Redeterminations

Individuals eligible for Medi-Cal (MC) are required to complete a redetermination annually and may be required at other times in accordance with general standards established by the Department of Health Care Services (DHCS).

The client must not be requested to provide information that is not relevant to ongoing eligibility or that has already been provided with respect to eligibility criteria not subject to change (i.e. date of birth, social security number, or U.S. citizenship).

Frequency & Timeliness

Individuals or families receiving MC must have an eligibility redetermination (RD) within 12 months of:

An approval of eligibility on any application, reapplication, or restoration which requires a Statement of Facts, or
The last annual RD, or
A (CIC) that triggers an eligibility redetermination.

The first RD must be completed by the last day of the twelfth month counting from the application month as the first month of eligibility. Each RD date after that is set for 12 months.

If the client submits the MC RD on the last day of the 12th month, it is considered timely.

The client is not required to complete the RD sooner than the eleventh month following the initial application, reapplication or most recent RD.

The RD due month does not change if the RD is completed early.

Note: Each case record must contain adequate information with supporting documents to verify an individual's eligibility. All reported eligibility information must be consistent with verifications, case history, and case documents.

MC RD Due Date

The annual MC RD due date is set from the first day of the application month in most cases. The following five examples describe when the RD is due in specific situations.

Example: Applicant is eligible from the first day of the application month

Application date	1/21/2016
Application approved	2/15/2016 (MC eligibility is effective 1/2016)
Eligibility effective date	1/1/2016
12th month ends (RD due)	12/31/2016

Initial 12-month Period

1/2016	2/2016	3/2016 to 11/2016	12/2016
Month 1	Month 2	Months 3 to 11	Month12
Application Month	Approval Month		RD Due Month
Eligible	Eligible	Eligible	Eligible

New 12-month Period

New 12 month period begins	1/2017
Next MC RD due	12/2017

1/2017	2/2017 to 11/2017	12/2017
Month 1	Months 2 to 11	Month 12
New 12-month begins	Eligible	Next RD Due

Example: Applicant is eligible for retroactive benefits

The RD due month is set from the application month, even if the person is granted retroactive benefits for any of the three months before the application month.

Application date	1/21/2016
Retro MC Requested	11/2015 & 12/2015
Application approved on	2/12/2016 (MC eligibility effective 11/2015)
Eligibility exists for both Retro months (11/2015 & 12/2015) and application month (1/2016)
12th month ends (RD due)	12/31/2016

Initial 12-Month Period with Retroactive Months

11/2015	12/2015	1/2016	2/2016	3/2016 to 11/2016	12/2016
Retro Month	Retro Month	Month 1	Month 2	Months 3 to 11	Month 12
Retro Eligibility	Retro Eligibility	Application Month Eligible	Approval Month Eligible	Eligible	First RD Due

The retroactive months of 11/2015 and 12/2015 are not counted in the 12-month period because the application was received in 1/2016. The new 12 month period is 1/2016 - 12/2016.

Example: Applicant is not eligible in the month of application

If the applicant does not meet all of the eligibility criteria during the month of application, the RD month is set from the first month in which the applicant meets all eligibility criteria. The first month in which the applicant meets all eligibility criteria is the initial month of eligibility. For example, a Non-MAGI MC applicant who has excess property in the month of application will have to spend down before eligibility criteria are met..

Application date	1/21/2017
No eligibility for 1/2017 & 2/2017
Application approved on	3/2/2017 (MC eligibility effective for 3/2017 & forward)
Initial month of eligibility	3/2017
12th month ends (RD due)	2/2018

Initial 12-month Period

01/2017	02/2017	03/2017	04/2017 to 01/2018	02/2018
MC ineligible	MC ineligible	First Eligible Month	Eligible	First RD due

New 12-month Period

New 12 month period begins	3/2017 - 2/2018
Next MC RD due	2/2018

Example: Family members have different initial eligibility dates

There are situations where one application covers one or more tax households and/or household members who are eligible in the month of application, and others who do not meet eligibility criteria until a later month or are added to the case during the 12-month period.

In these situations, the household members who were determined eligible first will set the MC RD due date for all household members in the case. New members who are added to the case do not get their own separate MC RD due date from other members already in the case. The change in income is considered a CIC.

Application date	1/21/2016
Application approved for two children in OTLIC program	1/2016
Parents are not eligible for MAGI MC in 1/2016 due to income. Parents report decreased income in 2/2016
Parents become eligible for MAGI MC due to decreased income	2/2016
Original 12th month ends	12/31/2016
Original MC RD due for all household members	12/2016
New MC RD due date because of CIC (Report of decreased income allows the parents to receive MC eligibility)	2/2017

1/2016	2/2016	3/2016 to 11/2016	12/2016	2/2017
Month 1	Month 2	Months 3 to 11	Month 12
Application Month; Children are eligible; Parents are over income for MAGI MC.	Parents are eligible due to less income	All household members are eligible	MC RD due for parents & children	New MC RD due date because of CIC

New 12-month Period

New 12 month period begins	2/2016 - 2/2017
Next MC RD due	2/2017

Example: A household with two children eligible for the CEC program and a third child moves into the home

The household now has three children with different CEC periods.

Application date for parents (Aria & Enzo), child #1 (Lucas) & child #2 (Emma)	1/21/2016
Application approved	2/2/2016 (MC eligibility effective 1/2016)
Child #3 (Chloe) was on MC in another household with a CEC period from	4/2016 - 3/2017
Chloe moves into the home	5/2016
Original MC RD due	12/2016
New MC RD due date because of CIC (Adding Chloe to the home)	5/2017
CEC period for Chloe, Lucas & Emma	6/2016 - 5/2017
New MC RD due date because of CIC (Adding Chloe to the home)	5/2017

Initial 12-month Period

1/2016

2/2016

3/2016 to

4/2016

5/2016

6/2016 to

11/2016

12/2016

5/2017

Month 1

Month 2

Month 3 to 4

Month 5

Months 6 to 11

Month 12

App. month for

parents, Lucas &

Emma eligible

with no share of

cost (SOC)

App. approval

month

MC eligible

Chloe returns

home with own

CEC period

MC eligible

New CEC for all

children

Annual RD Due

for household,

CEC ends for

Lucas & Emma

MC RD

due

The CEC period for Chloe continues until 3/2017 even if eligibility changes for the other household members at the annual RD. At the end of Chloe's CEC period, an ex parte eligibility review must be completed for Chloe.

MC RD Due Date for DDSD

During the application process, if the applicant alleges a disability, forward the disability packet to the Disability Determination Service Division (DDSD) for a disability evaluation. The county has 90 days to make a final eligibility decision for applications based on disability, excluding delays by the State. When the decision is received confirming an applicant's disability, then complete the MC eligibility process.

The applicant is determined eligible for MC effective the first day of the month of application. The MC RD must be completed by the last day of the 12th month.
If MAGI MC eligibility exists, approve the individual with a MAGI MC aid code and still forward the packet to the DDSD for a disability evaluation.

Example: A client applies for MC on 1/5/2017 and claims disability

Application Date	1/5/2017
DDSD Packet Sent	1/14/2017
DDSD Approval Decision	3/10/2017
Eligibility Effective Month	1/2017
12th Month Ends (RD Due)	12/2017
Next MC RD	12/2018

If the DDSD decision approving disability is received after 90 days, but prior to the last day of the 11th month, complete the normal RD process. Mail the RD packet to the client and allow 30 days for the client to provide the necessary information. The RD must be completed by the last day of the 12th month.

Example: A client applies for MC on 1/5/2016

The EW mails the DDSD referral packet on 1/12/2016, but DDSD provides a decision after 90 days.

Application Date	1/5/2016
DDSD Referral Packet Sent	1/12/2016
DDSD Approval Decision	6/20/2016
Eligibility Completed	8/20/2016
Eligibility Effective Month	1/2016
12th Month Ends (RD Due)	12/2016
Next MC RD	12/2017

DDSD Evaluation is Received After the 11th month

There are instances where receipt of the disability decision extends beyond the 11th month from the date of application. The county has 90 days to make a final eligibility determination for applications based on disability, excluding delays by the State. If the DDSD decision confirming disability is received after the 11th month, do NOT complete the normal annual RD process. Instead, review the case and determine if an eligibility determination can be made based on the information in the case or other available information. If there is insufficient information, contact the client to find out if there were changes that occurred that impact eligibility since the application date.

DO NOT send the MC RD forms to obtain updated information. If the applicant is determined MC eligible as of the application date, then the beginning date of eligibility is the first day of the application month. The RD due month is set 12 months from the date the applicant is determined eligible for MC.

Example:

Application Date	1/5/2016
DDSD Packet Sent	1/12/2016
First MC RD due:	12/2016
DDSD Approval Decision	6/9/2017
County Received DDSD Decision	6/15/2017
Eligibility Completed	8/15/2017
12-month period:	8/2017 to 7/2018
Eligibility Effective Month	1/2016
First MC RD Due	7/2017
Next MC RD Due	7/2018

Note: If the case is originally approved under Presumptive Disability (PD) as of January 2016 pending the disability determination from DDSD, the RD is still in December 2016 on the PD case.

MC RD and CalWORKs

If the CalWORKs (CW) application is approved, the MC RD date changes. The EW will determine eligibility for all family members using the new information contained on the CW application and update the eligibility status of the entire case as follows:

If all family members are approved for CW, then the MC only case no longer exists and the RD date is set based on the CW application month.
If there are family members who remain MC only eligible, the next MC RD date will be set 12 months from the CW application month.

When a client is receiving MC and later applies for CW, but is denied CW, the MC RD due date does not necessarily change. However, if the client reports on the CalWORKs application a change in a data element that requires a redetermination of eligibility for MC the MC RD due date may be reset to a new 12-month period. Refer to Change in Circumstance

Reminder: When processing a CW application, the MC program must be reevaluated.

MC RD Date when the CalWORKs Case is Discontinued

When a client is discontinued from CW for failure to complete the annual RD, the individuals are placed into aid code 38 pending a MC only determination. During this timeframe:

The case will have an overdue annual RD while the clients continue to receive MC benefits.
Follow the ex parte process (all available information within 90 days can be used to make a MC eligibility evaluation).
- If there is not enough information from the ex parte process to complete a MC eligibility determination, then mail out the appropriate MC RD forms to the client during the month after the CW case is discontinued using the same procedures required for processing a MC RD.
Transition the case to ACA (if necessary).
The client must be given at least 30 days to return the MC RD forms or provide the requested information. The ex parte process applies if the MC RD forms are returned or the information is provided timely, but are incomplete.
Upon completion of the MC RD, a new 12-month period is set as follows:

10/2016	11/2016	12/2016	1/2017	2/2017 to 11/2017	12/2017
CW RD disc. for no RD	MC RD pending (aid code 38)	MC RD completed (aid code 38)	New 12-Month period begins	MC eligible	MC RD Due

Note: If there are children in this household, the CEC period for the children is 1/2016 - 12/2016.

MC RD and Former Foster Youth

Former Foster Youth (FFY) clients do not have to meet income and property rules and do not have a SOC. The only requirements for an annual MC RD under the FFY program is confirmation of:

The FFY wants MC to continue, and
California residency.

EWs may obtain this information by contacting the client by telephone or mailing the MC 250A.

FFY should not receive any of the MC RD forms such as MC 216, MC 210 RV, etc., unless they are part of a household where other household members must complete a Non-Foster Care MC evaluation to continue their MC benefits.

FFY up to age 26 must not be discontinued due to a loss of contact or for not responding to the county at annual MC RD.