Soft Pause

 

Soft Pause protection is applied to prevent clients from being discontinued from MAGI MC when a CIC is reported by clients, via an annual renewal, or other review that results in certain adverse actions and clients are not eligible for one of the Consumer Protection Programs (CPP) implemented by CalHEERS (currently only Deemed Infant).

Soft Pause protection is only applied by CalHEERS. CalHEERS can send Soft Pause via a change DER or a solicited DER. When an individual is placed on Soft Pause protection by CalHEERS, the EW must determine if the individual is potentially eligible for Non-MAGI MC. Clients must maintain their prior eligibility until the EW has re-evaluated the case based on an ex-parte review (all income and property verifications must be within 90 days) and/or a response to the Non-MAGI MC Screening Packet.

When more than one individual is placed on Soft Pause at the same time in a case, only one (1) Non-MAGI MC Screening Packet must be sent to the household if the case cannot be reevaluated for MC eligibility based on the ex-parte review process. Soft Pause protection has been applied to intake cases when the initial MAGI eligibility assigned by CalHEERS changes during the application process. For example, when the income verified by the EW makes the client lose MAGI eligibility. EWs will be able to lift Soft Pause if this occurs.

 

Example:Example:An Intake EW receives a CalHEERS External Referral Data (ERD) application which has already been approved for MAGI MC. After reviewing the application, the Intake EW discovers the client entered incorrect income information. Once the Intake EW verifies and updates the correct income in CalSAWS, the client is placed on Soft Pause because the client’s income is over the MAGI MC income limit. The Intake EW lifts the Soft Pause and dispositions the MC application as appropriate.

 

The negative actions for MAGI MC that will trigger a Soft Pause protection are:

• Moving from MAGI MC eligibility to Advanced Premium Tax Credits/Cost Sharing Reductions (APTC/CSR)

• Losing MAGI MC eligibility (e.g. a 64-year-old individual (aid code M1) turning 65 years old).

• Changing from full scope MAGI MC to limited or restricted scope MAGI MC.

• Changing from full scope MAGI MC to pregnancy-related MC.

 

Soft Pause can apply to the following populations:

• Children under 21,

• Aged, Blind, and Disabled (ABD) persons,

• Parent/Caretaker Relative of a child under 21, and/or

• Pregnant women or women in the 365-day postpartum period.

 

Soft Pause Functionality

 

The CalSAWS Project has created functionality to lift Soft Pause in CalSAWS and send the information to CalHEERS. EWs are able to lift (release) Soft Pause and CalSAWS will continue to send the Soft Pause Lift to CalHEERS until the case is authorized. When Soft Pause is lifted, the change will take effect in the future month. 

To lift Soft Pause in CalSAWS [Refer to Job Aid: Medi-Cal-MAGI Soft Pause].

 

Note: Soft Pause protection can be manually lifted in CalSAWS. It currently cannot be lifted directly from within the CalHEERS portal.

 

Example:Example:If an EW lifts Soft Pause in May and authorizes the case, then the change will be effective in June to allow for a timely 10-day Notice of Action (NOA). However, if the Soft Pause lift is completed after May NOA cutoff, then the change will be effective in July.    

 

CalHEERS will reapply Soft Pause again after it has been lifted and the case is run back at a later time.

 

Example:Example:Soft Pause is applied on May 5th but it is lifted by an EW for June. It is now July and the client had reported another change on May 15th but no action was taken at that time. The EW makes the change now in CalSAWS and reevaluates the case for May and future months. CalHEERS reapplies Soft Pause effective May, June, and July. The EW will need to lift Soft Pause again and run EDBC for those months (i.e. May, June, and July). Once the DER is received, the EW will run EDBC again and authorize the case.

 

Example:Example:Single, non-disabled, 28-year-old (aid code M1) receiving MAGI MC reports a change in income over 266% FPL on May 4th. The client is put on Soft Pause and is eligible for APTC. The EW mails the Non-MAGI MC Screening Packet and allows 30 calendar days for the packet to be returned. The client fails to respond with the necessary information and verifications within 30 calendar days. The EW mails an SCD 50 requesting missing information and verifications, and allows another 10 calendar days. The client still fails to respond with the necessary information and verifications after 10 calendar days. The EW lifts the Soft Pause in June that will take effect in July. The EW runs EDBC, authorizes the case, and CalSAWS automatically closes the case.    

 

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