Medi-Cal Eligibility

One of the EW's responsibilities is to explore actual and potential Medi-Cal needs of each client and assist the client 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 second 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,	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 Application Withdrawal/Cancellation (SCD 166) signed and imaged into the case. Document the client declined retro Medi-Cal benefits in the Journal Detail 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., CalFresh, 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 Public Assistance (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/verification 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 aid, Medi-Cal eligibility must be explored. Refer to the CalWORKs Denials section of Medi-Cal Handbook Loss of Contact.

Cash Aid Discontinued

Appropriate actions must be taken for all discontinued CalWORKs cases.

If...

Then...

CalWORKs is discontinued,

Refer to the Ex Parte Process section of Medi-Cal Handbook Loss of Contact.

A Medi-Cal case is in Edwards v. Kizer status,

Complete an "ex parte" review and transfer individuals to the appropriate 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 an 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:
- Identification
- Immunization
- School attendance
- Welfare to Work participation.
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 EW must determine ongoing 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 Medi-Cal Renewal Form (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 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 Medi-Cal 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, including disability. If the client alleges disability, send a referral to DDSD. If no linkage exists, discontinue with a 10-day NOA.
A change in household composition that results in non-cooperation with CalWORKs AU requirements ExampleExample Absent parent returns to the home and fails to provide information/verification to the CalWORKs EW. The correct grant amount for the AU cannot be calculated.	Attempt to obtain information and/or verification necessary for an accurate eligibility determination. The reason for contacting the individual must be documented in the Journal Detail 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 on July 31, due to failure to provide the semi-annual income report (SAR 7). The 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 they are 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, Determination, Service Division (SP-DDSD).

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

Important: Verification of Incapacitated Parent deprivation does not necessarily mean disability criteria exist.

Complete the Screening Form/SP-DDSD Applicants (SCD 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-DDSD 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-DDSD 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-DDSD, 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-DDSD within the applicable time frames, provided that all other eligibility linkage factors have been exhausted.

Reminder: EWs must assist the client in completing the necessary forms, if requested.

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

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

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 the annual redetermination. Completion of the SAWS 2 Plus is required at intake to conduct an "ex parte" review.

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.