SAWS Soft Pause Removal

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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

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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

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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).

CalFresh income, deductions, resources and exclusions

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The California Department of Social Services (CDSS) has issued instructions about changes to CalFresh income deducation and resource exclusion rules.  Military combat pay is excluded from income when determining CalFresh eligibility and benefit level if the additional pay is the result of deployment to or service in a combat zone and was not received immediately prior to serving in a combat zone.

The CalFresh standard deduction increased to $144 per month effective fiscal year 2009, and for every year thereafter is indexed to inflation.

The cap on deduction for dependent care expenses is eliminated.

Funds in designated retirement accounts, in a Federal Thrift Savings Plan, in an ABLE account, in a myRA account or in an education savings account are excluded from resources.  (ACL 17-98, October 12, 2017.)

Disaster CalFresh for fire victims

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CDSS has issued several directives regarding CalFresh for victims of the Northern California fires.  These directives include issuance of mass replacement benefits, statewide access to CalFresh (and CalWORKs) services statewide, allowing purchase of hot food with CalFresh benefits and waiver of timely reporting requirements.

California has been approved to issue Disaster CalFresh. Current CalFresh recipients can request supplemental disaster benefits.   New applicants affected by the disaster can be eligible for Disaster CalFresh if the household lived in the disaster area at the time of the disaster, and experienced either damage to their home or self-employment property, disaster-related expenses, disruption in income or inaccessible liquid resources.

CDSS also has links to the application for disaster CalFresh and the affidavit form for issuance of replacement CalFresh.  Disaster CalFresh, October 2017.

Responsibility for developing written evidence in Social Security hearings

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Social Security has issued a ruling regarding the responsibilities of both the Social Security Administration and the claimant to develop evidence and other information in disability and blindness claims for both SSDI and SSI cases.  The ruling applies at all levels of review, including administrative law judge hearings.

Social Security states that the claimant has the primary responsibility to provide evidence in support of disability or blindness claims.  The Social Security Act also requires the Social Security Administration to make reasonable efforts to obtain all medical evidence from the claimant’s treating source that is necessary to properly evaluate the claim prior to evaluating medical evidence obtained from a consultative source.  Social Security must also develop a complete 12-month medical history when making a disability determination.  This means that Social Security will make an initial request for evidence from the medical source, and will follow up with the provider between 10 and 20 days after the request if it has not received the evidence.

Claimants must submit or inform Social Security of all evidence known to them that relates to the disability claim.  Claimants must submit or inform Social Security of any written evidence no later than 5 business days before an administrative law judge (ALJ) hearing.  The ALJ can ignore evidence submitted less than 5 business days before the hearing unless the claimant demonstrates good cause for late submission.  To satisfy the duty to inform, the claimant must provide information specific enough to identify the source of the evidence and the relevance of the evidence.

Representatives have a duty to assist claimants in obtaining evidence. Representatives must also submit or inform Social Security of evidence as soon as they obtain or become aware of it.  Representatives should not wait until 5 business days before the hearing to submit or inform Social Security of evidence unless they have a compelling reason for the delay.  In addition, representatives cannot inform Social Security of evidence without submitting it unless the representative shows they could not obtain the evidence despite good faith efforts. Violation of these duties can result in referral to the Office of General Counsel for disciplinary action.

At the Appeal Council level, the Appeals Council will not obtain or evaluate additional evidence when deciding whether to grant review unless there is good cause for failure to previously submit it or the case is a SSI claim that is not based on an initial application for benefits (an age-18 redetermination for example).  SSR 17-4p (October 4, 2017).

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