Telephonic Signature Process

Clients can provide all RD information over the phone, rather than submitting a paper packet. The RD is only considered complete, in this circumstance, when all information/verification is provided and a Telephonic Signature has been obtained. For RDs completed over the phone (when a packet hasn’t been returned), the EW can use the RD Packet to collect all necessary information.

If the client has provided a paper packet, but failed to sign it, a signature must be obtained in writing, or the EW must complete the full Telephonic Signature process, including a discussion of what was reported in the packet.

[Refer to Job Aid (JA): Electronic Signature (e-Sign) in CalSAWS for detailed system entries.]

MC 219

If the client prefers, the MC 219 can be read over the phone, however, this is not a requirement for Medi-Cal RDs like it is for other programs. Mailing the MC 219 is also sufficient. EWs must document, how the MC 219 was provided.

MC RD Packet Sent by CalSAWS Print Vendor

The process for sending and receiving the MC RDs is as follows:

Step	Who	Action
Step 1.	CalSAWS	Provides a file to the print vendor of all the auto-generated required MC RD forms for the future-future month’s MC RDs. Example Example On April 22nd CalSAWS will provide a file of all MC RDs without an AR due in June.
Step 2.	Print Vendor	Prints the barcoded MC RD forms out of CalSAWS. Creates the entire MC RD packets (required and informational forms). Mails the MC RD packets to the clients at least 60 days prior to the due month. Example Example The Print Vendor will mail, at the end of April, the MC RDs without an AR due in June.

Receiving MC RD Information Verbally

The general process on how to handle situations in which the client provides the MC RD information verbally (i.e. via phone or in person) varies as each District Office has the discretion to modify this process based on their individual operational needs, as long as it does not go against MC policy, the process can be modified accordingly.

Designated staff must take the following steps to manually log in the receipt of MC RD forms submitted without a barcode (e.g., original RD forms were generated and mailed during the batch process, and the client returns another RD form created outside of the CalSAWS automated system).

MAGI MC RD Overview Chart

The following chart illustrates a basic overview of the three processes that can occur for MAGI MC RDs:

 

 

Individual Level Determinations at MC RD

CalSAWS determines MC eligibility at the individual level during the MC RD automated renewal process. When individual(s) e-verify during the MC automated renewal process, their eligibility will remain in approved status and the CalSAWS case will remain active while any non e-verified individual(s) complete the MC RD process. If all individuals do not e-verify within the MAGI program income limit, a MC renewal packet will be sent for the individuals who did not e-verify.

ExampleExample

During the MC RD due month, CalSAWS will send an additional EDR for a MC eligibility determination two days prior to NOA Cut off and discontinue only the individuals who did not e-verify and did not complete the MC RD process. CalSAWS will automatically generate and send discontinuance NOA’s for any discontinued individuals.

Note: The 90 day cure period remains in effect for any individuals discontinued for MC due to not completing the MC RD process.

System Generated Case Comments

When an individual level determination is completed in the MC Renewal month and a MC Renewal packet is not received by NCO, CaSAWS will auto-generate case comments detailing which MAGI MC individual(s) e-verified and remain eligible and which individual(s) did not e-verify and were discontinued from MAGI MC. CalSAWS will auto-generate a separate entry for each individual.

Soft Paused Individuals at Renewal

CalSAWS will prevent the auto-extension of the renewal date for MAGI only cases where all individuals have been e-verified and any individual is in a Soft Pause protection. Because all individuals have been e-verified, CalSAWS will not trigger Renewal Packets and will prevent Negative Action at NCO for failure to complete the redetermination for MAGI only cases. In order to extend the renewal date, the RD must be manually run in CalSAWS and the Soft Paused individual must be released and transitioned into a proper aid code. For detailed Soft Pause system entries [Refer to Job Aid (JA): Medi-Cal MAGI Soft Pause].

Reminder: The CalHEERS Manual Verification page(s) showing e-verified income of each individual must be printed and sent to IDM as a verification before running EDBC in CalSAWS.

How to Identify These Cases in CalSAWS

The following case alert will auto-generate and TMTS will be created monthly:

• Alert 522 – “The RRR is due in 75 days for case with Soft Pause individuals. Case will not be automatically renewed. The manual RRR needs to be completed.”

The following case comment will auto-generate:

• “Renewal Date for MAGI case will not be extended because one or more individuals are on Soft Pause.”

The following case comment will only auto-generate on the 91st day if the RRR and soft pause release are not manually processed within the 90-day cure period from renewal due date (case will not  automatically discontinue since all members e-verified):

• “Renewal Date for MAGI case will not be extended after the 90-day cure period because one or more individuals are on Soft Pause.”

MAGI MC Only RD process

The electronic health information transfer (eHIT) process is an automated process to CalHEERS that occurs for the MAGI MC RD which does not involve initial EW action. The following outlines this automated process:

1. CalSAWS
   1. Two months before the MC RD due month, CalSAWS automatically sends an EDR to CalHEERS with the current existing CalSAW data.
2. CalHEERS
   1. Makes a MAGI MC eligibility determination based on the information CalSAWS sent.
   2. Sends a DER with MAGI MC eligibility results back to CalSAWS. If the CalHEERS results are:
      1. E-Verified:
         1. CalHEERS will send CalSAWS the eligibility results along with a NOA confirming eligibility. The eligibility result will have the client’s MAGI MC aid code for the upcoming benefit year.
         2. CalSAWS will automatically:
         3. Approve another 12-month MC RD period,
         4. Authorize the case, and
         5. Sends appropriate NOA(s).    
      2. Not E-Verified, Failed, or Verifications are Pending (These statuses indicate that results are not compatible through the Federal Hub):
         1. CalHEERS will inform the county via CalSAWS which data elements could not be electronically verified.
         2. CalSAWS will auto-generate and send the client the pre-populated MC 216 to request verification of information not e-verified.
         3. Allow the client at least 60 days to provide the information requested.      

For E-Verification guidance in CalSAWS [Refer to Job Aid (JA): Medi-Cal CalHEERS-MAGI Verifications.] 

MAGI MC Renewal Form (MC 216)

If CalHEERS cannot successfully e-verify current CalSAWS case information, CalSAWS will
auto-generate and send a pre-populated MC 216 form. CalSAWS will pre-populate case information for the client to update any changes and/or provide verification of the information.

Per MC regulation, MC clients must be given at least 60 days to provide the information requested on the MC 216.

Example Example If the MC RD month is 1/2017, the last day for the client to provide necessary information is 1/31/2017. The MC 216 must be mailed to the client no later than 12/1/2016. 

The information requested on the MC 216 may be provided by phone, mail, e-mail or in person. The client is not required to return the MC 216 form; however, the requested verifications must be provided.

Non-MAGI MC Only RD Process

CalSAWS will auto-generate and send the Non-MAGI MC RD packet at least 60 days before the end of the MC RD due month.

Example Example For cases with the MC RD due in 11/2016, CalSAWS will auto-generate and send the Non-MAGI MC RD packet in 9/2016. 

EWs must review Non-MAGI MC cases for potential MAGI MC eligibility. For example, the case has a 70-year-old individual who becomes a caretaker relative. When there is potential MAGI MC eligibility, the EW must first obtain tax filing household information, complete all essential and very important fields, and call the BRE for a MAGI MC evaluation without requesting property information. If the client is not eligible for MAGI MC, then request property information to complete the Non-MAGI MC RD.

For the Non-MAGI MC RD process, the client must provide paper verifications of income and property, as applicable. However, the MC RD forms DO NOT need to be returned. The MC RD information may be provided over the phone using Telephonic Signature, electronically (BenefitsCAL), in writing, or in person.Example

Examples Examples  

Eligibility determination requests to the CalHEERS Business Rules Engine (BRE) for Non-MAGI only cases are not to be made when no potential MAGI eligibility exists. Once all MC RD information has been obtained, EWs must process the Non-MAGI MC RD and determine benefits through CalSAWS.

Example Example A 75-year-old couple (both on Non-MAGI MC aid code 17) without dependents are non-potential MAGI individuals. This case would not have an e-HIT sent to the CalHEERS BRE. 

ACA Non-MAGI MC Process

The following is an outline of the ACA Non-MAGI MC process:

1. Two months before the MC RD due date, CalSAWS will automatically send the Non-MAGI MC RD packet for the Non-MAGI MC individuals in the case.
2. The client must be provided at least 60 calendar days to provide the information and verifications requested on the MC RD forms. If the client: 
   1. Does not respond:
      1. A required client contact must be made before discontinuance.
      2. CalSAWS will auto-discontinue the case for failure to comply with the MC RD process at the end of the MC RD due month.
   2. Provides information but not all required verifications:
      1. Mail an MC 355 requesting missing paper verifications and allowing 30 days for the client to respond.
      2. If verification is not provided within 30 days, then discontinue MC for failure to provide. (Note: CalSAWS will mail the MC 355 Reminder letter after 15 days.)
      3. If verification is provided within 30 days, then complete MC RD process and approve MC for another 12 months.
      4. Mail an MC 219 and document actions in the Journal Detail page.
   3. Provides the requested information and all required verifications:
      1. Process the MC RD.
      2. Authorize the case.
      3. Make sure MC has been approved for another 12 months.
      4. Send appropriate NOA(s).
      5. Mail an MC 219 and document actions in the Journal Detail page. 

Pre-ACA Non-MAGI MC Process

The following is an outline of the Pre-ACA Non-MAGI MC process:

1. Three months prior to the MC RD due date, EWs must review and update essential, very important, fields in CalSAWS. For successful E-hit from CalSAWS/Calheers refer to [CATS CalSAWS/Calheers Step by Step Guide to e-HIT interface] 
   1. NOTE: These are assigned via Tasks or Listings.
2. Transition Pre-ACA case to determine MC eligibility.
3. Determine if the case is MAGI MC, Non-MAGI MC, Mixed MC (MAGI MC & Non-MAGI MC), or another health coverage program (i.e. APTC, MCAP, etc.).
   1. If MAGI MC only, refer to MAGI MC only RD
   2. None of the individuals in the case are MAGI MC eligible,
      1. Refer to Mixed MAGI MC and Non-MAGI Medi-Cal RD (below)
      2. Evaluate for other health coverage programs (APTC, MCAP, CCHIP).

Mixed (MAGI MC and Non-MAGI MC) Medi-Cal RD

For Mixed MC household, the process begins with:

1. CalSAWS automatically sending an eHIT to CalHEERS with the most current CalSAWS data.
2. CalSAWS auto-generates and sends the pre-populated MC 217 for the MAGI and Non-MAGI MC household members whose information was not e-verified.

Example Example A 67-year-old individual on ABD-MN (Non-MAGI MC aid code 14) and his spouse, a 62-year-old individual eligible for MAGI MC (MAGI MC aid code M1) are on the same case. This case is considered a Mixed MAGI MC and Non-MAGI MC household. 

When processing an RD for a Mixed MC household, paper verification is required for all Non-MAGI MC clients (as applicable). If all information has been e-verified for the MAGI MC clients but there is no paper verification for the Non-MAGI MC clients, then MC eligibility can be determined for the MAGI MC clients but not for the Non-MAGI MC clients.

Exception:

The following are verifications that, when e-verified, shall be used in Non-MAGI Medi-Cal eligibility determinations:

• Citizenship and Identity Verification
• Immigration Status
• SSN Verification
• Medicare Verification
• Incarceration Verification
• Deceased Verification
• Disability Verification

Income and property verifications must still be provided. If no paper verification is received for the Non-MAGI MC clients after an MC 355 (allowing 30 days to provide missing paper verification) has been sent to the Non-MAGI MC client, then only the Non-MAGI MC clients must be discontinued.

When processing an RD for a Mixed MC household, if a Non-MAGI MC client provides all paper verification of income and property but the MAGI MC client’s income is not e-verified, then the MAGI MC client must provide paper verification of income. If no paper verification is received for the MAGI MC client after an MC 355 (allowing 30 days to provide missing paper verification) has been sent to the MAGI MC client, then only the MAGI MC client must be discontinued with 10-day NOA.

Example Example Macia Rossi is eligible for ABD-MN and her spouse, Alekos Rossi is eligible for MAGI MC on the same case. They both work but do not have any countable property. Alekos’ income is not e-verified and Macia only provided her paystubs. An MC 355 is mailed but Alekos does not provide paper verification; therefore, Alekos is discontinued from MC with a timely 10-day NOA. 

MAGI MC and APTC RD

Any changes reported during the annual renewal for APTC will be sent via eHIT to CalSAWS. [Refer to Job Aid (JA): Processing CalHEERS Referrals] for more information.

Example Example Parents are receiving APTC and the children are on OTLIC MC. During the October APTC renewal, the parents complete their APTC renewal online at www.coveredca.com with changes. A referral is sent from CalHEERS to CalSAWS and a Task is assigned to an EW. 

SSI QMB Cases

The EW must review MEDS to ensure that the individual is still receiving SSI. Once SSI eligibility is confirmed, only two requirements must be completed by the EW:

1. Re-verify the SSI/SSP client's net non-exempt income via the [INQX] screen on MEDS.
2. Check the [INQ1] and [INQB] screens on MEDS to make sure that QMB eligibility is being correctly reported to MEDS and that verification of Medicare Part A entitlement is on file.
3. Deny or discontinue QMB if the individual is ineligible for Part A.
4. Copies of MEDS screens used to verify income and Medicare eligibility must be kept in IDM. No other forms or verifications are necessary for SSI QMB RDs.

Mega-Mandatory Coverage Groups

The following programs are referred to as the Mega-Mandatory coverage groups.

Mega-Mandatory Groups and Aid Codes

Program Name	Aid Code
SSI/SSP	10, 20, 60
Title IV-E Foster Care	42, 49
State-Only (Cash) Foster Care	40, 43, 4K, 5K
Foster Care - Medi-Cal Only	45, 46
Title IV-E Adoption Assistance	03, 07
State-Only (Cash) Adoption Assistance	04
Adoption Assistance - Medi-Cal Only	06, 4A
Title IV-E Kinship Guardian Assistance Payment Program (KinGAP)	4F, 4S, 4T
State-Only (Cash) KinGAP	4G, 4W
Pickle	16, 26, 66
Disabled Adult Child	6A, 6C
Disabled Widow/Widower	36
Former Foster Youth	4M
Medicare Savings Programs (MSP) Only	80, 8C, 8D, 8A

MC RDs for individuals in the Mega-Mandatory coverage groups are completed following the rules that existed for those coverage groups before the Affordable Care Act (ACA). Eligibility in these categories must remain as long as the individual continues to be eligible for them. Eligibility for these groups is higher on the MC hierarchy than MAGI MC coverage groups.

The Mega-Mandatory individuals must be excluded from the tax household for any MAGI-linked individual in CalSAWS. Per Pre-ACA rules for Non-MAGI MC MFBUs, Mega-Mandatory individuals are considered Public Assistance or Other Public Assistance individuals for Non-MAGI MC eligibility determination. Therefore, they are excluded from the MFBU for the Non-MAGI MC RDs. EWs should verify that RDs on other family members in other aid codes do not create a negative action for individuals in the Mega-Mandatory coverage group.

MAGI MC Evaluation for LTC MC

Individuals in the MAGI MC full-scope aid codes are eligible to receive long-term care (LTC) services without a SOC and without regard to property; therefore, MAGI MC eligibility must first be explored before determining Non-MAGI LTC MC eligibility for individuals (including parents, children, or pregnant women) who are 19 years old up to 65 years old without Medicare.

The EW should use the tax household information obtained at RD, to determine whether the individual or family is MAGI MC eligible. If determined ineligible for MAGI MC, then complete the Non-MAGI MC eligibility determination using the information from the submitted MC 217.

 

MC RD for San Andreas Regional Center

An annual MC RD must be completed for individuals under the Department of Developmental Services - Home and Community-Based (DDS-HCBS) waiver for the San Andreas Regional Center (SARC). SARC is also required to complete an annual medical recertification for the DDS-HCBS waiver program. Whenever possible, the two reviews should be aligned and completed in the same month.

As documentation of continued medical certification for the DDS-HCBS waiver, SARC will forward a copy of the annual medical recertification to the EW. This document must be filed in IDM for the case. If the EW has not received verification of recertification from SARC by the time the annual MC RD is due, the EW must request the SARC liaison to contact SARC for confirmation of medical eligibility for the waiver program.

If an individual loses his/her medical certification for the DDS-HCBS Waiver, then the EW must evaluate the individual for all MC programs before discontinuing the case with a timely 10-day NOA.

The MC 210 RV can be completed for the SARC MC RD. When processing the MC RD for SARC, the EW must review the income reported to determine if the income remains above the MC income limits for zero SOC MC. If a client remains ineligible for zero SOC MC and the SARC certificate has been received, then he/she will remain on a SARC aid code. The EW must process the MC RD, approve another 12 months of SARC eligibility, and document all actions in the CalSAWS Journal Detail page.

However, if the income reported is below the MC income limits for zero SOC MC, then the EW must evaluate the client for MC and make sure the appropriate aid code is in MEDS. The client will no longer have a SARC aid code. The EW must process the MC RD, approve another 12 months of MC eligibility, and document all actions in the CalSAWS Journal Detail page.

When processing the MC RD for SARC, if income is not reported, then the EW must contact the client by telephone and ask for income information over the phone. If the client provides income information over the phone and the income is above the MC income limits for zero SOC MC, then the EW must process the MC RD, approve another 12 months of SARC eligibility, and document all actions on the Journal Detail page. If the income is below the MC income limits, then the EW must evaluate for MC eligibility.

If the EW is unable to reach the client by telephone to request income information, then the EW will pend the case for missing income information and mail an MC 355 requesting income information. The client must be given 30 days to respond. For SARC cases, the client can provide the income information over the phone or the information can be mailed. If the client does not respond within 30 days, then the case can be discontinued with a timely 10-day NOA for failure to respond. [Refer to Job Aid (JA): Requested Medi-Cal Types] for DDS-HCBS program selection in CalSAWS.

 

 

Related Topics

Redeterminations