|
|
Carry Forward (APTC/QHP to MAGI)
When an Advanced Premium Tax Credit (APTC)/Cost Sharing Reduction (CSR)/ Qualified Health Plan (QHP) client reports a change that result in termination of APTC/CSR/QHP health coverage, the client(s) are placed into a Carry Forward Hold. During the Carry Forward Hold the Covered California health plan will continue, if the client continues to pay their portion of the premium, until a full MC evaluation is completed by an EW and the Carry Forward Status (CFS) is lifted.
During this process, the EW may have to request additional information from the client if it is necessary to make a final MC eligibility determination. Clients may also submit additional verification if they feel it would impact their determination. All clients have the option of keeping their Covered CA health plan if they do not want MC; however, they will have to pay the full premium out of pocket cost for the Covered CA plan. No APTC will be provided. To keep coverage with their Covered CA health plan, clients can call their Covered CA health plan directly. This is considered a QHP and in CalSAWS appears as an X7 aid code.
Covered CA to Medi-Cal Referral Process
Covered CA benefits (APTC/CSR/QHP) will always end December 31st of the current year and clients will need to reestablish eligibility for January 1st of the following year. During the Covered CA annual redetermination process, the Covered CA client may be determined potentially eligible for the MC program. This occurs when the client actively completes the redetermination process or during the ex-parte review conducted by Covered CA.
A client may also be determined to be potentially eligible for MC following a Report a Change (RAC) in CalHEERS or if income changes outside of their renewal period including:
• Decreased earnings,
• An increase/addition of tax dependents, and/or
• Updates to the Federal Poverty Limits (FPLs).
When a Covered CA client is determined potentially eligible for MC, the client is referred to the Social Services Agency for a final determination. CalHEERS sends the case to CalSAWS using the e-HIT process and creates a Determination Eligibility Response (DER) (if there is already an open CalSAWS case, i.e. children on OTLIC and parents are APTC) in CalSAWS. Case information received in the DER will reflect the initial application date from the last Covered CA open enrollment or special enrollment period or the date of the RAC. An EW must complete an MC eligibility determination and provide adequate notice for approval, discontinuance, or denial of MC benefits. Carry Forward cases and clients may have Eligible, Pending Eligible, or Conditionally Eligible MC status.
CARRY FORWARD HOLD REFERRALS ARE HIGH PRIORITY
Notification
Covered CA mails an NOD64 "Covered California Carry Forward" notice.
Following the MC determination the regular MC NOA requirements apply.
Premium Reimbursement
If a change is processed and the client is now eligible for MC, clients are not able to request refunds of premiums paid to Covered CA plans. Reimbursements for payments made into the client’s APTC plan will also not be granted for retroactive MC months during the Carry Forward period, however retro MC may help with unpaid medical bills for those months.
Dual Coverage
A person, who is enrolled in a QHP with APTC and later becomes eligible for MC, is not disqualified from receiving APTC until the month following the MC approval, even if MC coverage is retroactive. For tax related questions clients can be referred to the Internal Revenue Service.
Retroactive MC Coverage
CalHEERS will allow MAGI to be granted retroactively for three months prior to when the individual in a CFS enters the Insurance Affordability Program (IAP) transition month. This will only be done if client requests retro MC and is otherwise eligible. MC 210 A is still required.
Note: If the APTC client reports a change through Covered California that makes them eligible for MAGI, the IAP transition month will always be the month the change was reported, regardless of when the EW processes it in CalSAWS. If the change is reported outside of Covered California, the IAP transition month is whatever month the EW actually processes it. It is important to process timely so clients do not lose out on any retro MC months that they request and may be eligible for.
Any months run prior to the three retro months will be denied by CalHEERS/CaSAWS. Denial NOA will not be triggered and is not necessary in this situation
Related Topics