Medi-Cal Eligibility

One of the EW's responsibilities is to explore actual and potential Medi-Cal needs of each applicant/recipient, and assist the recipient in arranging for needed health care from the appropriate sources.

Frequently there are instances in which cash aid is not authorized until the month following the month of application. Even though cash is not authorized until the 2nd month, Medi-Cal should be authorized for that initial month, if eligible.

Retro Medi-Cal

As part of the Intake process, the EW is responsible for exploring the possibility of retro Medi-Cal needs, which may have occurred within 3 months prior to the date of application/reapplication.

IF the applicant...	THEN the EW...
Has incurred medical treatment within that time span,	Must offer to take a retro Medi-Cal application. Use the “Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210 A).
Does not wish to apply for retro Medi-Cal,	Should have an “Informal Application Refusal” (SC 166) signed, imaged into the case. Document the clients declining of retro Medi-Cal benefits in the Journal page of CalSAWS.

"Ex Parte" Review

"Ex Parte" means that the Medi-Cal-Only eligibility determination is made based on the information contained in the case record WITHOUT THE INVOLVEMENT OF THE CLIENTS unless the EW cannot make an accurate determination of Medi-Cal eligibility during the "ex parte" process due to insufficient information/verification. All reasonable efforts must be made by only using information/verification from ALL case information available (i.e., Food Stamp, General Assistance, Foster Care, In Home Supportive Services, Medi-Cal, etc.).

Medi-Cal coverage under Edwards must be continued during the "ex parte" review process during which time, individuals must be evaluated for ongoing Medi-Cal and transferred to the appropriate Medi-Cal program." Ex parte" review has replaced the Edwards process for CalWORKs and Medi-Cal cases.

Exception: When a CalWORKs case is denied at intake and an "ex parte" review is required, the case is NOT set up on Edwards. Follow the "ex parte" time frames.

"Ex Parte" Review Required

The "ex parte" review process will now be utilized for all of the following:

Cases in Edwards Status
CalWORKs denials/discontinuances
Diversion approvals/denials
Medi-Cal Annual Redeterminations.

"Ex Parte" Review NOT Required

No "ex parte" review is necessary when persons are discontinued from CalWORKs for one of the following reasons:

Death
Recipient’s written request to discontinue Medi-Cal benefits
Incarceration
Loss of California Residency
The individual is transitioning into another PA program that provides Medi-Cal benefits.

Note: Other family members in the case must be reviewed for ongoing Medi-Cal eligibility.

Information Sources

Information/verifications available to the EW through the following resources must be used in the "ex parte" process when determining Medi-Cal eligibility:

Income Eligibility Verification System (IEVS)
Systematic Alien Verification for Entitlements System (SAVE)
Employment Development Department/State Disability Insurance (EDD)/(SDI)
State Data Exchange (SDX)
Beneficiary Data Exchange (BENDEX).

Cash Aid Denied

The EW must make every effort to determine eligibility for Medi-Cal Only benefits when the:

CalWORKs application is denied
Diversion application is approved or denied
Applicant has withdrawn the CalWORKs application.

In situations where cash applicants do not qualify for cash, Medi-Cal eligibility must be explored.

If...	And...	Then...
The client wishes to receive Medi-Cal,	The CalWORKs denial is due to failure to complete the CalWORKs interactive interview and/or sign the SAWS 2,	No "ex parte" review of Medi-Cal Only eligibility will be conducted.
The client wishes to receive Medi-Cal,	They have completed the interactive interview and signed the SAWS 2,	The EW is responsible for denying the cash aid application.
		The EW must review the client’s information through the "ex parte" review process.
		The EW must set up Medi-Cal based on the "ex parte" process. Note: Once the "ex parte" is completed and eligibility for Medi-Cal Only benefits is established, the annual redetermination date will be 12 months from the date of the CalWORKs application.
The client wishes to receive Medi-Cal,	The CalWORKs denial is due to the applicant’s failure to provide information and/or verification,	The EW must determine if the missing information/verification is relevant to an accurate Medi-Cal ONLY eligibility determination.
The client wishes to receive Medi-Cal,		The EW must evaluate for other Medi-Cal program eligibility without the additional or missing information/verification.
The applicant does not wish to pursue Medi-Cal,		The EW should obtain an “Informal Application Refusal” (SC 166) signed by the applicant and image into the case.
Aid is discontinued for a family due to financial ineligibility or excess property, or due to lack of deprivation,		It is the EW's responsibility, as part of the Intake or Continuing process, to explore continued Medi-Cal eligibility.
The family desires continued Medi-Cal coverage,		They must be evaluated for ongoing Medi-Cal eligibility.

Cash Aid Discontinued

Appropriate actions must be taken for all discontinued CalWORKs cases.

If...	Then...
CalWORKs is discontinued for a reason that does NOT affect Medi-Cal eligibility,	Immediately convert the case to Section 1931(b) and continue Medi-Cal eligibility.
CalWORKs is discontinued for a reason that DOES affect Medi-Cal eligibility,	Allow the case to convert to Edwards v. Kizer, but do NOT send an Edwards packet to the client.
A Medi-Cal case is in Edwards v. Kizer status,	Complete an "ex parte" review and transfer individuals to the appropri- ate programs prior to MEDS Cut-Off of the second Edwards month. REMINDER: DO NOT ALLOW CASES TO REMAIN IN Edwards v. Kizer STATUS LONGER THAN TWO MONTHS.

Evaluation Chart

The chart below describes the appropriate action required when CalWORKs is discontinued:

Reason For CalWORKs Discontinuance	Section 1931(b)	Edwards v. Kizer	"Ex Parte" Review Required
Failure to Provide the SAR 7	Yes	No	No
Non-Cooperation with the following requirements: Identification Immunization School attendance Welfare-to-Work Requirements	Yes	No	No
Excluded because the individual is: A fleeing felon Convicted of Intentional Program Violation (IPV).	Yes	No	No
Expiration of CalWORKs Time Limits	Yes	No	No
Failure to Complete the CalWORKs Redetermination (RD)	No	Yes	Yes
Loss of Contact/Whereabouts Unknown	No	Yes	Yes
The Only Eligible Child Leaves the Home	No	Yes	Yes
Change in Household Composition that has resulted in non-cooperation with the information gathering requirements for the CalWORKs AU	No	Yes	Yes
Change in Household Circumstances that affect Medi-Cal Eligibility	No	Yes	Yes
Property Exceeds the Limits	No	Yes	Yes
Income Exceeds the Limits	No	Yes	Yes
Failure to Cooperate with Child Support Requirements	No	Yes	Yes

Transfer to Section 1931(b) Medi-Cal

The implementation of welfare reform, January 1, 1998, de-linked the CalWORKs and Medi-Cal programs and created the Section 1931(b) Medi-Cal Program. When CalWORKs is approved, Medi-Cal eligibility under Section 1931(b) is established. However, a discontinuance of CalWORKs benefits does not always mean discontinuance from Section 1931(b) Medi-Cal is appropriate.

Persons who are discontinued from CalWORKs must continue to receive ongoing Medi-Cal benefits under Section 1931(b) when the CalWORKs discontinuance reason does NOT affect Medi-Cal eligibility.

CalWORKs cases discontinued for reasons that do not affect Section 1931(b) Medi-Cal program eligibility must continue eligibility until the next annual redetermination. These cases must not be allowed to convert into Edwards. The following reasons DO NOT affect ongoing Section 1931(b) Medi-Cal eligibility, and discontinuance is NOT appropriate.

Non-cooperation with the following requirements:
- Immunization
- School attendance
- Welfare to Work participation
- Identification.
Excluded because the individual is:
- A fleeing felon
- Convicted of an IPV
- Failure to provide the SAR 7
- Expiration of the 60 month time limit for receipt of CalWORKs benefits.

Note: Incomplete SAR 7s must be evaluated for the appropriate action. If the incomplete/missing information only affects CalWORKs eligibility and does not affect ongoing Medi-Cal eligibility, then the case must be converted to Section 1931(b).

Example:

Missing check stubs or missing signatures do not affect Section 1931(b) Medi-Cal eligibility. Only one pay stub is needed for Medi-Cal. If the income has not changed, then no check stubs are necessary.

Missing bank statements are only necessary to continue Medi-Cal for parents. Allow two months of Edwards for parents and transfer children to the property waiver program.

CalWORKs cases discontinued for reasons that affect the Section 1931(b) Medi-Cal program eligibility will be converted into Edwards. After Edwards, the CalWORKs worker must determine on going Medi-Cal eligibility by completing an “ex parte” review.

Edwards Medi-Cal

When a CalWORKs case is discontinued the case is automatically converted to Edwards by the fifth working day of the following month.

Edwards continues to be a “transitional” program for persons discontinued from CalWORKs. However, the completion of an Edwards packet is NO LONGER REQUIRED for continuation of Medi-Cal. Instead, an ex-parte review is required for discontinued CalWORKs cases that are in Edwards Medi-Cal.

Note: Foster Care must use the MC 210 RV in the Edwards process.

CalWORKs cases discontinued due to "Loss of Contact/Whereabouts Unknown" must continue under Edwards and an "ex parte" review is required.

Procedures for Cases in Edwards Status

The "ex parte" review process has replaced the Edwards process. An "ex parte" review to determine ongoing Medi-Cal eligibility is ALWAYS required whenever former CalWORKs individuals are placed into Edwards.

Follow the procedures below for discontinued CalWORKs cases:

REASON FOR CALWORKS DISCONTINUANCE	REQUIRED ACTION
Failure to complete the annual CalWORKs Redetermination	Complete a Medi-Cal annual redetermination using the "Medi-Cal Redetermination" (MC 210 RV) to request the necessary information.
Increase in Income	Evaluate for Section 1931(b), TMC, Four-month Continuing, FPL Programs, CEC or AFDC-MN/MI.
Loss of Contact/Whereabouts Unknown (Returned Mail)	Attempt to contact the client by phone.
	Send a “Request for Information” (MC 355) to the last known address following the procedures described below. Advise the client to contact the EW to update their current living situation.
	If a change of address is posted on the returned envelope by the Post Office, use the new address.
	If the "ex parte" process and all attempts to contact the client are unsuccessful, discontinue the case. Mail the 10-day NOA to the last known address.
The only eligible child leaves the home	Review for linkage under all other Medi-Cal aid categories, includ- ing disability. If the client alleges disability, send a referral to DAPD. If no linkage exists, discontinue with a 10-day NOA.
A change in household composition that results in non-cooperation with CalWORKs AU requirements Example: Absent parent returns to the home and fails to provide information/verifications to the Cal- WORKs EW. The correct grant amount for the AU cannot be calculated.	Attempt to obtain information and/or verifications necessary for an accurate eligibility determination. The reason for contacting the individual must be documented in the Journal page of CalSAWS.

Annual Medi-Cal Redetermination

The next Medi-Cal annual redetermination date will remain unchanged from the CalWORKs redetermination date, and should be no earlier than 12 months from the date of the most recent CalWORKs annual redetermination. If no such annual CalWORKs redetermination has been conducted, then the next Medi-Cal annual redetermination date will be 12 months from the date cash aid was granted.

ExampleExampleCalWORKs case is approved for cash aid in February. The case is discontinued July 31, due to failure to provide the semi-annual income report (SAR 7). Case is then converted to Section 1931(b) Medi-Cal effective August 1. The annual redetermination for Section 1931(b) is due in February which is 12 months from the date cash aid was granted.

Clients Alleging Disability

When an individual discontinued from CalWORKs or Medi-Cal alleges that he/she is disabled, and there is no other basis for ongoing eligibility, EWs must continue Medi-Cal benefits and pursue linkage by initiating a referral to "State Programs - Disability and Adult Programs Division" (SP-DAPD).

Note: Clients must meet the “Disability and Adult Programs Division” (DAPD) referral criteria (i.e. “Substantial Gainful Activity” [SGA]) before initiating a DAPD referral and continuing Medi-Cal on the basis of alleged disability.

IMPORTANT: Verification of Incapacitated Parent deprivation does not necessarily mean disability criteria exists.

Complete the “Screening Form/SP-DAPD Applicants” (SC 96).
Determine if the individual has a share-of-cost by completing the MC 176 M.
1. Note: Do NOT allow "Aged, Blind and Disabled" (ABD) income deductions. Only after the SP-DAPD determines that the client is disabled will the ABD income deductions be allowed.
Enter the share-of-cost amount in the appropriate CalSAWS page.
Transfer the individual into the appropriate program.
Begin the process of making a referral to SP-DAPD immediately, by having the client complete the "Applicant’s Supplemental Statement of Facts for Medi-Cal" (MC 223) and "Authorization for Release of Medical Information" (MC 220).
Transfer the individual into the appropriate disability-based program if the disability is confirmed by SP-DAPD, and send an approval NOA.
Discontinue Medi-Cal with a 10 day NOA if the disability is denied, or the recipient fails to supply requested information to the EW or the SP-DAPD within the applicable time frames, provided that all other eligibility linkage factors have been exhausted.

Reminder: EWs must provide assistance to the client in completing the necessary forms, if requested.

The following applies when clients claim disability and a DAPD referral is initiated.

If the DAPD referral is initiated at...	Then the individual...
Intake,	Is set up on a pending status DAPD program.
Intake,	Follow current procedures in transferring cases to continuing.
Continuing,	Is transferred into the appropriate program.
Continuing,	Continue Medi-Cal benefits during the DAPD evaluation period.

Request for Information

When there is insufficient information on file to determine ongoing Medi-Cal eligibility, the EW must first contact the client by phone to request the needed information. If the phone contact is unsuccessful, the EW must send a written request using the “Medi-Cal Request for Information” (MC 355) which includes an informational cover letter required by SB 87.

Reminder: The written request for information/verification must NEVER be combined with a discontinuance notice.

EWs may not request information/verifications from clients that:

Has been provided within the last 12 months
Is not subject to change (i.e., Identification, Social Security Card, etc.)
Is available for verification by eligibility staff
Is not necessary for completing a Medi-Cal eligibility determination.

Note: This includes information/verifications currently on file in ALL active case records of the individual and their immediate family members and/or any case records that have been closed within the last 45 days.

Follow the procedures below if additional information is needed in order to determine ongoing Medi-Cal eligibility. The exact reason for contacting the client must be documented in the Journal page of CalSAWS.

If...	Then...
The EW is unable to make an accurate eligibility determination through the "ex parte" process,	An attempt must be made to reach the family by phone to request the necessary information/verification.
The "ex parte" process and attempted phone call are unsuccessful,	Send the MC 355 requesting the information needed to complete the Medi-Cal eligibility review.
The individual fails to respond to the request for information or does not provide the necessary information/verification within the required time frames listed below,	Evaluate for other Medi-Cal program eligibility without the additional information/verification (i.e., Property Waiver Program).

"Ex Parte" Time Frames

Allow twenty (20) calendar days from the date the MC 355 or MC 210 RV is sent for the client to respond.

Note: MC 355 is used to request additional information/verification if the EW cannot make an accurate Medi-Cal eligibility determination through the “ex parte” process. The MC 355 is NOT used in place of the MC 210 RV or the SAWS 2 Plus. Completion of an MC 210 RV is required for CalWORKs cases discontinued for failure to complete annual reinvestigation. Completion of the SAWS 2 Plus is required at intake to conduct an "ex parte" review.

If...	Then...
The requested information is not received within the 20 day time frame,	The intake EW evaluates Medi-Cal eligibility without the additional information/verification.
	Deny the Medi-Cal application if the missing information/verification affects Medi-Cal and eligibility cannot be established.
	The continuing EW must follow current procedures to begin adequate and timely discontinuance of Medi-Cal benefits.
The requested information is received incomplete within the 20 day time frame,	The EW must attempt to contact the client either by telephone or by sending a “Notice to Communicate With Client” (SC 50).
	Allow an additional ten (10) days for clients to provide the requested information.
The client does not comply within 10 days from the date of the EW contact,	The intake EW denies the Medi-Cal application.
	The continuing EW must follow current procedures to begin adequate and timely discontinuance of Medi-Cal benefits.
The requested information is received but the MC 210 RV is not returned,	The EW must attempt to contact the client either by telephone or by sending a “Notice to Communicate With Client” (SC 50).
	Allow an additional ten (10) days for clients to provide the requested MC 210 RV. Note: MC 13 and MC 219 are also required if not yet on file.
The requested information is received AFTER the Medi-Cal case has been discontinued, but within 30 days from the discontinuance/denial date,	Evaluate ongoing Medi-Cal eligibility using the information received and rescind the discontinuance/denial if eligibility exists, otherwise case remains discontinued/denied.
The requested information is received and eligibility does not exist,	The intake EW denies the Medi-Cal application.
	The continuing EW must follow current procedures to begin adequate and timely discontinuance of Medi-Cal benefits.
The reason for the Medi-Cal eligibility review is loss of contact and the MC 355 or MC 210 RV is returned with no forwarding address/marked undeliverable,	The EW will discontinue the Medi-Cal case and send an immediate discontinuance NOA to the last known address.

Exhausting All Avenues of Eligibility

When conducting a review of eligibility caused by a change in circumstances, EWs must consider eligibility under ALL possible aid categories, beginning with no share-of-cost Medi-Cal categories.

Reminder: Children are protected under CEC if the "ex parte" review reveals a change in circumstances resulting in a share-of-cost or ineligibility for Medi-Cal, until the next annual redetermination or their 19th birthday, whichever occurs first.

If, after completion of the "ex parte" process, eligibility under all categories fails, the EW must send an MC 355 explaining that new information/ verification such as pregnancy, incapacity, or disability may provide a potential basis for eligibility which was not apparent in the "ex parte" review.