How to count self-employment or fluctuating income for MAGI determinations

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DHCS issued guidance to counties regarding how to treat fluctuating or self-employment income and how to use projected annual income in MAGI determinations in CalHEERS.  The letter notes that IRS rules for net income from self-employment activities are different from non-MAGI rules; IRS deductions are broader than those allowed for non-MAGI programs.

For projected annual income, counties can take an average to determine monthly income.  If income fluctuates monthly, the single streamlined application uses projected annual income.  If the individual’s current monthly income is lower than the projected annual income, counties should use the current monthly income.  CalHEERS is expected to be fixed in March 2015 to address this situation.  DHCS ACWDL 15-06 (1/21/15).

More guidance on cases transitioning from Covered California to Medi-Cal as of 1/1/15

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DHCS issued additional guidance to counties for those cases transitioning to Medi-Cal due to the Covered California annual redetermination process.  A prior letter referred to a batch data file sorted rejected cases into categories of “eligible,” “conditionally eligible,” or “pending eligible.”  This file has 1720 cases, 879 of which were provided temporary coverage and 841 rejected for a second time.

The 841 rejected cases are to be evaluated manually by the counties and consortia for eligibility.  The 879 temporary coverage cases were granted Express Lane aid codes and Medi-Cal coverage until the cases can be evaluated.  DHCS ACWDL 15-05 (1/20/15).

Counties must reinstate and cease termination of ABD-eligible Medi-Cal cases where RFTHIs were not returned

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DHCS issued a letter directing counties to stop terminating cases for specific aged, blind and disabled cases where the beneficiary did not return the Request for Tax Household Information form associated with MAGI rules.  Counties will also be reinstating those ABD beneficiaries who were terminated for not returning the RFTHI.  In these cases, the county must restore eligibility back to the date of discontinuance, then proceed to complete a 2014 redetermination based on ABD status before going onto a MAGI determination.  DHCS ACWDL 15-03 (1/20/15).

Non-COHS Medi-Cal managed care plans must treat medical exemption requests and denials as continuity of care requests

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DHCS is directing managed care plans to treat Medical Exemption Requests as automatic requests for continuity of care for those Medi-Cal beneficiaries transitioning into managed care.  MCPs must treat every exemption listed in data reports as an automatic continuity of care request.  MCPs must attempt to contact beneficiaries via letter and two calls, and must begin processing requests within five days. DHCS All-Plan Letter 15-001 (1/14/15).

Clarification for using personal care services to meet Medi-Cal share of cost

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DHCS recently clarified the process for using out-of-pocket expenses from personal care services to meet current or future share of cost amounts.  Previously, IHSS needed to assess and approve the need for personal care services, and the out-of-pocket costs of approved hours were used as an income deduction.  Since these services are now provided as a Medi-Cal benefit, out-of-pocket costs can now be used to meet share of cost and not income deductions.

These out-of-pocket personal care services must be prescribed by a healthcare professional.  The services need not be assessed by IHSS or provided by an IHSS provider, and they may exceed the maximum assessed IHSS hours as long as the need for hours has been documented.

The letter provides answers to frequently asked questions about using these out-of-pocket expenses toward the Medi-Cal share of cost.  DHCS ACWDL 15-02 (1/12/15).