Medi-Cal - Failure to Cooperate

CCR 50157, 50175, 50379, 51771.5

Failure to cooperate procedures for Medi-Cal are to be used when the client:

  • Refuses to complete any necessary medical support/paternity forms.
  • Fails to appear at the DCSS office as requested. DCSS will notify the EW after the client has missed two appointments (and has not contacted DCSS to reschedule).
  • Refuses to assign medical support rights at initial application.
  • Fails to cooperate fully with DCSS.
  • Fails to establish Good Cause and still refuses to cooperate.

Clients cannot be sanctioned for failure to provide essential information to DCSS without first being offered the opportunity to establish cooperation by signing the Attestation Statement at the DCSS office. If the client completes and signs the statement, the individual is considered to have cooperated with DCSS in meeting the requirement to provide information requested on the absent parent. This is completed by DCSS, not the EW.

Noncooperation

Any applicant or recipient who does not want to assign medical support rights, or who does not want to cooperate with the EW or DCSS, must be given the opportunity to:

  • Withdraw the Medi-Cal application, or
  • Cooperate, or
  • Request discontinuance.

Once eligibility has been established, ineligibility for Medi-Cal due to noncooperation in the medical support enforcement process can only be applied to a future month with a 10-day notice of action. The EW MUST NOT go back and retroactively make a person ineligible, declare an overstated share of cost, or calculate overpayments for prior months. Continued refusal to cooperate in medical support requirements makes the parent/caretaker relative ineligible for Medi-Cal; however, the child(ren) remain eligible for Medi-Cal benefits.

ExampleExample  An undocumented mother does not cooperate with medical support enforcement for her CalWORKs cash-aided children. Although her children continue to be eligible for CalWORKs (with a 25% grant reduction), the mother is not eligible for Medi-Cal benefits for herself as long as she remains the children's caretaker and refuses to cooperate.

EW Determines Noncooperation

If the applicant/recipient indicates an unwillingness to complete the medical support requirements, the EW must take the following steps:

  1. Deny or discontinue the parent/caretaker relative in the MFBU due to noncooperation with the Medical Support Requirements by entering the non-cooperation information into the Assign Medical Support Rights field of the CalSAWS Absent Parents page. The noncooperating parent or caretaker relative in the MFBU becomes an ineligible member.

Reminder: All income and resources of the ineligible member are included in the MFBU.

  1. Send a timely Notice of Action.
  2. Document on the Journal Detail page the reason for the action.
  3. Complete and send a CW 371 to DCSS, noting that the parent/caretaker relative refuses to cooperate and does not claim Good Cause.
  4. Establish or continue Medi-Cal for the child(ren).

Note: Restore Medi-Cal benefits if the sanctioned person, who was previously Medi-Cal eligible, subsequently becomes pregnant and pregnancy is verified. Pregnancy Verification is not required for the 200% Income Disregard program (providing pregnancy-related services only).

DCSS Determines Noncooperation

If DCSS determines that a client has failed to cooperate with medical support and the client is not a requesting a Good Cause determination, follow these procedures:

  1. DCSS:
    1. Makes the necessary entries in their system that will cause a task to be created in CalSAWS. The task will indicate the client must be sanctioned for not cooperating with the child support agency.
    2. May send an email to the priority inbox of the appropriate district office for a task to be created.
  2. The EW:
    1. Sends a timely denial or discontinuance NOA.
    2. Denies or discontinues the parent/caretaker relative in the MFBU due to noncooperation with the Medical Support Requirements by entering the non-cooperation information into the Assign Medical Support Rights field of the CalSAWS Absent Parents page. The noncooperating parent or caretaker relative in the MFBU becomes an ineligible member.

Reminder: All income and resources of the ineligible member are included in the MFBU.

  • Documents on the Journal Detail page the reason for the action.
  • Establishes or continues Medi-Cal for the child(ren).

Note: Restore Medi-Cal benefits if the sanctioned person, who was previously Medi-Cal eligible, subsequently becomes pregnant and the pregnancy is verified. Pregnancy Verification is not required for the 200% Income Disregard program (providing pregnancy-related services only.

Action If Client Agrees to Cooperate

When it is the first failure to cooperate and the client responds to the Medi-Cal notice of ineligibility and now wishes to cooperate, the EW must:

  1. Send the client a new CW 2.1 N&A and CW 2.1Q.
  2. Complete the CW 371 indicating that the client now wishes to cooperate in the medical support process.
  3. Send the CW 371 to DCSS.
  4. Reinstate Medi-Cal for the parent/caretaker relative. The eligibility condition will be considered met when the client agrees to cooperate and completes the CW 2.1 N&A and CW 2.1Q. Medi-Cal eligibility resumes the first of the month in which the client cooperates and completes the CW 2.1 N&A and CW 2.1Q. No forms are required to add the client back to the MFBU if he/she is listed on a current statement of facts (SOF) and the SOF was completed within the last 12 months.

Action after Second Noncooperation

If this is the second or subsequent time a client fails to cooperate, the client is NOT eligible again until he/she actually cooperates with DCSS, or establishes Good Cause for not cooperating. The EW must follow the same process stated above to notify DCSS that the client will now cooperate. However, DO NOT REINSTATE Medi-Cal FOR THE SANCTIONED PERSON UNTIL NOTIFIED BY DCSS that cooperation is complete.

Important: Medical support sanctions are suspended if the client becomes pregnant. Restore Medi-Cal for the parent/caretaker relative who is otherwise eligible for Medi-Cal and has reported a pregnancy.

Note: Pregnancy verification is required only if the client is requesting full-scope benefits. It is not required for pregnancy-related services only.

Good Cause Claim after Notice of Noncooperation

If the client responds to the notice and requests a Good Cause determination because there is the belief that the child or caretaker is in jeopardy if the DCSS referral process is completed, the EW must:

  1. Have the client complete a CW 51.
  2. Follow the Good Cause Determination procedures. Refer to Good Cause Determinations. (EAS 82-512, 82-514, CCR 50175, 50771.5, 50185)
  3. Reinstate Medi-Cal to the parent/caretaker relative. If the SSPM determines that Good Cause does not exist, take appropriate action.

Failure to Turn in Direct Medical Support

It should be a rare situation when a client receives direct medical support payments which are specifically for medical care; however, if this occurs and the client fails to turn it in to the SDU, the EW must:

  1. Send a letter informing the client of the responsibility to turn in direct medical support payments.
  2. Send a timely (10-day) NOA and discontinue Medi-Cal for the parent/caretaker relative if he/she fails for a second consecutive month to turn in direct medical support payments. The sanctioned person is an ineligible member of the MFBU. Discontinue the parent/caretaker relative due to noncooperation with the Medical Support Requirements by entering the non-cooperation information into the Assign Medical Support Rights field of the CalSAWS Absent Parents page.

    1. Reminder: Continue to count all income and resources of the sanctioned person.

  3. Continue Medi-Cal for the child(ren) in the MFBU.
  4. Count the direct medical support payment as unearned income and allow the disregard.

    1. Note: If Direct medical support is received for a health insurance premium, the health insurance premium remains an allowable deduction to the MFBU. Refer to “Medi-Cal Only - Direct Medical Support” (CCR 50175, 50185).

Action When Client Agrees To Turn in Direct Medical Support

If the client is sanctioned for failing to turn in direct medical support, the EW must reinstate the client's Medi-Cal when:

  • The client begins turning direct medical support payments over to the SDU, or
  • The absent parent begins making medical support payments to the SDU, or
  • The client certifies on the MC 176S or on a "Sworn Statement" (GEN 853) that no medical support payments from the absent parent are received.

Missed Appointment

When the EW receives notification from DCSS that the client has failed to cooperate and the EW is aware that the client had a good reason for not keeping the appointment, the EW must:

  • Contact DCSS using the "Social Services Agency (SSA)/Local Child Support Agency (LCSA) Communication Form" (SCD 1603),
  • Provide the reason why the appointment was missed, and
  • Ask DCSS to reschedule the client's appointment.

Good reasons for a missed appointment include the client or client family's illness, hospitalization, or other acceptable reason.

Paternity Sanction

In establishing paternity when both parents are living in the home, both parents are ineligible for Medi-Cal if either one fails or refuses to cooperate in this process. The mother must complete and sign the required medical support forms to establish paternity. If she does not cooperate, both she and the unmarried father in the home are ineligible for Medi-Cal.

Note: The unmarried father in the home may assist the mother in completing the forms to provide paternity information about himself, but THE MOTHER must sign the forms.

Related Topics

Child/Medical Support Overview

Parental Responsibility