Eligibility Determination Procedures

Identifying Potential Eligibles for the 250% WDP

An individual must be disabled and employed in order to qualify for 250% WDP. The following MC individuals must be reviewed for the 250% WDP:

Any individual requesting the 250% WDP
Any individual who:
- Is currently working
  - Exception: A recipient is allowed one annual 26-week period of unemployment.
- Alleges disability, and
- Does not qualify for MAGI MC or Non-MAGI MC with a zero share-of-cost (i.e., ineligible due to SGA or eligible for ABD-MN with a share-of-cost). The two programs must be explained and the client must be given the option to choose.

Twenty-Six Weeks of Temporary Unemployment

A 250% WDP participant is allowed one 26-week period of unemployment annually. The unemployment period starts from the date the client stopped working. If EWs have other sources of information to document the beginning period of unemployment, i.e. IEVS, EWs may use that as proof of unemployment. Otherwise, self-declaration is sufficient. The EW must follow up on the unemployment status at the end of the 26 weeks. If the participant remains unemployed past 26 weeks, determine eligibility for other MC programs.

Note: Any UIB income received is treated as unearned income.

No Face-To-Face Requirement

A face-to-face interview is NOT required at intake or at the annual redetermination, but may be requested by the individual.

Informing Requirement

Required Forms

“Important Information Regarding the Medi-Cal 250 Percent Working Disabled Program” (SCD 2315) explains program requirements must be provided to clients at the point of approval of 250% WPD.

Note: Although a face-to-face interview is not required, if the client requests an explanation of this form, the EW must review the content of this form with the client by phone or in person.

Retroactive Benefits

The 250% WDP allows three-months of retroactive eligibility. The client must complete the “Supplement to Statement of Facts for Retroactive Medi-Cal” (MC 210 A) for retroactive 250% WDP coverage. The applicable premium must be paid for each month for which retroactive coverage is requested.

The applicable premium amount pertains to individuals who applied for 250% WDP Retro benefits for months prior to July 1, 2022.

The payment or non-payment of premiums in one or more of the three retroactive months are not a factor in determining whether the client has failed to pay premiums for two consecutive months. If the client fails to pay premiums for any of the retroactive months, there is no discontinuance or penalty period.

Establishing a MEDS Record

If the EW determines that the applicant is eligible for the 250% WDP, the EW must confirm that the 250% WDP aid code appears in MEDS for the client.

The [INQM] screen will show an eligibility status code (ELIG-STAT: three digit code) which reflects whether the month is:

One of the history months (eligibility was reported for a month or months prior to the current MEDS month)
One of the two months of “exception eligibility” when the recipient has not paid FULL premiums but is still eligible (prior to July 1, 2022), or
A month of ineligibility because the recipient has been terminated from the 250% WDP.

Other Requirements

Clients requesting or receiving coverage under the 250% WDP must meet all other MC program requirements, including:

Providing all appropriate information or MC forms (i.e., CCFRM 604, MC 13, etc.)
Providing any necessary paper verifications
Completing an annual redetermination
Maintaining California residency
Identifying other health coverage
Completing medical support requirements, when applicable.