Denial or Discontinuance Due to Lack of Information, Non-cooperation, or Loss of Contact

Balderas v. Woods

The 1980 Balderas v. Woods court order requires that two contacts be made before denying or discontinuing an individual from cash assistance in order to avoid unnecessary fair hearing requests and help resolve eligibility through attempts to contact the client. The Medi-Cal (MC) program established the same two contact policy before a MC case may be denied or discontinued.

Reasons for Denial or Discontinuance

The application may be denied or eligibility may be discontinued if the Eligibility Worker (EW) has made a reasonable effort to assist the client and the client has failed, without good cause to:

Provide sufficient information to make an eligibility determination.
Provide the necessary verification.
Cooperate in resolving incomplete, inconsistent or unclear information on the Statement of Facts (SOF).
Respond to request to clarify information received from IEVS.
Cooperate with the District Attorney’s office to establish paternity or obtain medical support and payments.
Assist the Department of Health Care Services (DHCS) in pursuing any third parties who may be liable to pay for medical care, services or support.
Keep the EW informed of their whereabouts resulting in a loss of contact. (Mail sent to the client must be returned by the U.S. Post Office marked “whereabouts Unknown, Not Deliverable, etc.” for a loss of contact determination).

Reminder: Applicants with limited English proficiency and/or applicants with disabilities may require interpretive or additional assistance throughout the application process. EWs must inform all applicants/clients of their rights to ask for an interpreter if they have difficulty speaking or understanding the English language. EWs must take appropriate steps to make sure that alternative communication services are available to all MC applicants/clients.

Two Contact Requirement

The EW must make sure at least two contacts are made with the applicant before denying MC benefits.
The two contacts begin when a Mail-In Application/SOF is received. This policy does not apply to “No-Shows”. It only applies to clients who send an application by mail or have a face-to-face interview.

Other applicant contacts may occur before receipt of the MC application and are, in addition to the two contacts, required under the Balderas v. Woods lawsuit (i.e., EW receives new information via IEVS reports, or the applicant provides new information about income or property after providing the MC application).

Note: EWs must only request information that has not been or cannot be e-verified by the Federal Hub.

First Contact

If the application is not complete and additional information is needed, the EW must make a verbal or written contact to request the information and allow 10 calendar days to provide the information. All verbal communication must be thoroughly documented in the Journal page.

Second Contact

If the applicant does not provide the information or verification by the requested due date, the EW will make a second verbal or written contact to notify the client that the requested information was not received and allow 10 calendar days to provide the information. All verbal communication must be thoroughly documented in the Journal page.

Note: This policy only applies to applicants, not Continuing cases.

Contact

Contact is a communication that meets the following requirements:

Requests a specific information or action needed to complete the applicant’s MC eligibility determination
Provides a due date that the applicant must provide the specified information or complete the requested action
May be either verbal or written. Verbal contact is defined as live communication between the EW and the applicant

Note: Voice mail or answering machine messages left by the EW for the applicant are NOT considered verbal contact. However, if the client calls back and either talks to an EW or leaves a voice mail message with sufficient information to determine eligibility, the EW is not required to make another contact.

Documentation Requirements

Reasonable Effort

EWs must thoroughly document the reasonable effort made by indicating that he/she has:

Notified the client what is specifically needed.
Asked the client if they have a problem or difficulty getting the information.
Offered assistance, i.e., the EW can contact the Assessor's office for verification of real property, whether it is located here or elsewhere.
Secured a copy of trust documents/wills for client by getting a release of information and calling the attorney, if necessary. (It is essential to read trust documents/wills to understand the true situation.)
Consulted their supervisor (if necessary).

Two Contacts

The two contacts must be clearly documented in the Journal Detail page. Documentation must include:

The date of contact,
The method of contact,
The requested information and due date, and
The result of each contact.

Relative Responsibility

Due to changes required by the Sneede v. Kizer lawsuit, relative responsibility and excluded child provisions must be considered before denying or discontinuing an applicant or client for failure to provide information. If eligibility for certain family members is cleared, only part of the family might be ineligible.

Example 1Example 1

The family consists of a mother, her separate child, stepfather and their mutual child. All are requesting MC. All eligibility is cleared except for proof of the stepparent's earnings. There has been no further response to requests for additional information.

In this case, the EW has enough information to approve MC for the mother's separate child. Only mother, the stepfather and their mutual child would be denied for failure to provide information. Mother will be an ineligible member of her child's household.

Example 2Example 2

A family of 4, married parents with mutual children apply for MC. Mom states that their 20-year-old has part time employment. All eligibility is cleared, but verification of the child’s separate income is not provided. Only the 20-year-old would be excluded and denied for failure to provide information.

Example 3Example 3

Mother, father and 2 mutual children are applying for MC. Proof of father's earnings is not provided. Since he is responsible for all persons in the household, all must be denied.

Subsequent Action

A person or family whose eligibility is denied or discontinued due to any of the “Reasons for Denial or Discontinuance” may:

Reapply at any time, including the original month of application.
Have the denial or discontinuance rescinded if good cause exists.

Good Cause

For purposes of this section good cause includes, but is not limited to:

The County fails to:
- Provide the client with the required status report (MC 176 TMC) or MC Redetermination (RD) forms.
- Inform the client that they may be discontinued if a status report or MC RD form is not completed and returned.
- Properly and timely process the submitted status report, MC RD form, or other SOF.
The post office fails to deliver the MC 176 TMC or MC RD forms in a timely manner.
The client and the authorized representative fail to complete and return a status report or MC RD packet or provide the required information/verifications within the time limits, due to:
- Physical or mental illness or incapacity.
- The level of literacy combined with social/language barriers.