Suspension of Medi-Cal Benefits for Incarcerated Juveniles

[Senate Bill 1147, WIC 140.29.5]

SB 1147, along with WIC Sections 14029.5 and 14011.10 requires the suspension of Medi-Cal benefits instead of discontinuance for individuals under 21 who were Medi-Cal beneficiaries on the date they became an inmate of a public institution. In addition, SB 1147 requires restoration of Medi-Cal benefits on the day an eligible juvenile is no longer an inmate.
SB 1147 applies to juveniles who meet all of the following requirements:

Are Medi-Cal beneficiaries at the time of incarceration,
Comply with annual RD requirements during incarceration,
Remain otherwise eligible for Medi-Cal during incarceration,
Are no longer considered an inmate of a public institution within one year of their incarceration date, and
Are Medi-Cal eligible on the day they are released.

Suspension date

Suspension of Medi-Cal benefits begins on the date the youth becomes an inmate of a public institution. The suspension of Medi-Cal benefits ends on the soonest of:

The date the youth is no longer an inmate, or
The end of the month of the one year period, or
The end of the month the juvenile turns 21 or 26, or
The end of the month a juvenile becomes ineligible for Medi-Cal (i.e., has placed in a facility outside of California).

Process for Suspending Medi-Cal Benefits

When the FC EW learns of a juvenile’s incarceration reported by the juvenile’s SW/PO, the FC EW must:

Determine if the incarcerated juvenile is in a Child Only Medi-Cal case.
1. Note: FC EW will not process cases with other family members.
Medi-Cal eligibility is suspended effective the date he/she becomes an inmate of a public institution. A notice that Medicaid is suspended must be mailed as soon as the youth’s institutionalized status is reported.
When Medi-Cal eligibility is discontinued for an incarcerated juvenile while under suspension, he or she must receive a proper 10-day notice about the discontinuance and the end of the suspension.
For the first year of a juvenile’s incarceration all standard redetermination requirements apply. If redetermination requirements are not met for an incarcerated juvenile, suspension of Medi-Cal eligibility must end with a proper 10-day notice.
The juvenile’s eligibility must be suspended with a proper notice (mailed in sufficient time to reach the beneficiary by the effective date of the action).
Benefits are restored for juveniles on the date the Release Date is reported reflecting the date the juvenile is no longer considered an inmate. The juvenile will be able to access covered Medi-Cal services as of the Release Date entered into MEDS if they are still Medi-Cal eligible. When suspension ends due to release, the appropriate NOA must be sent to inform the family or caretaker that Medi-Cal benefits are restored.

Suspension of Medi-Cal for Incarcerated Juveniles in Child Only Medi-Cal Cases

To suspend eligibility for incarcerated juveniles in Child Only Medi-Cal cases, an online MEDS transaction is used to report the incarceration information on the “Institutionalized Client Update” MEDS screen. MEDS will set an OHC Code value of “I” to identify suspension of Medi-Cal.
MEDS will add the “I” OHC code to the MEDS record when a Suspension Start Date is reported to MEDS. When Medi-Cal benefits are suspended for a juvenile due to incarceration, a proper notice of action must be sent to notify the caretaker relative and the assigned SW/PO about the suspension of benefits. This notice must be mailed in sufficient time to reach the beneficiary by the effective date of the action.
MEDS will end suspension of benefits on the date reported to MEDS reflecting either the date the juvenile is no longer an inmate of a public institution, or the first of the month following the month in which the juvenile loses eligibility during incarceration. The juvenile will be able to access Medi-Cal covered services as of the Release Date entered into MEDS if they are still eligible for Medi-Cal. The Health Insurance System (HIS) database will be updated immediately to show the day prior to the Release Date as the end date of the suspension.
The ‘I’ OHC code will still appear on the MEDS record until the following month but will not adversely affect the juvenile’s eligibility once the suspension end date is reported. When suspension of Medi-Cal benefits ends because a juvenile is released, an appropriate notice must be sent to inform the family or caretaker relative that Medi-Cal benefits are restored.
When an incarcerated juvenile in a Child Only Medi-Cal case whose Medi-Cal has been suspended becomes ineligible during the first year of incarceration, turns 21, or is incarcerated for more than one year, eligibility must be terminated. The FC EW must confirm that the termination action has updated MEDS and request an online MEDS transaction to report the suspension end date. This will remove the “I” OHC code, which is necessary when eligibility and/or suspension ends for any reason. A proper 10-day NOA must be sent explaining the reason for termination of Medi-Cal eligibility and the right to request a Fair Hearing.

Impact on Eligibility for Child Only cases

When benefits are suspended, eligibility must be reviewed at the next annual RD if it is due during the first year a juvenile is an inmate of a public institution. The FC EW must confirm that the juvenile is still an inmate and is otherwise eligible for Medi-Cal. The ex parte review process of contacting the assigned SW/PO is necessary. Verbal contact added in CalSAWS journal entry is acceptable. If there is no information that would impact the juvenile’s Medi-Cal eligibility, suspension continues until the end of the last month of the one year period of incarceration, the end of the month the juvenile turns 21, or the date of release, whichever is sooner.
If a juvenile becomes ineligible for Medi-Cal during the first year of incarceration, the suspension must end at the end of that month and eligibility terminated with a 10-day NOA explaining the discontinuance reason and the right to request a Fair Hearing.
If a juvenile is incarcerated for more than one year, MEDS will send an alert 60 days prior to the end of the suspension period to remind the EW to terminate Medi-Cal eligibility at the end of the last month of the one-year period and send a NOA explaining the reason for discontinuance and the right to request a Fair Hearing. The NOA must be mailed in sufficient time to reach the beneficiary by the effective date of the action.
When suspension ends because the juvenile is released within one year of the suspension date entered, MEDS will end the suspension and restore Medi-Cal effective as of the end date. EWs should assist the client as needed to ensure benefits are restored on the date of release.
If suspension ends because a juvenile turns 21 while incarcerated, eligibility must be discontinued with a proper NOA only after an SB 87 redetermination. The EW must determine the juvenile is not eligible under another Medi-Cal program before eligibility is terminated. MEDS will send an alert 60 days prior to the youth’s 21st birthday to discontinue Medi-Cal if appropriate.

Notice of Action Requirements

The Notices of Action (NOAs) for SB 1147 are as follows:

The “Notice of Action Suspension of Medi-Cal Benefits for an Incarcerated Minor” (MC 0377) must be sent when the Medi-Cal eligibility of an incarcerated juvenile is suspended. The NOA must be mailed in sufficient time to reach the client by the effective date of the action and a copy of the NOA if must be sent when applicable to the assigned SW/PO.
The “Notice of Action Restore Medi-Cal Benefits Upon Release of an Eligible Minor” (MC 0376) must be sent when benefits are restored to a juvenile because he/she is no longer considered an inmate. A copy of the NOA when applicable must be sent to the assigned SW/PO.
The “Notice of Action Discontinuance of Benefits” (MC 0377) must be sent with proper 10-day notice when the Medi-Cal eligibility of the incarcerated juvenile is terminated while he or she is under suspension. A copy of the NOA when applicable must be sent to the assigned SW/PO.

MEDS Screens

The “Institutionalized Client Update Screen” is used for entering information on incarcerated juveniles in Child-Only cases. This screen will accept manual entries to the “Suspension Start Date” and the “Release Date” fields. Once information is entered on this screen, MEDS will immediately update the HIS database with the Suspension Start Date (and Release Date, if reported) and create a transaction to update MEDS with an OHC code of “I” for the suspension months reported.

MEDS will remove the OHC indicator “I” for the month following the Release Date month when Release Date is reported to MEDS. Staff may view the information entered about the incarcerated juvenile by choosing the VIEW INSURANCE SEGMENT option from the HIS action request menu.

Note: The Suspension Stop Date cannot be reported to MEDS in advance. The MEDS update must be done on or after the reported Release Date.