County of San Diego Health and Human Services Agency HHSA County Medical Services CMS Program Guide Linkage to MediCal Number Page 0205 1 of 3 Background CMS requires all applicants to be evaluated for MediCal as a condition of eligibility for CMS If the applicant is determined linked to MediCal eligibility and refuses to apply for or accept MediCal coverage they are not eligible for CMS CMS benefits must be discontinued when the recipient becomes enrolled in MediCal as outlined in 1501 PolicyProcedure A CalWORKs Linkage Refer parents of minor children who are disabled incapacitated or unemployed to CalWORKs Evaluate linkage based upon the definition described in MPG 0502 Refer to 0805 for case processing if the parent is denied CalWORKs B Potential MediCal Linkage Disability Determination Services Division DDSD Referral If the CMS applicant is not enrolled in MediCal and declares a disabling condition process the MediCal DDSD and CMS applications concurrently If the applicant refuses to apply for or comply with the entire MediCal DDSD application process the applicant is not eligible for CMS Previous MediCal DDSD Application Denied Returning CMS Applicant Review the denial reason when a CMS applicant is denied disability linked MediCal DDSD and returns to apply for CMS within 90 days of the MediCal DDSD denial If the Denial reason is correct and is not due to no show failure to provide or failure to cooperate o certify CMS for up to the allowable period if otherwise eligible and o document the MediCal DDSD denial reason in case comments Denial reason is questionable eg SSI denied for reasons other than no disability 250 Working Disabled Program not evaluated for working individual etc o refer the individual to appeal the MediCal DDSD denial and o approve CMS for the allowable period ONCE the applicant has complied with the MediCal DDSD appeal process if otherwise eligible 90 day appeal timeframe has expired o process the MediCal DDSD application and retroactive months as needed and CMS applications concurrently and o approve CMS for the allowable period once the applicant has fully complied in completing the MediCal DDSD application process has met all MediCal eligibility and verification requirements and the DDSD packet has been imaged into the CalWIN Electronic Records Management System CERMS if otherwise eligible Note The DDSD decision is not required prior to the approval of CMS benefits Previous MediCal DDSD Application Denied New CMS Applicant Evaluate if the denial is within the MediCal 90 day appeal timeframe when a new CMS applicant was denied MediCal DDSD because she is not linked and yet continues to declare a disabling condition If the Denial is within the appeal timeframe o refer the applicant to appeal the denial and o approve CMS for the allowable period once the applicant has complied with the MediCal DDSD appeal process if otherwise eligible County of San Diego Health and Human Services Agency HHSA County Medical Services CMS Program Guide Linkage to MediCal Number Page 0205 2 of 3 Appeal timeframe has expired o process the MediCal DDSD application and retroactive months as needed and CMS applications concurrently and o approve CMS for the allowable period once the applicant has fully complied with the MediCal DDSD application process has met all MediCal eligibility and verification requirements and the DDSD packet has been imaged into CERMS if otherwise eligible Note The DDSD decision is not required prior to the approval of CMS benefits Previous MediCal DDSD Application Denied Unrelated to Disability If the MediCal DDSD application is denied for a reason unrelated to disability such as no show failure to provide or failure to cooperate do not approve CMS benefits until she has fully complied in completing the entire MediCal DDSD application process Cash Assistance Program for Immigrants CAPI Applicants CAPI is a cash program for certain immigrants who are not eligible to SSISSP solely due to their immigration status Do not approve CMS benefits to an applicant who has an active CAPI case CMS benefits because the applicant is linked to MediCal A CMS applicant who has a pending CAPI application must also apply for MediCal DDSD and may be approved CMS for the allowable period while the DDSD decision is pending if otherwise eligible The DDSD process for CAPI is the same as MediCal However a separate MediCal DDSD application has to be requested by the applicant C Pending SSISSA Disability ApplicationAppeal A CMS applicant not enrolled in MediCal who has a pending SSDISSI application or appeal decision should have applied for MediCal DDSD at the time she applied for SSDISSI If the applicant did not apply for MediCal DDSD in order to protect the MediCal filing date process the MediCal DDSD including any retro months and CMS applications concurrently as instructed in 0210 Note You may deny the MediCal DDSD application on the basis of no disability in CalWIN for applicants appealing an SSDISSI denial issued within the last 12 months for not having a disabling condition This denial action protects the MediCal DDSD filing date so that if the final SSDISSI appeal decision is favorable to the CMS recipient CMS Recovery staff will initiate corrective action to rescind the MediCal DDSD application denial and receive reimbursement from MediCal Legal Aid SSI Advocate Referral A CMS applicant who has been identified as potentially eligible to SSI may be referred to the Legal Aid SSI Advocate for assistance in applyingreapplying for SSI benefits or assisting with the process of filing an SSI appeal Complete and fax or mail the SSI Advocate Referral CMS2 form to the SSI Advocate and note in case comments that an SSI Advocate referral was made Refer to 0806 for additional information D Deceased Person Because CMS is the program of last resort do not consider an application for CMS made on the behalf of a deceased person CMS denies all provider claims for services given to a CMS applicant who passes away while in the hospital Deceased applicants are linked to MediCal because Medi County of San Diego Health and Human Services Agency HHSA County Medical Services CMS Program Guide Linkage to MediCal Number Page 0205 3 of 3 Cal defines disability as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death E MediCal Disability Linkage Established A CMS applicantrecipient is not eligible for CMS if she is determined to be federally disabled according to the criteria in Title II or XVI of the Social Security Act or by State DDSD Following a determination that a CMS applicantrecipient has been determined disabled a Member Alert will be placed in AuthMed by CMS Recovery A CMS recipient who has applied for MediCal has the responsibility to complete the entire MediCal application process If the applicant has been determined disabled but fails to finish the entire MediCal eligibility determination process she CANNOT return to CMS Impact No impact to other programs References None Release Date December 23 2014 Sunset Date This policy will be reviewed for continuance by January 1 2017