Suspension of Medi-Cal Benefits for Incarcerated Individuals

SB 1147 and AB 720 require the suspension of MC eligibility, rather than discontinuance, for individuals who were MC clients at the time they became inmates of a public institution. In addition, SB 1147 requires that MC must be restored without a new application on the day the individual is no longer considered an inmate of a public institution, up to one year.

Beginning January 1, 2023, SB 184 extends the suspension of MC for adult and youth inmates to remain in effect for the duration of their incarceration, as long as they remain eligible for MC, and end the suspension on the date the individual is no longer an inmate of a public institution. MC must be restored (unsuspended) without a new application when the individual is no longer considered an inmate of a public institution.

Program Requirements

The following are requirements for the MC suspension process:

Are a MC beneficiary at the time of incarceration,
Are incarcerated more than 28 days, (Refer to 28-day MC Suspension Policy)
Remain otherwise eligible for MC during their period of incarceration,
Comply with CIC RD requirements (this applies to adult inmates)
Are eligible on the day they are released.

The suspension of MC benefits will end for the following reasons:

On the day of release from incarceration,
No longer an inmate of a public institution,
The end of the month that the individual becomes is IE for any other for MC program,
Death of the inmate.

Medi-Cal Suspension

The following policy applies to suspended individuals:

Counties are no longer required to conduct annual renewals for incarcerated adults and youths however Change in Circumstance redetermination requirements for adult inmates remain in place. Incarcerated adults must comply with CIC requirements during their incarceration if the county becomes aware of a CIC that potentially affects eligibility. IF CIC RD requirements are not met, the eligibility must be discontinued with proper notice.

When MC eligibility is discontinued for an incarcerated individual while under suspension, he/she must receive a proper 10-day NOA about the discontinuance and the end of the suspension. When MC eligibility is terminated for an incarcerated individual while under suspension, the EW must mail the MC 0377 D “Discontinuance of Benefits” with appropriate 10 day NOA.
If an incarcerated individual, who is a member of an open MC case that includes other family members, is eligible upon release, MC must be restored effective the day the juvenile is no longer considered an inmate of a public institution, without requiring a new application. If the family member’s case is discontinued prior to the incarcerated individual’s release, a pre-release application will be completed when they get a release date.
When suspension ends due to release, the appropriate NOA must be sent to inform the family or caretaker relative that MC benefits are restored.

MEDS

To suspend eligibility for incarcerated individuals on their own case, an online MEDS transaction is used to report the incarceration information on the “Institutionalized Client Update” MEDS screen. MEDS will set an Other Health Coverage (OHC) Code value of “I” to identify suspension of MC. Beginning 2/27/2023, MC suspensions can be done via updating the appropriate fields on the CalSAWS [Living Arrangement Detail] page. (Refer to MC Suspension)
MEDS will end suspension of benefits on the date reported to MEDS reflecting either the date the juvenile is no longer an inmate of a public institution, or the first of the month following the month in which the juvenile loses eligibility during incarceration. The juvenile will be able to access MC covered services as of the Release Date entered into MEDS if they are still eligible for MC. The Health Insurance System (HIS) database will be updated immediately to show the day before the Release Date as the end date of the suspension.
The ‘I’ OHC Code will still appear on the MEDS record until the following month but will not adversely affect the juvenile’s eligibility once the suspension end date is reported. When suspension of MC benefits ends because a juvenile is released, an appropriate NOA must be sent to inform the family or caretaker relative that MC benefits are restored.
If an incarcerated individual who is the only member on the case becomes ineligible during the first year of incarceration eligibility must be terminated. The EW must confirm that the termination action has updated MEDS and request an online MEDS transaction to report the suspension end date. This will remove the “I” OHC Code, which is necessary when eligibility and/or suspension ends for any reason. A proper 10-day NOA must be sent explaining the reason for termination of MC eligibility.
If an individual is incarcerated for more than one year, MEDS will send an alert 60 days before the end of the suspension period to remind the EW to terminate MC eligibility at the end of the last month of the one-year period,. The EW must send a timely “Discontinuance of Benefits” (MC 0377 D) explaining the reason for discontinuance and the right to request a Fair Hearing. Effective January 1, 2023, MC should not be terminated for incarcerated individuals regardless of the duration of their sentence.

Restoration of Benefits After Release from Incarceration

When suspension ends because the individual is released, MC eligibility must be restored as follows:

Update the [Departure Date] field (release date) on the [Living Arrangement Detail] page.
If the individual is already released, enter the date the person was released if known or the date the county was notified of the release on the [Departure Date] field.
The “Suspension of Medi-Cal Benefits Activated” (MC 0466F) must be issued to the client.
For an individual in a case with other household members:
- Update the [Departure Date] field (release date) on the [Living Arrangement Detail] page. Reevaluate the household’s eligibility including the incarcerated individual.
- If the family’s case is closed, a pre-release application will be created prior to the individual’s release.
Refer to Medi-Cal Suspension for further guidance on the suspension process.

Reminder: If the former incarcerated individual was discontinued from a case, the individual can be added back to an open case or request benefits per the normal add a person or application process.

Medi-Cal Eligibility for Juveniles Placed Temporarily in Juvenile Detention Centers

A juvenile will not, for MC purposes, be considered an inmate of a public institution when the minor is in a juvenile detention center before judgment due to care, protection or in the best interest of the child (e.g., Child Protective Services), if there is a specific plan for that person that makes the stay at the detention center temporary. This would include those juveniles awaiting placement but still physically present in juvenile hall.

The minor is eligible for MC if all eligibility requirements are met. Current MC regulations do not place any time limits on MC eligibility for these individuals.

Note: This change impacts foster care eligible youths returning home with Wraparound Services.