Santa Clara County Social Services Agency page 1

Date: 10/17/14 (Revised)

References: ACWDL# 14-31 & 14-32

Cross-References: MC HB Update# 2014-13 & 2014-21

Clerical: No

Handbook Revision: Yes

Update 2014-22: Medi-CalMedi-Cal Renewals: Part II- MAGI MC

Background Per Medi-Cal (MC) Update 2014-13, the MC Redetermination (RD) process was partially reinstated in June 2014. The mailing of MC RD packets began in late April for MC RDs due in January & June and subsequent months continued for the remainder of 2014.

In August 2014, CalWIN began running SQLs to discontinue MC cases that had not provided the MC RD information and extending the MC RD due date to 2015 for the cases that had provided the MC RD information.

Reminder:The actual MC RD information was not entered into CalWIN nor processed during this time period.

[Refer to “Redeterminations,” page 10-4 for complete information on MC RDs.]

Changes Beginning with MC RDs due in 2015, the Modified Adjusted Gross Income (MAGI) MC RD process will consist of three major components:

1. A review, collection of data and update process to ensure the most current information is reflected in the CalWIN case and all eligible cases are transitioned to MAGI MC. [Refer to “Review, Update and Transition Process,” page 10-44.]

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Note:LIHP RDs must be processed as MAGI MC cases. If any information is needed in order to complete the review, update and transition process, contact the client to obtain the information.

2. CalWIN data sent via an e-HIT to the CalHEERS Business Rules Engine (BRE) in order to electronically determine MAGI MC eligibility. [Refer to “Electronic Verification e-HIT to CalHEERS,” page 10-47.]

3. A pre-populated “Medi-Cal Renewal form” (MC 216) for beneficiaries whose MAGI MC eligibility cannot be electronically determined via the CalHEERS BRE. [Refer to “MC 216,” page 10-49.]

Note:Additional guidance will be issued separately for: - Non-MAGI MC RDs, - Mixed Household MC RDs: * MC & APTC, and * MAGI MC & Non-MAGI MC.

[Refer to “2015 MAGI MC RD process,” page 10-43 for additional information.]

Review, Update & Transition Process

The process for 2015 MAGI MC RDs begins with an ex-parte review of all available information, in CalWIN, IDM, CalHEERS, MEDS, and any other state and/or federal system and/or report. All “Request for Tax Household Information” (RFTHI) forms previously submitted via SCD 2350, MC 01-2014, MC 262, CSC 91 or provided verbally must be entered into CalWIN.

If any of the needed information is not available, the EW must call the client and attempt to obtain the missing information.

Reminder:The RFTHI does NOT need to be obtained in writing. The client may verbally provide this information.

In order to ensure that all eligible cases are sent through the CalHEERS BRE for the electronic verification process, all the “essential” fields and RFTHI must be correctly entered in CalWIN and all eligible cases must be transitioned to MAGI MC prior to the electronic verification process taking place. The ex-parte process (including data entries into CalWIN) must take place three months prior to the MC RD due month.

[Refer to “Review, Update and Transition Process,” page 10-44 for additional information.]

Update 2014-22: Medi-Cal page 3

Other Cases/ Programs

The ex-parte review also includes the review of information in companion cases and/or for other programs (i.e. CalWORKs, CalFresh and/or General Assistance). Information from closed companion cases and other closed programs may be used if the case and/or program was closed within the last 90 days.

Transition Before Transitioning a case, review the case for the following aid codes for additional conditions prior to transitioning the case.

Aid codes Additional Conditions

39, 3T, 59, 5T For the Transitional Medi-Cal (TMC) population, the EW must:

23, 63, 64, 67 (Not limited to these aid codes)

For Disability-based MC, review MEDS to determine if the client is also receiving Medicare.

If the client is... Then...

Receiving Medicare, DO NOT transition the case. Leave the case as is. Further information will be provided regarding Non-MAGI MC RDs.

NOT receiving Medicare,

Proceed with the transition process to trigger a MAGI MC eligibility determination.

e-HIT to CalHEERS

Two months prior to the MC RD due month, CalWIN data will be sent via an e-HIT to the CalHEERS BRE in order to electronically determine MAGI MC eligibility. Beginning in November 2014, CalWIN will begin the electronic process for MC RDs due in January 2015.

• If CalHEERS confirms continued MAGI eligibility based on information sent from CalWIN, CalWIN will receive an eligibility result back from CalHEERS along with a Notice of Action (NOA) confirming eligibility. The eligibility result will consist of the client’s MC aid code for the upcoming benefit year. the case will auto-authorize during the overnight batch.

• If a client is not found to be MAGI MC eligible via the automated process, in the transaction response CalHEERS will inform the county via CalWIN which data elements could not be electronically verified. CalWIN will auto-generate and send the MC 216 to the client.

• Review the case to determine if the case is entitled additional TMC.

- If the case is still TMC eligible, continue to follow current TMC process.

- If the case is no longer TMC eligible, proceed with the transition process.

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[Refer to “Electronic Verification e-HIT to CalHEERS,” page 10-47 for additional information.]

MC 216 CalWIN will auto-generate and send the pre-populated MC 216. CalWIN will pre-populate the information contained in CalWIN for the client to update any changes and/or provided verification of the information.

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

Example:If the MC RD month is 1/2015, the last day for the client to provide necessary information is 1/31/2015. The MC 216 must be mailed to the client no later than 12/1/2014.

[Refer to “MC 216,” page 10-49 for additional information.]

MAGI MC RDs Due 12/2014

The MAGI MC applications received during the pre-enrollment period (10/1/2013 to 12/31/2013) and in the month of January 2014, all have an application date in January 2014. These cases have an RD due date of December 2014.

In October 2014, CalWIN will send an e-HIT to the CalHEERS BRE in order to electronically redetermine MAGI MC.

If the case cannot be electronically verified with the BRE, CalWIN will auto-generate and send the pre-populated MC 216.

[Refer to steps 4 to 5 in the Process section on page 6.]

2015 MAGI MC RD Timeline

The following is a timeline of the above processes for MAGI MC RDs in 2015:

Ex-Parte Review

e-HIT to BRE

MC 216 Sent (If needed)

MC 216 Info. Due (If sent)

RD Due Month

90-Day Cure Period

10/2014 11/2014 11/2014 01/31/2015 01/2015 02/2015 through 04/2015

11/2014 12/2014 12/2014 02/28/2015 02/2015 03/2015 through 05/2015

12/2014 01/2015 01/2015 03/31/2015 03/2015 04/2015 through 06/2015

01/2015 02/2015 02/2015 04/30/2015 04/2015 05/2015 through 07/2015

02/2015 03/2015 03/2015 05/31/2015 05/2015 06/2015 through 08/2015

03/2015 04/2015 04/2015 06/30/2015 06/2015 07/2015 through 09/2015

04/2015 05/2015 05/2015 07/31/2015 07/2015 08/2015 through 10/2015

Update 2014-22: Medi-Cal page 5

Process The following outlines the process for MC RDs:

05/2015 06/2015 06/2015 08/31/2015 08/2015 09/2015 through 11/2015

06/2015 07/2015 07/2015 09/30/2015 09/2015 10/2015 through 12/2015

07/2015 08/2015 08/2015 10/31/2015 10/2015 11/2015 through 01/2016

08/2015 09/2015 09/2015 11/30/2015 11/2015 12/2015 through 02/2016

09/2015 10/2015 10/2015 12/31/2015 12/2015 01/2016 through 03/2016

Ex-Parte Review

e-HIT to BRE

MC 216 Sent (If needed)

MC 216 Info. Due (If sent)

RD Due Month

90-Day Cure Period

Step Action

1. Three months prior to the RD due month (i.e. TMTs 1/2015 MC RDs will be created in 10/2014), TMTs will be created for pre-ACA Non-MAGI MC cases for district offices to take the following action.

If there is a(n)... Then...

Split ACA Case (i.e. ACA Future Merge),

Refer to CalWIN Announcement titled “Merging/Combining ACA and Pre-ACA MC Cases.”

External Referral Data, Refer to CalWIN Announcement titled “Linking CalHEERS Cases to CalWIN cases and Adding-a-Person.”

CalHEERS case for some MC HH members,

Refer to CalWIN Announcement titled “Linking CalHEERS Cases to CalWIN cases and Adding-a-Person.”

If none of the above exist, proceed to Step 2.

2. Review all available information in CalWIN, IDM, MEDS, and CalHEERS and ensure:

- All of the “essential” fields are correctly entered in the CalWIN cases for all members as appropriate.

- All of the RFTHI data is entered completely and correctly in CalWIN for all active MC members, as appropriate.

- The most recent income and household composition reported is correctly reflected for the MC case in CalWIN

[Refer to CalWIN Announcement 311 “Transitioning Pre-ACA MC to ACA (MAGI and/or APTC)” for step-by-step information on entering the “essential” fields and transitioning pre-ACA cases to MAGI MC.]

[Refer to “CalWIN Announcement 300.1 “Entering Information in CalWIN from the SCD 2350/ CSC 91” for step-by-step information on entering the RFTHI data in CalWIN.]

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3. Determine if the case has a 2014 or 2015 MC RD due date:

If the MC RD due date is in...

Then...

2014, Run the MC RRR Queue and process the 2014 MC RD in order to update the RD due date to 2015.

2015, Determine if the case has already been transitioned correctly in CalWIN.

• If the case is still a Pre-ACA case:

- Ensure that the Transitioned field is Yes on the Collect Case Summary window.

- Do NOT Run or Initiate the MC RRR Queue. The 2015 MC RD due date MUST remain the same.

- Run EDBC.

- Refer to CalWIN Announcement 311 “Transitioning Pre-ACA MC to ACA (MAGI and/or APTC)” for step-by-step information on transitioning pre-ACA cases to MAGI MC.

• If the case is MAGI MC:

- The Transitioned field will be disabled.

- Do NOT Run the MC RRR Queue. The 2015 MC RD due date MUST remain the same.

4. Two months prior to the RD due month (i.e. In November 2014 for MC RDs due January 2015), CalWIN will begin the electronic verification process by sending an e-HIT to CalHEERS for an electronic MAGI MC eligibility determination using the information currently in CalWIN.

If the client is... Then...

Found to be MAGI MC eligible,

CalWIN will auto:

• Extend the MC RD for another 12 months.• Send approval NOA.

NOT found to be MAGI MC eligible,

• CalWIN will auto-generate and send the client the pre-populated MC 216 to request verification on information not electronically verified.

• Allow the client at least 60 days to provide the information requested.

Step Action

Update 2014-22: Medi-Cal page 7

TMT On a monthly basis, TMTs will be auto-created for the review, update and transition process. This TMT will have a note that indicates the RD due date.

In addition, if the MC 216 is returned by the client, a TMT will be auto-created. This TMT will have “MC RRR received” note.

5.

If the information requested is...

Then...

Provided and the client is MAGI MC eligible,

CalWIN will auto:

• Extend the MC RD for another 12 months.

• Send approval NOA. [Refer to “MAGI MC RD Approval NOA,” page 10-48.]

Provided and the client is NOT MAGI MC eligible,

UNTIL FURTHER NOTICE, LEAVE THE INELIGIBLE INDIVIDUAL IN THE MAGI AID CODE. The following process is currently not functional in CalWIN and CalHEERS.

• Send the client the CSC 99 and MC 604 IPS forms.

• Allow 30 days for the client to complete and return the form.

• If the form is returned, evaluate for Non-MAGI MC.

• If the form is not returned by the due date:

- Discontinue MC. - Issue a timely and adequate MC discontinuance

NOA.- Evaluate for and set-up the client with APTC

coverage.

[Refer to “Discontinuance of MAGI MC at RD,” page 10-53 for additional information.]

Provided but is insufficient to determine eligibility,

• Work with the client to collect the necessary information, per current policy.

• If the client is not making a good faith effort to provide the requested information, and the 60 days to provide the information has passed, discontinue the case for failure to provide.

• Document in the Maintain Case Comments window.

Not provided by the due date,

CalWIN will auto:

• Discontinue MC benefits for failure to comply with MC RD process.

• Issue a timely and adequate discontinuance NOA.

Reminder: Two required contacts must be made prior to discontinuance. [Refer to “MC Annual RD is not returned,” page 10-56.]

Step Action

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Forms The following are new MC RD related forms which may need to be used depending on electronic verification results and/or MAGI MC eligibility:

“Medi-Cal Renewal Form” MC 216

The MC 216 will be pre-populated with the case information in CalWIN. This form is auto-generated and sent by CalWIN when MAGI MC eligibility cannot be determined through the electronic verification process.

“Evaluation for Non-MAGI MC” (MC 604 IPS)

The MC 604 IPS acquires the necessary Non-MAGI MC asset, income, and deduction information to evaluate an individual for Non-MAGI MC eligibility when such information has not been previously obtained or is not current (i.e within the last 90 days).

“Non-MAGI Informing Letter” (CSC 99)

The CSC 99 is sent in conjunction with the MC 604 IPS and it:

• Informs the client that he/she does not or no longer qualifies for MAGI MC.

• Informs the client that he/she may still qualify for Non-MAGI MC.

• Provides an overview of Non-MAGI MC and APTC/CSR.

Informs the client that he or she will be enrolled in a no Share of Cost (SOC) Non-MAGI MC if found eligible when the requested information is returned to the county.

Reminders The following are MC RD related reminders which have been issued in previous Updates:

90-Day Cure Period

MC beneficiaries have up to 90 days from the effective date of “Failure to complete the MC RD” discontinuance to provide appropriate information for the county to review eligibility for possible restoration of benefits, back to the effective date of discontinuance (no break in aid).

Note:In order to rescind the case, the client only needs to provide the information required at the MC RD. A full MC application is not needed.

[Refer to “The 90-day Cure Period,” page 10-53 for additional information.]

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Loss of Contact

If the MC RD Packet is sent back, as “return to sender” or “no forwarding address” an attempt to contact the client must be made. This must include:

• An ex-parte review of information available to the county (in CalWIN, CalHEERS, MEDS, IDM, etc.) about the client or his/her family members, with more current contact information for the client.

• Attempts to contact the client by telephone, or by other means available.

• Mail the MC 355 to the client (allow 30 days).

If all required attempts to contact the client fail, a discontinuance NOA must be sent and document the inability to make appropriate contact in the Maintain Case Comments window.

[Refer to “Loss of Contact,” page 10-66 for additional information.]

Change in Circumstance

Whenever the client reports a change in circumstance that triggers an eligibility redetermination, such as, when a client reports a change in income or household composition on their CF SAR 7, MC recipients are to have their MC RD date reset for a new 12-month period. These type of changes require a BRE/EDBC run to see if continued eligibility remains.

Since the BRE/EDBC is triggered to see if MC eligibility remains, the MC RD due date should be reset if the outcome of the eligibility determination resulted in continued MC eligibility.

Note:MC RD changes are effective the month following the month the change in circumstance is reported.

Example:An MC/CF combo case with a MC RD due date of 03/2015. On 7/6/2015, the client reports a decrease in income on their 06/2015 SAR 7. Because EDBC and the BRE are triggered and the client remains MC eligible, the MC RD is reset to 07/2016.

[Refer to “Resetting the Annual RD Date Based on Change in Circumstance,” page 10-11 for detailed information.]

FFCC The MC RD process for Former Foster Care Children (FFCC) is simplified. Therefore, FFCC should not receive the MC 216 unless they are part of a household where other household members must complete a MAGI MC evaluation to continue to receive MC benefits.

Former foster youth up to age 26 must not be discontinued due to a loss of contact or for not responding to county at RD.

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[Refer to “MC RD & FFCC,” page 10-11 for detailed information.]

Implementation The information contained in this MC Update is effective immediately upon receipt.

Other Programs

The information contained in this MC Update only affects MAGI MC RDs, which also includes MC and CalFresh, MC and General Assistance, and MC and CalWORKs cases.

DENISE BOLAND, DIRECTOR, Department of Employment and Benefit Services

Contact Person(s): Idelle Villarreal, Application & Decision Support Specialist, (408) 755-7540. Flavio Barbosa, Application & Decision Support Specialist, (408) 755-7540.