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)

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).