries.  Applicants transitioning from Covered CA to Medi-Cal may be eligible for the three-month retroactive Medi-Cal coverage period.

DHCS ACWDL 17-07 (February 24, 2017).

MCAP Integration into Medi-Cal Fee for Service System

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Between 10/1/16 and 6/30/17, CalHEERS will assign MCAP-eligible pregnant women into aid code 0G.  This will allow MCAP eligibles to receive full-scope Medi-Cal services through fee for service until the end of their post-partum period.

MCAP eligible pregnant women are those with MAGI incomes between 213 and 322 percent FPL.  Prior to 10/1/16, these women were enrolled in contracted health plans with no copays or deductibles.  Those still in health plans will continue receiving services that way until the end of the month of the 60th day following the end of their pregnancy.  New MCAP beneficiaries are being enrolled in FFS.

DHCS MEDIL I 17-03 (February 7, 2017).

Implementation of Medi-Cal Asset Verification Program Pilot

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DHCS is piloting a new Asset Verification Program in order to detect unreported assets for Aged, Blind, and Disabled Medi-Cal participants who are not receiving SSI/SSP.  Asset verification can be performed at any time a change of circumstances is reported or at any eligibility determination.  The Program allows DHCS to obtain account balances at financial institutions over the previous five years.

During this pilot, DHCS will search financial accounts for up to 3000 beneficiaries, based on the first day of the month.  Ten counties (including 2 LSNC Health counties) will receive AVP information, perform an ex parte review to determine discrepancies, and determine how many clients would normally receive a follow up contact due to the discrepancy.  Counties will provide DHCS an estimate of number of beneficiaries affected.

The pilot began in late January 2017.  In may 2017, DHCS will release pilot findings with implementation set to begin in fall 2017.

DHCS MEDIL I 17-05 (February 3, 2017).