Craig v Bontá - Loss of SSI/SSP

Issue

The Superior Court in the Craig v Bontá lawsuit prohibited the Department of Health Care Services (DHCS) from terminating the MC benefits of clients discontinued from Supplemental Security Income/State Supplementary Payment (SSI/SSP) on or after June 30, 2002, except for those clients discontinued due to death or loss of residence.

Decision

The Superior Court ruled that the Ex Parte Redetermination Process must be implemented for clients losing SSI/SSP eligibility effective July 1, 2003.

Ex Parte Redetermination Process

The Ex Parte Redetermination Process consists of three parts:

Ex Parte Review (without client contact)
Direct contact (phone call)
Request for information

Ex Parte Review

The Ex Parte review involves evaluation of all sources of information available to the EW to make a MC redetermination. Information sources include the following:

Information from the Social Security Administration through the State Data Exchange (SDX) on MEDS. However, Social Security Administration does not calculate income the same way that the MC program determines income. Therefore, verification of this information is necessary.
Craig v Bontá cases and/or cases of any of their immediate family members, which are open or were closed within the last 45 days (MC, CalWORKs (CW), CalFresh (CF), General Assistance (GA), etc.).
Other sources of relevant information, including Income Eligibility Verification System (IEVS), Systematic Alien Verification for Entitlements (SAVE), Medi-Cal Eligibility Data System (MEDS) and the Federal Data Services Hub (Federal Hub).
Incarceration information can be found on [INQU] MEDS screen. [Refer to MEDS Handbook Chapter 1 for more information on [INQU] and to Clerical Handbook Chapter 5.5 for instructions of the EW32 online transaction to remove suspension or to correct the existing incarceration information.]

If the EW cannot establish continued MC eligibility after the Ex Parte review, then the EW must contact the client either by direct contact or written request for information.

Direct Contact

The EW must attempt to contact the Craig v Bontá client if MC eligibility cannot be established by the Ex Parte review. The client’s telephone number is displayed on the Address Inquiry [INQA] Screen on MEDS. If the telephone number is not available on the [INQA] screen, or the number is incorrect, then a written request for information is required.

The EW must inform the client that his/her MC eligibility is being redetermined and more information is needed to confirm continued eligibility.

Reminder: All telephone contacts must be clearly documented in the Journal entry. If the EW’s efforts to obtain the necessary information to redetermine eligibility after Ex Parte review and telephone contact have failed, then the EW should send a written request for information.

Request for Information

When the Ex Parte review and telephone contact have NOT been successful, the EW must send the “Request for Information” (MC 355) or “Request for Tax Household Information” (SCD 2350) depending on potential eligibility for MAGI MC or Non-MAGI MC.

EWs may not request information that:

Has previously been provided,
Is not subject to change, or
Is not necessary to complete a MC eligibility redetermination.

When Written Requests are Not Required

Written requests for information are not required in the following situations:

If the telephone contact establishes continued MC eligibility, or
If the telephone contact with the client establishes ineligibility for MC.

MC 355 or SCD 2350 Timelines

Craig v Bontá clients MUST be given a minimum of 30 days to respond to the written request for information.

If the client...	Then the EW must...
Does not return the completed form or provide the required information to the EW within 30 days of the date the EW mailed the form,	Send the client an SCD 50 requesting the missing information and explain that their MC will discontinue if they do not provide the information. If after 10 days the client still has not provided the information, send a discontinuance Notice of Action (NOA) stating that his/her eligibility will be terminated 10 days from the date of the NOA and the reasons for termination.
Submits an incomplete form or partial information within 30 days,	Attempt to contact the client either by telephone or in writing to request the necessary information. If the client does not provide the necessary information to the EW within 10 days from the date the EW contacts the client about the incomplete form/partial information, a 10-day discontinuance NOA of MC eligibility must be sent. Reminder: All telephone contacts must be clearly documented in the case record.
Submits the needed information or returns the form within 90 days of the discontinuance,	Determine eligibility as though the form had been submitted in a timely manner. If the client is found eligible, the discontinuance must be rescinded.

Note: The steps outlined above are general guidance for the Craig v Bontá redetermination process. Actual business processes may vary depending on individual office needs. EWs should ask their supervisors for more information on business process.

When an Ex Parte Redetermination is Not Necessary

An Ex Parte Redetermination is not necessary in the following situations:

If...

Then...

The facts clearly demonstrate that a Craig v Bontá client is not eligible for MC due to an event such as:

Death, or
Loss of California residency.

Benefits must be discontinued WITHOUT an Ex Parte Redetermination.

NOTE: The [INQP], [INQM], and [INQX] MEDS screens indicate if a person is deceased or moved out of state.

The EW receives a written request from a Craig v Bontá client to discontinue MC benefits,

The EW does not have to complete an Ex Parte Redetermination.
Send the client’s written request to Imaging.
Clearly document by adding a Journal entry.
Send the appropriate NOA.

Craig v Bontá Redetermination Process

Follow the guidelines below to re-evaluate MC eligibility for Craig v Bontá clients:

DHCS
1. Forwards listing of Craig v Bontá clients to counties.
EW
1. Receives assigned Task from clerical staff.
2. Completes Ex Parte Redetermination Process.
3. If the Ex Parte process is unsuccessful, follows the Two Contact Requirement outlined in the MC HB Chapter 9.
4. Sends appropriate NOA(s). For negative actions (i.e., discontinuance or SOC), send the appropriate 10-day NOA(s). Include 90-day Cure period language for failure to respond to verification NOAs. The following verbiage must be added to the NOA: "You can still get Medi-Cal, but you need to give us more information. We need it within 90 days, by (enter discontinuance date + 90 days). We can give you Medi-Cal from (enter discontinuance date) if you are still eligible. If we do not get the information by (enter discontinuance date + 90 days), you must reapply for Medi-Cal. Welfare and Institutions Code, Section 14005.37(i).)
5. Checks MEDS after 2 business days.
  1. REMINDER: EW may need to complete a “Request for Online Action” (SCD 1296) to send a MEDS transaction to add/activate/change/terminate eligibility in MEDS.

Case Assignment for Craig v Bontá

Follow the chart below for case assignment:

Open Case-CalSAWS	Caseload	Assignment
No	N/A	Assistance Application Center (AAC)
Yes	43LS0DD04	AAC
	MC-Only Caseloads (excluding A7QB)	Benefits Service Center (BSC)
	Other Caseloads	Assigned District Office (i.e. North County, South County, etc.)

DDSD Disability Referral Packets

A “LIMITED” DDSD referral packet must be sent on all Craig v Bontá disability redetermination referrals including SSI/SSP discontinuance reasons other than “Cessation of Disability.” If the client was discontinued for “Cessation of Disability” and claims a different disabling condition, then a “FULL” DDSD referral packet must be submitted.

Aid Codes Under State Control

Due to the Craig v Bontá lawsuit, DHCS created three MEDS aid codes for the aged, blind, and disabled population losing their SSI-based MC. They are as follows:

State-Controlled Aid Codes	Description
1E	Craig v Bontá Continued MC eligibility for the Aged
2E	Craig v Bontá Continued MC eligibility for the Blind
6E	Craig v Bontá Continued MC eligibility for the Disabled
6N	Former SSI NLD in SSI Appeals Status

Exception: The State will maintain control or discontinue the MC benefits for those clients who are appealing Social Security Administration findings of “no longer disabled,” clients who have moved out of state, or persons discontinued due to death or incarceration.

Exception Eligibles Report

“Exception Eligibles” reports were originally designed to track cases that were the result of exceptional circumstances such as the Edwards and Burman lawsuit cases, Accelerated Enrollment (AE), Breast and Cervical Cancer Treatment Program (BCCTP), CHDP Gateway, and the Single Point of Entry (SPE) child cases. This report now includes the Craig v Bontá cases.

DHCS sends the “Exception Eligibles” tracking reports on a monthly basis as the primary tool for processing the Craig v Bontá cases. All the clients in aid codes 1E, 2E, and 6E are identified on this report and on the renewal MEDS alert listing with MEDS alert number 9546, 9548, 9582 and 9583.

[Refer to MEDS Handbook Chapter 11 for how to process the renewal Craig v. Bontá MEDS alerts.]

Identification of Craig v Bontá Clients Groups by Codes

The discontinued SSI/SSP groups are being tracked and identified by assigning special codes in the [Pickle] fields on MEDS. The impacted groups whose aid codes were transferred to the Craig v Bontá aid codes are the following:

No Longer Disabled
Disabled Adult Child
Disabled Widow(er)s
Pickle
All Others Discontinued from SSI/SSP Benefits (i.e., excess income, excess property, etc.)
Clients in Long Term Care.

Exception: Since MEDS does not currently have the information necessary to identify clients who were receiving In-Home Supportive Services (IHSS) at the time they were discontinued from SSI/SSP, those IHSS clients will not have a unique [Pickle Status], but will have one of the [Pickle Types] codes identified below.

The codes placed in the [Pickle Type] and [Pickle Status] fields on MEDS allows DHCS to track eligibility and to group clients on the county reports. The groups identified below must not be discontinued from MC without first receiving an Ex Parte Redetermination as required by Welfare and Institutions Code, Section 14005.37.

Loss of SSI/SSP Due to Disability Group

Clients losing SSI/SSP eligibility on the basis that they are no longer disabled will continue to be placed in the MC aid code 6N for three months to allow time for an appeal to Social Security Administration.

If the appeal is filed within the three-month period, the MEDS programming edits from the SDX file will register that an Social Security Administration appeal is in progress and will keep the client in the full-scope aid code 6N until the appeal process ends.
If the client loses his/her appeal or the appeal is not filed within the three months, MEDS programming logic will change the 6N aid code to a 6E aid code to ensure the client is reported on the “Exception Eligibles” tracking report. Once these clients appear on this report, the Ex Parte Redetermination Process must be completed.
Code “D” will be placed in the [Pickle Type] field on MEDS to identify this unique population. There are no special eligibility determination procedures for this group.

Disabled Adult Child (DAC) Group

The Disabled Adult Child (DAC) clients will automatically be moved into aid code 2E or 6E. Code “T” will be placed in the [Pickle Type] field on MEDS to identify this unique population. Upon seeing the “T” on the MEDS record, EWs must complete an eligibility determination for the DAC program when evaluating the case under the Ex Parte Redetermination Process.

Disabled Adult Widow(er)s Group

The Disabled Widow(er)s and surviving divorced spouses will automatically be moved into aid code 6E. Code “W” will be placed in the [Pickle Type] field on MEDS to identify this unique population. Upon seeing the “W” on the MEDS record, EWs must complete an eligibility determination for the Disabled Widow(er)s program when evaluating the case under the Ex Parte Redetermination Process following the Pickle regulations.

Pickle Group

The aged, blind and disabled Pickle clients will automatically be moved into aid code 1E, 2E or 6E. Code “C” will be placed in the [Pickle Type] field on MEDS to identify this unique population. Upon seeing the “C” on the MEDS record, EWs must complete an eligibility determination for the Pickle program when evaluating the case under the Ex Parte Redetermination Process following the Pickle regulations.

All Other Discontinued from SSI/SSP Benefits

Clients losing SSI/SSP eligibility, who do not fall into one of the specific groups above, will automatically be transferred into aid code 1E, 2E or 6E and code “X” will be placed in the [Pickle Type] field on MEDS.

Alleged Disability

The client can be granted MC on the basis of alleged disability if there is a new condition (different from what Social Security Administration based the cessation of disability).

Losing SSI/SSP due to Incarceration

An individual's incarceration status does not prevent them from being eligible for a Medi-Cal program. Members who lose SSI/SSP linked Medi-Cal due to incarceration are transitioned into a Craig v Bonta aid code 1E, 2E or 6E and must be evaluated for ongoing eligibility in other available Medi-Cal programs including MAGI and Non-MAGI through the redetermination process before discontinuing the Craig v Bonta aid code. If an Ex Parte determination is not successful, the request for additional information must be sent to the last known address or to the correctional facility if known following the Two contact requirement. If unable to determine ongoing eligibility for any Medi-Cal program, the member must be discontinued with a timely 10-day notice. The Medi-Cal suspension policy should also be reviewed for these individuals and applied as appropriate.

ICTs and Craig v Bontá Clients

When the original (Sending) County receives the “Exception Eligibles” report and finds the Craig v Bontá client moved to another county, the Sending County must do an Inter County Transfer (ICT) to the new (Receiving) County. The Receiving County is responsible for the Ex Parte Redetermination Process.

The Sending County must report the residence address change to MEDS so that the individual will appear in the Receiving County’s “Exception Eligibles” report. The Sending County must include in the ICT packet the “Medi-Cal Intercounty Transfer” (MC 360) form, clearly documented as an ICT for a Craig v Bontá client, all appropriate MEDS screens, and any other pertinent information.

CEC and Craig v Bontá Children

Continuous Eligibility for Children (CEC) for Craig v Bontá children applies as follows:

If the SSI/SSP Redetermination has been...	Then...
LESS than 12 months,	An Ex Parte review (no client contact) is required. Use the information from existing case records, MEDS, SAVE and IEVS. The EW must place the Craig v Bontá child in the appropriate CEC aid code and set the redetermination date for 12 months from the last SSI/SSP determination date. Unless there is conflicting information, the EW must not contact the child or the child’s parents/caretaker relatives for additional information. The child is eligible for CEC for the remaining 12 months from the last SSI/SSP determination date until the next RD. The EW must make sure that the 12-month CEC Time Clock is correct. The begin date must be the date of the last SSI/SSP determination and end date to be the next RD. If the child did not live with the parent (when on SSI), use the income as shown on MEDS INQX screen as the child’s income. Evaluate the child for MAGI MC. If the child is ineligible for MAGI MC, then set up the child on CEC and do not contact the child.
LESS than 12 months,	NOTE: To determine whether the discontinued SSI child lived with a parent (when on SSI), check the SSI-LVG-ARR-CD in the INQX screen. A code of “C” means the child lived with the parent. If the REDET-DT field on the MEDS [INQM] screen does not show a redetermination date, check Title XVI section of the IEVS report for the “Date of Last Redetermination.” If neither the INQM nor IEVS has the last redetermination date, the EW must contact the Social Security Administration to obtain this date via “Referral To/From Social Security” (SCD 169) and clearly indicate that the request is about a Craig v Bontá client.
OVER 12 months before the Craig v Bontá child’s discontinuance,	There is no time left in the CEC “guaranteed” period, and the EW will need to follow the Ex Parte process to establish eligibility which may include contacting the child’s parents. Upon redetermination, a new 12-month CEC period, if appropriate, begins at that time.

Annual Redetermination

The annual MC Redetermination (RD) dates are as follows:

Type of Craig v Bontá cases	The annual RD will be 12 months from the date the...
Persons discontinued from SSI/SSP BEFORE 07/01/03,	EW determined the client’s MC eligibility.
Persons discontinued from SSI/SSP 07/01/03 and AFTER,	Client was discontinued from SSI/SSP.
NOTE: If a Craig v Bontá individual is being added to an active case, the same annual RD due date for other family members in the case applies. If CEC applies, evaluate if the child’s eligibility goes beyond the family’s annual RD due date. Do NOT change the existing RD due date. When the existing RD becomes due, the following applies to the former SSI child only: If no SOC MC is determined during the annual RD, a new 12-month CEC period begins. If the former SSI child is found ineligible or eligible with share of cost (SOC), the child must remain in a CEC aid code until the end of the original CEC period. ExampleExample Last SSI redetermination date was 12/2016. Child discontinued from SSI 2/2017. Child’s 12-month CEC is from 1/2017 - 12/2017. RD for existing family member’s case is due 6/2017. At RD, child is found eligible with SOC, the former SSI child continues on CEC for 7/2017 - 12/2017.

Note: If MEDS or IEVS does not have the last SSI redetermination date, the EW must contact Social Security Administration to find out when the last redetermination was completed.

IHSS and Craig v Bontá Clients

The “Exception Eligibles” report includes individuals who were discontinued from SSI/SSP. Some of these individuals received In-Home Supportive Services (IHSS) when they were discontinued from SSI/SSP. However, the “Exception Eligibles” report does not identify which clients received IHSS. These Craig v Bontá clients are mixed throughout the report with other SSI/SSP discontinued clients. However, the Ex Parte Redetermination Process is the same for all Craig v Bontá clients listed on the report.

Individuals who ONLY received IHSS and were not discontinued from SSI/SSP, do not fall under the Craig v Bontá lawsuit and will not be included on the “Exception Eligibles” report.

Forms

All Craig v Bontá clients must receive information regarding MC property limits and spend down.

MC Informational Craig v Bontá Packet

The packet consists of the following forms and must be provided to all Craig v Bontá clients:

• Redetermination of Medi-Cal Benefits Coverletter (SCD 104)

• Rights and Responsibilities (MC 219)

• Keep Your Medi-Cal on Target (SCD 391)

• Notice Regarding Standards for Medi-Cal Eligibility (DHCS 7007)

Reminder: The “Medi-Cal Annual Redetermination” packet and “Application for Cash Aid, Food Stamps, and/or Medical Assistance” (SAWS) are NOT required for the Craig v Bontá clients MC redetermination as long as all necessary information to determine ongoing eligibility is provided.