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Transitioning from MAGI MC to Non Magi or APTC
When a client reports a change during or outside of their MC RD that requires a redetermination of eligibility, the result may require the case to be transitioned from MAGI MC to Non-MAGI MC and/or APTC. This process, known as CIC, requires the MC RD due date to be reset to a year from the reported change(s) via CalSAWS. When a change of circumstance results in the reset of the MC RD due date, the client must be notified by his/her preferred method of contact. EWs also need to mail the MC 219 to the client and document that it was mailed in the Journal Detail page.
MAGI MC Ineligibility
When a client is determined to be ineligible for MAGI MC, the EW must complete an ex-parte review (all income and property verification must be within 90 days) and/or send out the Non-MAGI MC Screening Packet. An eligibility determination for a Covered CA healthcare program will happen automatically at the same time in CalSAWS. The client may or may not be placed into Soft Pause. The instructions below shows the process to follow for the Non-MAGI MC Screening process. The client only needs to provide the information required to determine ongoing eligibility along with paper verifications if necessary. (i.e. pay stubs, etc.)
Note: For a Non-MAGI MC eligibility determination, the e-verification of income by the Federal Hub cannot be used; paper verification of income must be obtained from the client.
Clients can have SOC Non-MAGI MC eligibility and APTC simultaneously. The EW must assist the client with their Covered CA health plan selection to the fullest extent possible.
If the client is placed into Soft Pause, the EW must complete an ex-parte review (all income and property verification must be within 90 days) and/or mail a Medi-Cal request for information (MC 355) and allow 30 days.
If the necessary verifications are provided, then:
• Lift Soft Pause [Refer to Job Aid: Medi-Cal MAGI Soft Pause]
• Evaluate the case for Non-MAGI MC.
• Mail appropriate NOAs.
• Check MEDS in 2 business days.
• Make sure CalSAWS, CalHEERS, and MEDS match.
• Document actions in the Journal Detail page.
If the necessary verifications are not provided, then:
• Lift Soft Pause [Refer to Job Aid: Medi-Cal MAGI Soft Pause]
• Discontinue the individual(s).
• Mail appropriate MAGI MC discontinuance NOA.
• Check MEDS in 2 business days.
• Make sure CalSAWS, CalHEERS, and MEDS match.
• Document actions in the Journal Detail page.
If the client is not placed into Soft Pause but automatically approved for Covered CA and CalSAWS case closed, then the EW must complete an ex-parte review (all income and property verification must be within 90 days) and/or mail a Medi-Cal request for information (MC 355) and allow 30 days.
If the necessary verifications are provided, then:
• Rescind the CalSAWS case.
• Evaluate the case for Non-MAGI MC.
• Mail appropriate NOAs.
• Check MEDS in 2 days.
• Document actions in the Journal Detail page.
If the necessary verifications are not provided, then:
• Mail appropriate MAGI MC discontinuance NOA.
• Check MEDS in 2 days.
• Make sure CalSAWS, CalHEERS, and MEDS match.
• Document actions in the Journal Detail page.
Optional Forms for Non-MAGI MC Screening
This includes:
• “Non-MAGI Informing Letter” (CSC 99)
• “Non-MAGI Medi-Cal Brochure” (Pub 10 in CalSAWS)
The CSC 99 “Non-MAGI Informing Letter” has multiple objectives:
• Informs the beneficiary that he/she does not or no longer qualifies for MAGI MC.
• Informs the beneficiary that he/she may still qualify for Non-MAGI MC.
• Provides a brief overview of Non-MAGI MC and APTC/CSR.
• Informs the beneficiary that he/she may still be eligible for either free MC or SOC MC if found eligible when the requested information is returned to the county.
Mixed MC Cases (MAGI MC/Non-MAGI MC)
The information provided above still applies to mixed MC cases. However, if a client has reported a change, the EW must be in receipt of all current necessary verifications prior to redetermining MC eligibility and resetting the MC RD due date. This includes current property and income information (i.e. paper verifications) for all individuals in the case, including individuals already active with Non-MAGI MC eligibility.
Children turning 19 years old
Children who turn 19 years old and age out of the MAGI MC OTLIC program, may still be eligible for the adult, parent/caretaker relative, or pregnancy MAGI MC coverage group or Non-MAGI MC.
Individuals turning 65 years old
Each month there is a population of Modified Adjusted Gross Income (MAGI) Medi-Cal (MC) NON-parent/caretaker relative and/or NON-pregnant individuals who will be turning 65 years old and, as a result, they will no longer be eligible for MAGI MC due to their age.
Medicare
If clients receiving aid code M1 report they have been approved for Medicare and they have started receiving it, then they are no longer eligible for aid code M1. The EW must review the case and determine if the client is still eligible for MAGI MC through the parent/caretaker relative and/or pregnancy coverage group. If the client is not eligible, then follow the same process from the MAGI MC Ineligibility section.
MAGI MC to APTC
Whenever there is a change and MAGI MC is reevaluated which results in all family members becoming eligible for APTC ONLY, the CalSAWS case will close automatically. However, the APTC ONLY case will remain open in CalHEERS. For these cases, Covered CA is responsible for case maintenance; however, if an APTC ONLY household reports a change to the county, then an EW must update the information into CalHEERS.
Note: For an APTC household with CCHIP, the information directly above still applies. The no “wrong door” policy applies to CCHIP.
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