Individual Medi-Cal determinations while household is pending

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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)

Benefits eligibility for persons paroled as refugees

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The California Department of Social Services has issued instructions about benefits eligibility for persons paroled as refugees.  The immigration status paroled as a refugee is a category of parole that includes persons who enter the United States under the Central American Minors program and persons eligible for conditional entry, between February 1970 and April 1980 whose application for admission to the United States was denied because of an inadequate number of visas.

Persons paroled as refugees are eligible for Refugee Resettlement Program benefits, CalWORKs and CalFresh.  Persons paroled as refugees should be eligible for SSI after one year and are eligible for CAPI until they are eligible for SSI because they are considered permanent residents under color of law.  ACIN I-48-16 (June 29, 2016).

Medi-Cal Termination NOAs for Over Income and Not Otherwise Medi-Cal Eligible

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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).

Medi-Cal Coverage for Services under End of Life Option Act

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DHCS issued an All Plan Letter to guide managed care plans about the administration of the End of Life Option Act benefit.  This benefit allows terminally ill beneficiaries over the age of 18 with the capacity to make medical decisions to be prescribed aid-in-dying medications if they meet certain conditions.  Coverage is carved out of managed care plans, so effective June 9, 2016, physicians must seek reimbursement through Medi-Cal Fee for Service.

If a managed care doctor also contracts under fee for service, that physician may choose to become the beneficiary’s attending physician through the steps of obtaining end of life services.  Services provided after the initial visit are no longer the responsibility of the managed care plan.  Managed care physicians who are not FFS providers would need to advise beneficiaries about seeking out FFS providers.

DHCS APL 16-006 (June 2016).

Adoption Assistance Program eligibility for children relinquished to private adoption agencies

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The California Department of Social Services has clarification about Adoption Assistance Program (AAP) eligibility when a child is relinquished to a private adoption agency.  When a private adoption agency is involved, the adopting family can be eligible for AAP if the child is eligible to receive SSI or the child was eligible to receive AAP based on a prior adoption that dissolved due to death or termination of parental rights of the previous adoptive parents.

For eligibility based on a finding that remaining in the home is contrary to the child’s welfare, CDSS states that private adoption agencies cannot seek the required juvenile court finding that staying with the natural parents is contrary to the child’s welfare.  Only the county child welfare agency can seek that finding.  This means if there is no petition to remove the child from the home or no subsequent judicial determination that remaining in the home is contrary to the child’s welfare, the child is not eligible for AAP based on a juvenile court finding.  In addition, if a court only sanctions a voluntary relinquishment, the child is not eligible for AAP.

Children adopted through private agencies can be eligible for state-only AAP if the county child welfare agency certifies that the child was at risk of dependency.  The private agency must get this certification from the county child welfare agency.  The county child welfare agency has discretion whether to make this finding.   For this certification, the county child welfare agency must find that the child was at risk of dependency without voluntary relinquishment and there was substantial risk of abuse or neglect.  ACL 16-38 (May 10, 2016).

The Work Number

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The California Department of Social Services has issued instructions about using an employment verification service called The Work Number.  After counties execute contracts and Memoranda of Understanding, they can use The Work Number for initial and ongoing CalWORKs and CalFresh eligibility, fraud investigations, and to verify employment and income for TANF participation rate data.

If a county takes adverse action based on information received from The Work Number, the county must send a notice stating the name, address, and telephone number of The Work Number, the right to get a copy of the report from The Work Number if requested within 60 days, and that the information can be disputed by contacting The Work Number.

The Work Number is in addition to the existing IVES income verification system.  As with IVES matches, counties must contact the assistance unit and give an opportunity to resolve any discrepancies before taking adverse action.  ACL 16-43 (May 12, 2016).