Medi-Cal public health crisis or disaster reminders

The Department of Health Care Services has issued a reminder regarding Medi-Cal processes during a public health crisis for disaster.  For all populations affected by a public health crisis or disaster, counties must continue to provide benefits beyond the certification period, as needed, to provide additional time to submit renewals or verifications.

Counties must also modify eligibility requirements at application or renewal to allow for self-attestation.  Counties can accept an affidavit under penalty of perjury to verify residency, income and property when individuals are not able to provide necessary verification because of a public health crisis or disaster.

Counties may receive urgent intercounty transfer requests when beneficiaries need to relocate to be with friends or family in another county.  Beneficaries may contact either the sending county or the receiving county to assist with either a permanent or a short-term transfer of their case.   (MEDIL I-20-06, March 12, 2020.)

Reasonable accommodations in CDSS and DHCS programs

The California Department of Social Services (CDSS) and the Department of Health Care Services (DHCS) have issued a joint letter reminding counties of their obligation to ensure equal access to persons with disabilities to state and federal funded programs.  This includes providing reasonable accommodations to qualified persons with disabilities and effective communication through auxiliary aids and services.  These obligations apply to all county administered programs, services and activities funded by, or with federal pass-through funds from CDSS and/or DHCS.  These obligations also apply to county contractors and vendors that provide program benefits or services.

Counties must adopt written policies detailing how they will comply with these requirements.  Counties must have a procedure for complaints regarding disability discrimination, including failure to provide a reasonable accommodation.  Counties must inform clients of the county complaint procedure and they may file discrimination complaints with the appropriate state or federal agency.

Title II of the Americans with Disabilities Act (ADA) prohibits counties from excluding from participation, denying benefits or services to, or discriminating against any qualified person with a disability.  A qualified person with a disability is a person with a disability who, with or without accommodation, meets the essential eligibility requirements for the program provided by the public entity.  Disability is a physical or mental impairment that substantially limits one or more major life functions, a record of such an impairment or being regarded as having such an impairment.  California law defines disability more broadly by removing the word “substantially” from the definition of disability, and counties are required to follow California law.  The ADA also guarantees equal access to individuals who have a relationship or association with a disabled person.

The ADA does not require public entities to allow a person with a disability to participate if that person poses a direct threat to health or safety of others.  However, the county must determine whether a person is a direct threat only evaluating whether reasonable accommodations can mitigate or eliminate the risk.  The determination of whether a person poses a direct threat must be made based on objective factual evidence and an individualized assessment.

The ADA requires counties to make reasonable accommodations by modifying their policies, practices, or procedures when necessary to provide equal access to persons with disabilities.   This includes waiving a program rule or policy to help a person with a disability, or a change in the way a county carries out a policy or practice affecting a person with a disability.

Counties must notify all clients of the right to request reasonable accommodations and the protection against discrimination on the basis of disability.

When the county has actual knowledge of a disability or when the need for an accommodation is obvious, county staff must offer to assist with appropriate disability specific accommodations.  Counties are encouraged to train staff to identify disabilities and offer to assist identifying accommodations.

When an individual asks for a change in county policies, practices, or procedures because a disability, this request should be treated as a reasonable accommodation request.  While counties can make a reasonable accommodation request form available, counties cannot require individual to use a specific form for a reasonable accommodation request.   Reasonable accommodation requests can be made in person, by telephone or in writing by the individual or someone acting on the individual’s behalf.  It is not necessary that a person be an authorized representative to request a reasonable accommodation.  There is no limit to the number of accommodation requests a person can make, and each request must be individually evaluated.  Counties cannot impose an arbitrary limit on the duration of a reasonable accommodation.

County staff must document all reasonable accommodation requests and subsequent county actions in the individual’s case file.

If an accommodation is not immediately agreed upon, or if there is a disagreement about the appropriateness of a requested accommodation, county staff must engage in an interactive process with the individual requesting the accommodation or a person acting on their behalf.

A county can deny a reasonable accommodation request only when the accommodation would  fundamentally alter the nature of the program, service or activity, or would impose an undue financial or administrative burden taking into account all resources available to the program, service or activity.  The determination that an accommodation request would be a fundamental alternation or an undue burden must be made by the county welfare department director or designee and must be accompanied by a written statement of the reason for the decision.  If such a decision is made, the county must take alternative action to ensure that the person with a disability can access relevant benefits or services while avoiding a fundamental alteration or undue burden.

Counties cannot impose eligibility criteria that exclude or tend to screen out individuals with disabilities unless such criteria are shown to be necessary for the operation of the program.  Counties must provide programs, activities and services in the most integrated manner possible.  Counties cannot change individuals with disabilities for the cost of reasonable accommodations.

Counties must ensure effective communication with individuals who have vision, hearing or speech disabilities.   Communication with these individuals must be equally effective as communication with people who do not have these disabilities.  This requirement extends to companions of applicants or recipients.  For persons who are blind, have vision loss, or are deaf-blind, this requirement includes providing individuals with disabilities with auxiliary aids and services when necessary to communicate effectively. This can include providing written communication in large print, braille, accessible electronic format for use with a screen reader or via audio recording or a qualified reader.  For persons who are deaf, have hearing loss, or are deaf-blind, this requirement also includes providing a note taker, qualified sign language, oral, cued-speech or tactile interpreter, real-time captioning, telecommunication devices, or written materials.  For persons who have speech disabilities, this requirement includes providing a qualified transliterator.  Counties cannot require persons with communication disabilities to provide their own interpreter.  Counties may allow another adult accompanying an individual with a disability to interpret only in emergency situations or when requested by the persons with a disability.  Counties cannot rely on minors to interpret except in emergency situations when no other interpreter is available.

If counties choose to use Video Remote Interpreting, the service must meet specific technical performance standards.

Counties must consider how the individual normally communicates and must give primary consideration to a request for a particular auxiliary aid or service.

Counties must modify their policies, practices and procedures to allow individual with disabilities to use service animals on their premises.  Counties may not require certification or other proof that an animal has been trained or licensed as a service animal.  When it is not obvious what service an animal performs, county staff may only ask if the animal is required because of a disability and what work or tasks the animal is trained to perform.  (ACL 19-45, May 16, 2019.)

Disability and domestic violence questions computer system flags

The California Department of Social Services (CDSS) has issued directions regarding AB 2030.  AB 2030 requires CDSS to include in any amendments or revisions to standard application or semi-annual reporting forms after January 1, 2019 that allow applicants or recipients to disclose disabilities, the need for reasonable accommodations because of a disability and any experiences of domestic violence. 

CDSS states that initial application forms and semiannual report will capture the need for reasonable accommodations the next time they are revised.

The current welfare computer system vary in how they flag reasonable accommodations.  CalWIN has an icon for disability accommodations that is displayed in the upper-right side of the “Display Individual Demographics Summary” window.  CalACES North (formerly known as C-IV) can flag cases with an indicator type that county users can select (special accommodations, special circumstances etc.)  CalACES South (formerly known as LRS) allows any county user with access to falg a case to alert the first point of contact.  These flags are identified by a banner at the top of every page.  (ACL 19-13, February 21, 2019.)

Recent DHCS Clarifications on Verifications and Paperwork

Annual Redetermination Signature Requirements

DHCS is clarifying the signature requirements for the MAGI and Non-MAGI renewal forms, as well as the property supplement form.  The renewal form may be signed by handwriting,  electronic signature, or telephonic recorded signature. Beneficiaries may respond via the Internet, mail, phone, in person, or other electronic means.  Counties must accept electronic signatures. DHCS MEDIL I 18-13 (September 14, 2018).

Supplemental Income Verification

  • October 12, 2018 ACWDL 18-21

CDSS administers a commercial income verification service on behalf of counties for the CalFresh and CalWORKs programs.  Any recent reports from this service should be used to determine Medi-Cal eligibility as part of ex parte review. DHCS ACWDL 18-21 (October 12, 2018).

Social Security Number in MEDS for Children in the Child Welfare System

  • October 16, 2018 ACWDL 18-23

As a condition of eligibility, a Medi-Cal applicant must provide a Social Security Number to receive full-scope Medi-Cal.  Because of post-adoptive records, counties have inconsistencies in entry and maintenance of records.  DHCS directs counties to use the child’s existing SSN (if available) and CIN in MEDS throughout the child’s history in the child welfare system.  If the adoptive parents change the child’s SSN, the county should use the new SSN in MEDS. DHCS ACWDL 18-23 (October 16, 2018).

New Medi-Cal Authorized Representative Forms

DHCS is providing counties with new documentation around designating an authorized representative for Medi-Cal.

  • Appointment of Authorized Representative Form (MC 382): provides an applicant/beneficiary with a way to appoint an AR, limit the AR’s scope, and authorize an individual or organization as AR.
  • Notice of Authorized Representative Appointment (MC 380): notifies the beneficiary and AR of appointment and scope of appointment.
  • Authorized Representative Standard Agreement for Organizations (MC 383): allows an individual acting on behalf of an AR organization to sign agreements.
  • Cancellation or Change to a Medi-Cal Authorized Representative Appointment Letter (MC 381): informs the applicant/beneficiary of cancellation or change in scope of AR appointment.

The current MC 306 Appointment of Representative form will no longer be acceptable after June 4, 2019. DHCS’s guidance includes examples about AR appointment and cancellation.

DHCS ACWDL 18-26 (December 4, 2018)

Expanding Guidance on Medi-Cal Spousal Impoverishment Rules

The Affordable Care Act broadened the definition of an “institutionalized spouse” to include HCBS recipients and persons who have requested HCBS and generally reside at home or in the community. DHCS ACWDL 17-25 (July 19, 2018) initially extended spousal impoverishment rules from institutionalized spouses in long term care settings to applicants and recipients of other HCBS and waiver programs.  DHCS has clarified that the spousal impoverishment provisions apply to registered domestic partners.

Spousal impoverishment rules apply to the first month when a request for HCBS or IHSS has been made and the individual meets a nursing facility level care.  These rules must be applied to HCBS spouses who request IHSS and provide a verification form.  These provisions should be applied retroactively; DHCS provides examples of how to apply these rules.

The Letter walks through the process of applying spousal impoverishment rules to the HCBS spouse and community spouse.  First, the county needs to characterize property and apply any CSRA protections. Next, the county would calculate income. An eligible individual would be placed in a budget unit separate from the community spouse once the couple’s property meets the CSRA limit plus $2000.

The HCBS spouse will remain eligible (short of change in circumstance) unless and until the county denies the HCBS request.  At annual renewal, the HCBS spouse only needs to confirm continued HCBS participation. Continuous eligibility ends when the HCBS spouse or institutionalized spouse does not receive HCBS waiver services or inpatient care for a full calendar month.

If the community spouse applies for Medi-Cal, that spouse will need to spend down non-exempt countable property before the end of the month of application.  A spousal income allocation is still permitted.  However, if the community spouse requests HCBS, there is no longer a community spouse.  The letter also goes through applying these rules retroactively, including reimbursement through the Conlan process.

DHCS ACWDL 18-19 (August 21, 2018)