County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Application Procedures
040201
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Revision Date
04012021
Background
All MediCal applicants have the option of applying for MediCal benefits by mail electronically or by attending a facetoface interview The application process begins with the applicant requesting an application or completing an electronic application
Purpose
This section is revised for the sunset review and to incorporate MediCal Memo 1907
Policy
As part of the application process all MediCal applicants must be informed of their rights and responsibilities The applicants MediCal eligibility and Share of Cost SOC determination is made after the applicant has applied completed the Statement of Facts SOF and provided all essential information and verifications
Applicants who
Choose the mailin process may complete the application and all required verifications by mail
Apply electronically may submit the completed MediCal application and all required verifications electronically and may include a telephonic signature
Request a facetoface interview will complete the SOF during the intake appointment
Procedure
040201A SAWS 1 Initial Application for CalFresh Cash Aid andor MediCalHealth Care Programs When a SOF is used the application cannot be denied on the basis that there is no SAWS 1 or that the SAWS 1 is incomplete Even though a SAWS 1 is not required for MediCal eligibility it may be used to establish the date of application
If an individual is unable to apply on their own behalf or is deceased a SAWS 1 may be filed by any of the following people
The applicants guardian conservator or executor
An adult who is in the applicants household or family
A person who knows the applicants need to apply
A public agency representative
Someone acting responsibly for the applicant if the applicant is a minor or incapacitated
040201B Ways to Apply An individual may apply for MediCal benefits by
Calling Access at 866 2629881 to request a mailin application
Calling 211 to apply over the phone with a 211 San Diego agent
Visiting a Family Resource Center FRC or outstation site to request a mailin application or a facetoface interview
Submitting an electronic application through MyBenefitsCalWIN MyBCW or Covered California CA
Applying through the Perinatal Care Network PCN
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Application Procedures
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Making the request while receiving aid under another Public Assistance PA program
For applications received via MyBCW that do not include the information necessary to evaluate eligibility for example name and address only send the application packet and 1485 HHSA Allow 15 days to return
040201C Processing Requests for a FacetoFace Interview When an applicant requests MediCal at a Family Resource Center FRC or outstation site and chooses to attend a facetoface interview
Step Action
1 Ask the applicant to complete and sign a SAWS 1 to establish the date of application
2 Schedule an appointment according to FRCoutstation procedures
3 Complete the application registration process and assign the pending case to the central pending case bank based on FRC procedures
4 Provide the applicant with a MediCal application packet Note FRC staff may screen the applicant at the time of request and provide any supplemental forms that may be required
5 Inform the customer that if MediCal eligibility is approved and they are eligible to enroll in a health plan the Health Care Options HCO packet will arrive by mail for the customer to choose a health plan If the customer would like to obtain assistance with their MediCal managed care health plan enrollment or to make changes the customer can Contact HCO Walkin to any FRC
6 Complete case comments documenting all case actions taken and image the SAWS 1
Actions to take on the day of the appointment
If the applicant Then
does not attend and if no contact is made from the applicant to reschedule send a MediCal mailin application packet as outlined in 040212
attends the facetoface interview follow procedures outlined in 040211
040201D Processing Requests for a MailIn Application Whether the request for an application is by phone or in person take the following actions to provide the applicant with the necessary information at the time of the request
Step
Action
1
Explain to the customer that they can apply for MediCal as a mailin or attend a facetoface interview 2
Inform the customer that if MediCal eligibility is approved and they are eligible to enroll in a health plan the Health Care Options HCO packet will arrive by mail for the customer to choose a health plan
3 Ask the customer if they would like to apply for CalFresh in addition to MediCal If the customer is interested in applying for CalFresh in addition to MediCal or needs CalFresh expedited services explain to the customer that a facetoface interview may provide them with faster benefits and is advisable especially if the customer does not have access to a regular source of communication Inform all other applicants that they should expect an
If the applicationpacket is Then assign the application to a Human Services Specialist HSS to
received process
not received deny Note FRCs are encouraged to attempt a reminder phone call prior to denial with those families who do not submit the application
If the application packet is Then assign the application to an HSS to
received process
not received deny Note FRCs are encouraged to attempt a reminder phone call prior to denial with those families who do not submit the application packet
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page Application Procedures 040201
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Applications from Covered CA Advanced Premium Tax Credit APTC beneficiaries transitioning to MediCal will reflect the initial application date from the last Covered CA open enrollment or special enrollment The Document Processing Center DPC will register the application using the date of transition
If an application is inadvertently sent to another county by a resident of San Diego County and then forwarded by the other county the date of application is the date stamped by the sending county
Note The date of application will always be the earlier of the two dates when the SOF and SAWS 1 are received separately
Program Impacts
None
References
42CFR 435907f WI Code 1400537r CCR Title XXII Section 50151 ACWDL 1228 0106 1917 MEDIL I 1012 1202 1601 MediCal Memo 1907
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Application Packet
040202
1of 4
Revision Date
04012021
Background
The Department of Health Care Services DHCS provides guidelines on the material that must be provided to all households at time of application for MediCal To facilitate the application process and remove barriers to access the material provided to MediCal applicants will be kept as simple as possible and will be made into packets
Purpose
To provide policy and procedures for MediCal intake packets This section is revised for the sunset review no policies or procedures were changed
Policy
In compliance with state requirements provide informational material to all household members at the time the initial application is submitted to the county In addition to the DHCS mandated informational material the packet will include Civil Rights and County approved informational material
Applicants who request to apply for MediCal by attending a facetoface interview may visit a Family Resource Center FRC and will be handed the MediCal application packet The Document Processing Center DPC is responsible for mailing the Application Packet to applicants who submit their MediCal application electronically
Those opting for the mailin process may
Pick up the application packet in person at an FRC
Receive the application packet by mail by calling Access or 211
Mailin application forms are also available for pick up from other sources for example DHCS MediCal website outstation sites clinics etc
Provide Supplemental NonModified Adjusted Gross Income MAGI evaluation forms to applicants who meet potential NonMAGI eligibility as stated in 040223
Procedure
040202A MediCal Application Packet Give or mail to all applicants including mailins Low Income Subsidy LIS Extra Help applicants and those who wish to apply by attending a facetoface interview the MediCal application packet The
MediCal application packet will contain the following forms
Form Number
MC 018
MC 020
MC 219
Pub 183 English or 184 Spanish
Pub 68
MC 003
Form Title
MC Information Notice MediCal Information for Applicants Cover Letter
MC Information Notice Notice to Beneficiaries Regarding IRS Form 1095B
Important Information for Persons Requesting MediCal
Child Health Disability Prevention CHDP Information
My MediCal How to Get the Health Care You Need
Early Periodic Screening Diagnosis and Treatment EPSDT Brochure
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Application Packet
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MC 372
GEN 1365
2046 HHSA
Pub 13
1475 HHSA
2044 HHSA
1664 HHSA
0998 HHSA
CF 285
16157A HHSA
Breast and Cervical Cancer Treatment Program BCCTP Brochure
Notice of Language Services
Language Needs Determination
Your Rights Under California Public Benefits Program Pamphlet
Mental Health Managed Care Notice
Civil Rights Information
National Voter Registration Act NVRA Voter Preference Form
California Voter Registration Form VRC
San Diego Gas Electric CARE Program Form
CalFresh Outreach Flyer for MediCal Applicants NonLongterm care LTC only
Application for CalFresh Benefits nonLTC only
Women Infants and Children WIC Brochure
Text Messaging Service Agreement
Traffic Flow Flyer
Your Opinion Counts Survey
For applicants picking up a MediCal application at the FRC include
1468 HHSA MailIn Cover Letter
CCFRM604 Application for Health Insurance
Postage paid preaddressed return envelope
For applicants requesting a MediCal mailin application include
1485 MediCal MailIn Reminder Notice
CCFRM604 Application for Health Insurance
Postage paid preaddressed return envelope
Note The CCFRM604 also known as the MediCal application or Single Streamlined Application is not required when the applicant completes any other Statement of Facts SOF as indicated in 040204
040202B Medicare Savings Program MSP Only Applicants MSPOnly applicants may use the MC 14A Qualified Medicare Beneficiary Specified LowIncome Medicare Beneficiary or Qualifying Individual Application instead of the Single Streamlined Application The following forms are sent to MSPOnly applicants
Form Number Form Title
MC 018
MC 020
MC 219
Pub 68
Pub 13
MC 372
GEN 1365
2046 HHSA
1475 HHSA
MC Information Notice MediCal Information for Applicants Cover Letter
MC Information Notice Notice to Beneficiaries Regarding IRS Form 1095B
Important Information for Persons Requesting MediCal
My MediCal How to Get the Care You Need
Your Rights Under California Public Benefits Program Pamphlet
Breast and Cervical Cancer Treatment Program BCCTP Brochure
Notice of Language Services
Language Needs Determination
Mental Health Managed Care Notice
San Diego Gas Electric CARE Program Form
County of San Diego Health and Human Services Agency HHSA
Application Packet
0998 HHSA 2044 HHSA 1664 HHSA
16157A HHSA
MediCal Program Guide
Number
Page
040202
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CalFresh Outreach Flyer for MediCal Applicants NonLTC Only
Civil Rights Information
National Voter Registration Act NVRA Voter Preference Form
California Voter Registration Card VRC
Text Messaging Service Agreement
Traffic Flow Flyer
Your Opinion Counts Survey
040202C Supplemental Forms Mail supplemental forms to the applicant after the completed MediCal application is submitted and the Human Services Specialist HSS evaluates the applicants circumstances For applicants requesting a facetoface interview provide these forms to the applicant during the interview Case comments must be entered to support the HSS actions
Medical Support Enforcement MSE Forms Provide the following forms to applicants requesting MediCal for a child born out of wedlock or with an
absent parent
Form Number
CS 196 CW 21 NA CW 21 Q
Form Title
Child Support Services Program Notice
Child Support Notice and Agreement
Child Support Questionnaire
Postage paid preaddressed return envelope
Forms Provided to NonMAGI and LIS Extra Help Households at Application NonMAGI and LIS Extra Help evaluation forms must only be provided to MediCal applicants who are subject to a property evaluation for MediCal eligibility
Form Number
14146
Pub 10
MC 604 IPS
MC 007
DHCS 7077
DHCS 7077A
APTCCSR Brochure
Form Title
NonMAGI Cover Letter for Applicants
NonMAGI MediCal Programs Brochure
Additional Income and Property Information Needed for MediCal
MediCal General Property Limitations
Notice Regarding Standards for MediCal Eligibility only if the individual is institutionalized or requesting nursing facility level of care
Notice Regarding Transfer of a Home for Both a Married and Unmarried ApplicantBeneficiary
Covered CA Can Help You Get Affordable Health Coverage
Postage paid preaddressed return envelope
Statement of Citizenship Alienage and Immigration Status Form MC 13 The Statement of Citizenship Alienage and Immigration Status MC 13 is not provided to all applicants at initial application The form is provided to applicants when appropriate
040202D Case Comments
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page Application Packet 040202
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Enter case comments indicating that the MediCal application packet andor supplemental forms were provided to the applicant
Program Impacts
Forms and Document Capture Forms are available for printing in Eligibility Forms Library EFL andor Xerox The MediCal application packet and the NonMAGI evaluation forms are available in preassembled packets for ordering
Other Programs Affected California Work Opportunity and Responsibility for Kids CalWORKs application packets must include the MC 020 MC Information Notice Notice to Beneficiaries Regarding IRS Form 1095B
References
ACWDLs 0106 0712 0832 1701 1726 2022 MEDILs I 1202 1421 1454 1454E 1535 1536
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Applicants Rights and Responsibilities
040203
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Revision Date
04012021
Background
All applicants must be informed of their rights and responsibilities The Rights and Responsibilities for MediCal form MC 219 was updated to reflect new rules and changes in accordance with the Affordable Care Act ACA
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
Each applicant must be informed of their rights and responsibilities under the MediCal program even if it appears that the applicant is ineligible As part of the applicants rights information that must be supplied to the applicant includes
Copy of the Right and Responsibilities form MC 219
Information on general MediCal property limits MC 007 and MC 005 if applicable
Income Eligibility Verification System IEVS information
Additionally evaluate the applicants potential eligibility to other Public Assistance PA programs such as CalWORKs and CalFresh only when requested Refer the applicant to apply for Supplemental Security IncomeState Supplementary Payment SSISSP if they appear eligible to that program The applicant would only be evaluated for County Medical Services CMS if they are not eligible to MediCal
Procedure
040203A Inform Applicant of Rights All MediCal applicants shall be provided with the following information
Requirement MC 219 Rights and Responsibilities Description Give or send the MC 219 Important Information for Persons Requesting MediCal to the applicant Document in case comments that the information was provided to the applicant It does not have to be returned by the applicant
For CalWORKs applicants who are determined ineligible to CalWORKs but wish to apply for MediCal only the signed SAWS 2 Plus is an acceptable replacement of the MC 219
Give applicants who request MediCal after a CalFresh only application the MC 219
MC 007 General Property Limits Give the MC Information Notice 007 to all applicants who are subject to a property evaluation All applicants shall be informed of their right to reduce nonexempt excess property within the month of application provided the applicant receives adequate consideration Adequate consideration applies only to an institutionalized individual after January 1 1990
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Applicants Rights and Responsibilities
040203
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Ways to Reduce Excess Property
IEVS
Health Care Options HCO
Provide options as to how excess property may be reduced and how adequate consideration may be obtained to establish eligibility in the month of application Do this as soon as there is an indication that the applicant may be ineligible because of excess property
Such options shall include but are not limited to
Paying medical or other bills
Purchasing exempt items
Paying off mortgages or car loans
Making home repairs or improvements to property
Borrowing against the cash values of nonexempt property and life insurance policies and then reducing the proceeds by receiving adequate consideration
Informing the applicant that the cash surrender value of nonexempt life insurance policies and any other asset will be considered unavailable as the applicant continues to make a good faith effort to liquidate the asset
Setting aside up to 1500 for the individuals burial as a designated Burial Fund
Refer to MPG 090109 for more information on reduction of excess property spend down
The Single Streamlined Application informs MediCal applicants that their Social Security number SSN will be used to access State and Federal information on income and resources
Explain to the applicant that
the SSN will be used to match information provided to the State by employers Employment Development Department EDD and financial institutions
although applicants who are not Unites States citizen and who request restricted benefits are not required to provide a SSN their SSN will be used to access income and resource information if the applicant voluntarily provides a SSN or if the SSN is available through a prior case record
information received through IEVS is used to ensure that the eligibility and share of cost SOC determination is correct and that the information may be verified through collateral contacts when discrepancies are found
Inform the applicant that if MediCal eligibility is approved and they are eligible to enroll in a health plan the Health Care Options HCO packet will arrive by mail for the customer to choose a health plan If the applicant would like to obtain assistance with their MediCal managed care health plan enrollment or make changes the customer can
Contact HCO by telephone
Walkin to any Family Resource Center FRC
040203B Review of Potential Eligibility for Other PA Programs When reviewing the application evaluate the applicants apparent eligibility for CalWORKs CalFresh and SSISSP
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Applicants Rights and Responsibilities
040203
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If the applicant appears eligible for
CalWORKs andor CalFresh
SSISSP
Then
advise the applicant of their potential eligibility
have the applicant modify the SAWS 1 if they wish to apply for additional types of aid
document in case comments that the applicant was advised of potential eligibility for the aid if the applicant does not want to apply for additional aid
refer the applicant to the Social Security Administration SSA if the customer does not refuse to apply for SSISSP
document the referral in case comments
proceed with the eligibility determination of any other program for which the applicant may be eligible pending SSISSP determination
040203C Review of Potential County Medical Services CMS Eligibility Adults between the ages of 21 and 64 who have no linkage to any MediCal program shall be advised
That they have no apparent basis of eligibility for MediCal
Of their right to complete a formal MediCal application even though they have no apparent MediCal eligibility
Of the Countys CMS program and provide the CMS brochure
CMS is the Countys safety net program for adults who are NOT
Determined linked to MediCal eligibility
Enrolled in MediCal
Enrolled in Medicare
Enrolled in Covered California Health Care Plan or in any health care plan that meets the Minimum Essential Coverage MEC requirement under the ACA
040203D Applicants Responsibilities Applicants or representatives are responsible for providing essential verifications and reporting certain changes in a timely manner Responsibilities include
Completing all documents required in the application process or in the determination of continuing eligibility
Providing all verifications requested by the Human Services Specialist HSS needed to determine eligibility and SOC as specified in MPG 0407
Report all facts that pertain to the determination of eligibility and SOC
Report within 10 days any changes in income assets or living situation which pertain to the determination of eligibility or SOC
Cooperate fully in any investigation required for quality control
Report and use other health coverage available to the individual or family
Promptly notify any changes in residence from one county to another within the state InterCounty Transfer ICT procedures are described in MPG 0302
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Applicants Rights and Responsibilities
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Complete all the forms necessary to process a medical support referral to Californias Department of Child Support Services DCSS
Cooperate with DCSS Medical Support Enforcement MSE program
040203E MSE Program Referral MediCal applicants must cooperate with the MSE program when requesting MediCal for a child born out of wedlock or with an absent parent A customer must complete all the forms necessary to process a medical support referral to DCSS Refer to MPG 0418 for forms and referral procedures
Determine a beneficiary who refuses to cooperate without good cause with the MSE program to be an ineligible member of the MediCal Family Budget Unit MFBU
Program Impacts
None
References
MEM 50184 ACWDL 9198 2004 MEDIL I 1309 1605
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Acceptable Statement of Facts SOF
040204
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Revision Date
04012021
Background
A Statement of Facts SOF is required to determine an applicants eligibility to MediCal
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
040204A Acceptable SOF The following forms may be accepted as an application and SOF for MediCal
Form
CCFRM604 Single Streamlined Application
Electronic Statement of Facts from MyBenefitsCalWIN MyBCW or Covered California CA MC 210 rev 022010 or later MediCal mailin
MC 321 HFP Healthy FamiliesMediCal Joint Application
SAWS 2 Plus Application for CalWORKs CalFresh andor MediCalHealth Care Programs May be used in lieu of the MediCal SOF Page 1 is the equivalent of the SAWS 1
CF 285 CalFresh Application May be used in lieu of any other MC application when a CalFresh recipient requests a MediCal evaluation within 12 months from the date of the CalFresh
application
Requires completion of Request for Tax household Information RFTHI
Usage
Serves as an application for MediCal benefits
Does not require a SAWS 1
Note The SOF may also be used to evaluate the customer for Covered California Advance Premium Tax Credits APTC and Cost Share Reduction CSR
Program Impacts
None
References
CCR Title XXII Sections 50159 and 50161 42CFR 435907f WI Code 1400537r ACWDLs 0335 and 0340
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Acceptable Statement of Facts SOF
040204
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County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number
Page
Persons Who May Complete and Sign the Statement of Facts SOF
040205
1of 5
Revision Date
04012021
Background
This section provides regulations regarding who may complete and sign the Statement of Facts SOF
Purpose
This section is revised to provide clarification on defining a knowledgeable person and methods of establishing competency
Policy
040205A Who May Complete and Sign the Statement of Facts While anyone who knows of an individuals need may apply for MediCal on that individuals behalf by completing and filing the SAWS 1 the following individuals may complete and sign the MediCal SOF
Applicants
Adults in the applicants household as defined by the household composition regulations
Family
An Authorized Representative AR
For incompetent or incapacitated individuals someone who is acting responsibly on behalf of the applicant
The tax filer for the household
An AR must be properly appointed by the customer in order to act on their behalf including signing the application For example an AR may sign the Single Streamlined Application on behalf of the customer however the Authorized Representative section of the Single Streamlined Application or another acceptable AR appointment method must still be signed by the customer using the approved methods outlined in 040207C
A Certified Enrollment Counselor CEC application assistor or insurance agent is not automatically considered an AR They must be appointed as one by the customer
Note If the applicant is incapable of signing because of a physical condition the applicant should provide the information and then a relative a knowledgeable person or a Human Services Specialist HSS can sign the SOF If the applicant can only make a mark a witness must also sign the SOF
040205B Competency Competency is defined as being able to act on ones own behalf in business and personal matters Incompetence does not mean the applicant does not understand English or the application process or that the applicant just prefers to have someone else act on their behalf Incompetence generally refers to an applicants mental condition Regulations do not require that the court or some other entity must first declare that a person is incompetent
The following individuals may complete the application for incompetent applicants
Spouse
Conservator guardian or executor if there is one
County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number
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Persons Who May Complete and Sign the Statement of Facts SOF
040205
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A relative or person with knowledge of the case can be broadly interpreted nursing facility staff may have sufficient information and knowledge of the circumstances when no family member or protective services is involved
Representative of a public agency or county department requires diligent search
When a relative or friend with personal knowledge of the applicant applies indicating that the applicant is comatose senile or incompetent and completes and signs a sworn statement to this effect then the HSS may process the application with that individual acting on behalf of and as the representative for the applicant When the SOF is completed and signed by a representative give them form DHCS 7068 to complete
When the applicant is in longterm care LTC the HSS may reach a competency decision by one of the following methods
Calling the LTC facility and inquiring as to the customers ability to handle their own affairs
Obtaining a statement from the customers physician
Visiting the facility to communicate with the customer or staff
Obtaining satisfactory evidence from family members which provides the HSS with sufficient reason to believe that the LTC individual is incapable of handling their own affairs Such evidence may include conservatorship documents or a written statement from a family member stating that the individual is unable to complete the application process without assistance
Note If a physicians statement is provided that statement alone supersedes all other methods of determining competency
040205C Defining Knowledgeable Person When the SOF is completed and signed by someone other than the applicant or their spouse that person assumes the responsibilities of the applicant and is liable for declarations made on behalf of the applicant
The person must have real personal and specific knowledge of the applicants current circumstances and relevant only for the months the customer is requesting benefits Prior personal knowledge of the incompetent individual is irrelevant The person must be able to answer vital income and property questions with a response other than unknown however they must be given an opportunity to exercise due diligence in obtaining and submitting the necessary information If the knowledgeable person does not have all the information required to make an eligibility determination conduct a diligent search for the remainder
If the person signing the SOF willfully conceals or fails to report essential facts that person not the customer could be referred for a fraud investigation If the knowledgeable person is found to not have real personal and specific knowledge of the applicants affairs determine if another knowledgeable person such as a relative or an LTC representative if the applicant is in LTC exists If no such person is available sign and complete the SOF
040205D Diligent Search If it is determined that protective services are not needed undertake a diligent search of known information to determine eligibility Complete and sign the SOF The SOF must be countersigned by
County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number
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Persons Who May Complete and Sign the Statement of Facts SOF
040205
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another county representative who confirmed by personal contact the inability of the applicant to act on their own behalf The Supervising Human Services Specialist SHSS may make a phone call to the facility to confirm the customers incompetency and countersign the SOF Refer to MPG 040901 for diligent search procedures
040205E Child Applicants The following individuals may apply for a child
Parents custodial or noncustodial
Any adult in the Advance Premium Tax CreditCost Sharing Reduction APTCCSR tax household or nonfiler household
Noncustodial Mother or Father not in their tax household
Family member such as Grandparent
Authorized representative
Someone acting responsibly for the child such as a family friend
The person or representative of the agency having legal responsibility for the child completes and signs the SOF A nonrelated adult who has care and control of the child may complete the SOF if the child is not in need of protective custody and is not able to act as an adult To determine if the child needs protective custody complete a referral to Child Welfare Services CWS and comment in the case record that a referral to CWS was made
The child applicant completes the SOF when any of the following applies
The applicant is 1821 years of age not living with a parent or caretaker relative and the applicants parents are not claiming them for tax purposes
The applicant is 1418 years of age not living with a parent or caretaker relative and who does not have a parent caretaker relative or legal guardian handling their financial affairs
The applicant is a child applying for Minor Consent Services and meets the requirements specified in MPG 0404
040205F Tax Dependents The following individuals may apply for tax dependents
The tax dependent
Tax filer that claims the tax dependent
Another tax dependent within the applicants tax household
Adult who is in the applicants tax household
An authorized representative
Someone acting responsibly for the dependent if they are incapacitated
040205G Protective Services Referrals Assume total control of a MediCal case and refer the case to protective services to determine if a Public Guardian PG or Adult Protective Services APS staff should become the responsible agent when the following conditions are met
The applicant is unable to apply for or complete a MediCal eligibility determination process due to incompetence or being in a comatose condition or suffering from amnesia and
The applicant does not have a spouse conservator guardian or executor or
County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number
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Persons Who May Complete and Sign the Statement of Facts SOF
040205
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An applicant has a representative assuming case management responsibilities due to the applicants mental condition but the representative is noncooperative not acting in the best interests of the applicant for example misappropriating income or property of the applicant or contact is lost
Note For incompetent Craig v Bonta beneficiaries only if the beneficiary does not have a representative complete form 1478 HHSA PUBLIC ADMINISTRATORCRAIG V BONTA REFERRAL When completing the section of the form that asks State examples of probable cause write the reason why the beneficiary is unable to handle their own affairs The original of the 1478 HHSA is to be forwarded to Mail Stop O95 attention Craig Liaison Image a copy of the form
040205H NonCooperation of the Acting Individual
Do not deny LTC applicants MediCal solely due to the noncooperation of the individual actingon their behalf
Unless a suitable individual is located the noncooperative individual should be notified that the application is denied
File a second SAWS 1 as well as an application for retroactive coverage if the second SAWS 1 is filed after the month in which the initial SAWS 1 was submitted
Proceed with the diligent search procedures to make the eligibility determination
040205I Exploitation of LTC Individuals Finances When it appears that the LTC individuals income may be being exploited by another person
Notify the agency where the income originates for example Social Security Administration SSA Veterans Affairs VA etc
Treat the income as unavailable and do not use in determining the share of cost SOC if the HSS receives information that the income will temporarily cease until a representative payee is found
When it appears that the LTC individuals resources including bank account may be being exploited by another person
Refer case to PG APS or LTC ombudsman
If the PG APS or LTC ombudsman indicate that they are taking steps to recover the property treat it as unavailable until the property has been seized
Program Impacts
None
References
CCR Title XXII Sections 50032 50159 and 50161 ACWDLs 9462 0228 1712 2028
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number
Page
Persons Who May Complete and Sign the Statement of Facts SOF
040205
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County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Splitting Cases at Application
040206
1of 2
Revision Date
04012021
Background
This section provides direction for splitting cases at application when an adult who is not the tax dependent spouse or unmarried parent of a common child is requesting MediCal on the same application
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
While anyone who knows of an individuals needs may apply for MediCal on that individuals behalf the MediCal Statement of Facts must be completed and signed by one of the following
the applicant
the spouse
the unmarried parent of a common child
their household tax filer
Adults who do not meet the criteria above must apply for themselves and should be on their own case
If the adult is also requesting MediCal preserve the request date and provide a MediCal application
Procedure
040206A Required Action Take the following steps to split the case at application
Step Action
1
Remove the nontax dependent from the case by marking them as not requesting and not a tax dependent 2
Complete a SAWS 1 to preserve the earlier application date 3
Appreg a new application for this individual 4
Mail the Single Streamlined Application to the individual 5
Follow the procedures outlined in 0402 for MailIn applications
040206B Examples Example 1 Applicant applied for MediCal on November 1 They are also requesting for their sibling They claim they file taxes separately
This application belongs to the applicant since they signed the Single Streamlined Application
Open a case for the sibling on their own case and preserve the request date using the receipt date Nov 1 on their application
Send the sibling a Single Streamlined Application including the MailIn packet
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Splitting Cases at Application
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Example 2 Applicant applied for MediCal on November 15 and requested for their 30yearold child They claim that they file taxes separately
This application belongs to the applicant since they signed the Single Streamlined Application
Open a case for the child on their own case and preserve the request date using the receipt date Nov 15 on their application
Send the child a Single Streamlined Application including the MailIn packet
Programs Impacts
None
References
DHCS Clarification
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page Authorized Representative 040207
1of 5
Revision Date
04012021
Background
A customer can appoint an individual or organization to assist them with MediCal applications and redeterminations Reminder Authorized Representatives AR are appointed by competent customers This section covers requirements relating to ARs
Purpose
This section was updated to include clarifications from All County Welfare Directors Letter ACWDL 2028 regarding MediCal AR policies and procedures
Policy
040207A Scope of Duties The MediCal customer defines the scope of duties each AR may have and may specify that the AR assume any combination of the following duties
Assist in the application and redetermination processes
Review the case record with or without the customer present with some limitations as stated in MPG 020107
Submit verification to and obtain information from State Programs Disability Determination Services Division SPDDSD
SubmitProvide requested verifications medical records and other information to the county andor SPDDSD
Obtain information from the county and SPDDSD regarding the application status
Act on behalf of the customer in the application redetermination and ongoing MediCal processes
Receive copies of notices The customer can specify how many if any notices the AR must receive
Sign the application or complete and submit the renewal form on behalf of the beneficiary
ARs must be properly appointed by the customer to act on their behalf including signing the application For example an AR may sign the Single Streamlined Application on behalf of the customer however the Authorized Representative section of the Single Streamlined Application or another acceptable AR appointment method must still be signed by the customer using the approved methods outlined in 040207C
ARs have the same rights as the MediCal customers they represent to request MediCal information and forms in the threshold language or accessible format they prefer such as Braille or Large Font when they are authorized to receive notices or other correspondence
The AR authorization does NOT grant the AR the authority to access other programs or assign another AR to represent the customer When the beneficiary does not indicate scope of duty preferences or the AR form does not have them the AR has full authority to complete the duties listed above with one exception The exception is that the AR would not automatically receive copies of all notices The beneficiary must request that affirmatively
AR designations are not required for individuals with legal authority to act on behalf of the customer under state law This may include but is not limited to conservatorship guardianship and Power of Attorney Documentation of this can be provided electronically by fax by mail or in person
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Note A signed authorization is not required for the applicant to have someone accompany and assist them in the application process ARs are appointed by competent customers only No AR appointment is required for a customers spouse or the parent of a minor child living in the home
040207B Acceptable Authorized Representative Forms The following are acceptable Authorized Representative forms
Form MC 382 Appointment of Authorized Representative
The AR section of the Single Streamlined Application electronic Covered CA portal or paper
The AR section of the SAWS 2 Plus
The DPA 19 is acceptable for appointing an AR during the appeals process
ARs appointed via the MC 306 or other valid forms prior to 1012019 remain valid until they are cancelled by the customer or AR If an MC 306 or other valid form is received beginning 1012019 it is considered a valid AR appointment form however complete the MC 382 using the information provided on the MC 306 and mail to the AR and beneficiary as part of the initial notification process in MPG 040207F However an MC 306 that expired before 112014 is not valid and a new authorization is required
If the AR is appointed by the Single Streamlined Application or the SAWS 2 Plus attempt to contact the customer to determine the scope of duties they wish to assign the AR complete the MC 382 with the customer and notate the attempt and result in the case comments
If the Human Services Specialist HSS cannot contact the customer to determine the scope of duties the AR will have full authority except for automatically receiving copies of all notices and the HSS must document all attempts to contact the customer in the case file and complete the MC 382
Note Do not send the CSF 14 Authorization for Release of InformationAR for customers to appoint a MediCal AR as this is not a MediCal form However if a signed CSF 14 is received from the customer appointing a MediCal AR honor that form and process it until the Department of Health Care Services DHCS provides further direction
040207C Methods to designate an AR
The AR appointment can be made by phone in person by mail or electronically
To designate an AR the county must accept electronic signatures including telephone recorded signatures as well as handwritten signatures transmitted via fax or email to appoint an AR and specify the scope of the ARs duties
When completing the MC 382 over the phone
Complete the form with the customer and mark their preferences
Read section D Acknowledgement and Signatures to the customer This constitutes a telephonic signature
Narrate in the case file describing how the appointment form was completed
Mail a copy of the completed form to the customer and AR It does not need to be signed and returned
Note The AR is not required to sign the MC 382
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040207D Organizations Appointed as AR
Organizations can be appointed as authorized representatives but form MC 383 Authorized Representative Standard Agreement for Organizations must be signed by the individuals from the organization before they can serve as an AR
The MC 383 may be provided telephonically electronically by fax in person or by mail
When an AR appointment for an organization is received without a MC 383 work with the organization to complete the form for example complete the 383 over the phone mail the form to organization or let the organization know where it is available on the DHCS website
Keep a copy of the MC 383 in the case record
When mailing forms to the AR mail them to the organization address
The MC 383 is not an appointment form and the customer does not complete it
When taking the MC 383 over the phone
o
Complete the form with the AR and mark their responses
o
Read the agreement section to the AR This constitutes a telephonic signature
o
Make a case comment describing how the 383 form was completed
o
Make a copy of the completed form to send to the AR
There is no limit to the number of ARs that a customer may have If there is conflicting information from different ARs the customer must clarify the information or appoint a lead AR
DHCS does not expect staff to evaluate organizations for conflicts of interest If staff receive information from a customer that their appointed AR has a conflict of interest not disclosed to them please elevate the information to MediCal program
040207E MediCal Eligibility Data System MEDS AR Field Do not use information from the AR field in the INQD screen in MEDS as verification of current AR appointment If contacted by an AR listed in the MEDS INQD screen and no current AR authorization is in the case file then contact the customer via the customers preferred method of contact to confirm if they would like the individual or organization to act as their AR Follow the process outlined in
040207Cwhen completing the AR appointment over the phone
040207F Changes
The AR or customer may cancel the AR appointment at any time
Only the customer may change the scope of duties
Changes can be completed over the phone electronically in person or in writing
040207G Noticing Requirements At the initial appointment of an AR send the following to the AR and the customer within TEN DAYS of receiving the information
MC 380 Notice of Authorized Representative Appointment
A copy of the MC 382 Appointment of Authorized Representative
Send a copy of the MC 219 Rights and Responsibilities for MediCal to the AR only Narrate the above actions in the case comments
When cancelling or changing the appointment of an AR mail the MC 381 Cancellation or Change to a MediCal Authorized Representative to both the AR and beneficiary Include a copy of the AR
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authorization with any disability packet sent to DDSD If received after the submission of the packet send the authorization with an MC 222 form
040207H Effective Dates The appointment of an AR remains in effect until the customer cancels or modifies the authorization or the acting AR informs the county that they are no longer acting as AR The appointment is valid for 90 days after a denial or discontinuance unless
The appointment is canceled by the AR or customer
The HSS determines that good cause exists for the AR appointment to continue because its in the best interest of the customer
A fair hearing is filed
The appointment will continue through the fair hearing process to ensure the AR can assist with reinstating benefits
If the customer loses competence or dies after appointing an AR honor the AR appointment made prior to the loss of competence However a spouse or any individual with legal documentation such as a power of attorney executor of their estate or the guardianconservator will have ultimate authority for the deceased or incompetent customers MediCal case and may cancel an AR appointment
040207I Durable Power of Attorney DPA A power of attorney is a written instrument however denominated that is executed by a natural person having the capacity to contract and that grants authority to an attorneyinfact A power of attorney may be durable or nondurable A DPA contains a clause which states that it will not be affected by the incapacity of the principal person who appoints the attorneyinfact who is the individual acting on the principals or applicants behalf or it may state that the DPA will become effective at the time the principal becomes incapacitated
Types of DPA There are many forms of DPA The HSS must review the DPA document to determine what authority has been given to the designated attorneyinfact Some examples of transactions that the attorneyinfact can handle include
Buying and selling property
Managing bank accounts bills and investments
Filing tax returns
Applying for government benefits
040207J Loss of Contact with AR If unable to reach the AR after reasonable attempts via the ARs preferred method of contact have been made contact the customer via their preferred contact method to notify them of the countys inability to reach the AR and the reason that the county is contacting the AR for example verification needed Work directly with the customer to obtain the necessary information The ARs appointment would continue and would not terminate unless requested by the customer or AR Request updated contact information if the AR makes contact
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Authorized Representative 040207 Page 5 of 5
References ACWDLs 1712 1826 1826 Errata 2028 DSS Manual 22085 19005 WIC 140145d2
Sunset Date This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Public Guardian Conservator or Representative key person
Number
Page Acting on Behalf of Incompetent Applicants
040208
1of 2
Revision Date
04012021
Background
The following section defines the roles and responsibilities of Public Guardians Conservators or Representatives acting on behalf of incompetent individuals
Purpose
This section was updated to include clarifications from All County Welfare Directors Letter ACWDL 2028 regarding the requirements of the DHCS 7068 Responsibilities of Public GuardiansConservators or ApplicantBeneficiary Representatives and Authorized Representative AR appointment for individuals with legal authority to act on the behalf of the customer
Policy
040208A Definition
A Conservator is a person appointed by the court to act as the guardian custodian or protector of another
Public Guardian is a county agency acting as a public entity appointed to act on behalf of people who have lost their ability either mentally or physically to handle their own affairs The Public Guardian acts as the individuals advocate No private person is allowed to be a public guardian
A Representative Key Person is a person acting on the behalf of another who is incapable of handling their own personal or business affairs The representative must have specific and personal knowledge of the incompetent individuals current circumstances The Representative may be a friend relative or someone else who has known the customer and will act responsibly on their behalf Human Services Specialist HSS should evaluate if the individual meets this criteria
Note A Key PersonKnowledgeable Person cannot appoint an AR without the signature of the customer For example an LTC applying for an incompetent individual cannot appoint an AR per MPG 040207
040208B Roles of Conservators and Public Guardians Conservators and Public Guardians may
Manage and control the conservatees estate
Perform all the tasks that a MediCal customer would be required to perform
Designate an AR to assist them as any other customer may do and like any AR the functions of the designated AR would be restricted to those stipulated on the MC 382 form
Act fully for the conservatee
AR appointment is not required for individuals who have provided verification of legal authority to act on behalf of the customer under state law This may include but is not limited to conservatorship guardianship and Power of Attorney Documentation of this can be provided electronically by fax by mail or in person
If the HSS believes that the AR is not acting in the best interest of the conservator or the conservatee the HSS will so advise the conservator and suggest that they revoke the MC 382 and appoint another AR if they so desire The conservator is however ultimately responsible for the customer and is subject
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Public Guardian Conservator or Representative key person
Number
Page Acting on Behalf of Incompetent Applicants
040208
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to being removed as the conservator if they act irresponsibly The HSS should refer these situations to the Public Guardians Office or the State MediCal Fraud Bureau
040208C Reporting Responsibilities It is very important that the public guardianconservator or customer representative key person be aware of their ongoing responsibilities for timely reporting changes to income property health coverage or any other changes that may affect eligibility of the customer whom they represent
040208D Required Forms
DHCS 7068 Responsibilities of Public GuardiansConservators or ApplicantBeneficiary Representatives
MC 219 Important Information for Persons Requesting MediCal
Give or mail the required forms to the public guardian conservator or representative key person at initial application and at each redetermination The signature address and telephone number of the representative key person is required on the DHCS 7068 The signed form must be retained in case file and a copy given to the representative The DHCS 7068 is not required for individuals who have provided verification of legal authority to act on behalf of the customer under state law This may include but is not limited to conservatorship guardianship and Power of Attorney
When the DHCS 7068 or the AR forms are submitted for an incompetent individual a review must be completed to validate that this casereferral meet the criteria of a diligent search otherwise it is not a diligent search or the representativekey person are questionable
The DHCS 7068 does not give the Public Guardian Conservator or Representative any authorization to receive case information This form only provides their reporting responsibilities as someone who has volunteered to assist an incompetent customer to apply for and retain MediCal
040208E Mailing NoticesCorrespondence It is not necessary to send a copy of a Notice of Action NOA or correspondence to the incompetent MediCal customer
References
ACWDLs 1712 2028
Sunset Date
This policy will be reviewed for continuance on or by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Statement of CitizenshipNonCitizen Status
040209
1of 2
Revision Date
04012021
Background
United States US citizenship and noncitizen status is used to determine the level of benefits a MediCal applicant is potentially eligible for
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
Applicants who claim to be US citizensnationals or to have satisfactory immigration status SIS on their application will have their citizenship or immigration status electronically verified via the California Healthcare Eligibility Enrollment and Retention System CalHEERS through the Federal Data Services Hub per 040222 Additionally selfattestation of citizenship via telephonic signature and electronic signature for applications submitted online will be an acceptable form of attestation see MPG 0407 for this process MediCal eligibility should not be delayed denied or discontinued solely for failure to respond to a request for the Statement of Citizenship Alienage and Immigration Status form MC 13
Procedure
040209A When Documentation is Not Required The MC 13 form or any additional citizenshipimmigration status documentation is not required when
The applicant claims to be US citizennational or to have SIS AND whose citizenshipimmigration status is verified via electronic means including California birth record match or the Social Security Administration SSA citizenship verification process
They are secondary adults on a case who did not sign the application and the primary applicant attests the individual is a US citizennational AND their citizenshipimmigration status is verified via electronic means including California birth match or the SSA citizenship verification process
The applicant is not claiming US citizenship or SIS
040209B Verbal Attestation The MC 13 form is not required for immigrants who verbally attest to an immigration status and have associated documentation that is sufficient to request verification via electronic means or the Systemic Alien Verification for Entitlement SAVE verification process
The MC 13 form will only be completed
During the application process when it is unclear or staff are unable to determine from the application or verbal statement if the individual is claiming US citizenship or SIS
During the redetermination a change report or any other time after the initial application is approved when unable to determine if the individual is claiming US citizenship or SIS and only after an ex parte review of all the information available to the county
When the applicant wants to claim the last category of Permanently Residing in the United States under Color of Law PRUCOL Individuals who claim this status are not required to provide additional documentation
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Statement of CitizenshipNonCitizen Status
040209
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040209C Reasonable Opportunity Period ROP An otherwise eligible applicant attesting to citizenshipsatisfactory immigration status pending verification of their status will be granted full scope MediCal benefits during the 90day ROP to provide
If verification is Then
submitted which states SIS or applicants status is fullscope benefits continue
verified by current policy
provided or final determination is received but does not prove SIS
not submitted
reduce benefits to the appropriate level with adequate and timely notice
Note Former Foster Youth FFY who aged out of Foster Care on or after their 18th birthday are eligible to full scope MediCal from age 18 up to age 26 regardless of immigration status FFY should remain full scope MediCal even if US citizenshipSIS is not verified during the 90day ROP see MPG 051510B See MPG 041305 for information on restoring full scope benefits
040209D Failure to Respond to a Request for the MC 13 Form When a MC 13 form is necessary to determine if a fullscope MediCal beneficiary is attesting to citizenshipSIS and the form is not returned
If age 26 or over reduce benefits to the appropriate scope with proper notice
If under the age of 26 remains fullscope MediCal based on Senate Bill 104
If FFY is age 18 up to age 26 remains fullscope MediCal
Program Impacts
None
References
ACWDL 1441 1532 1612 1701 1816 1923 2017 MEDIL I 1421
Sunset Date
This policy will be reviewed for continuance on or by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Application for Retroactive MediCal
040210
1of 6
Revision Date
04012021
Background
Prior to the passage of the Affordable Care Act ACA individuals requesting retroactive MediCal coverage were required to complete and submit the Supplement to Statement of Facts for Retroactive CoverageRestoration MC 210 A form With the implementation of the ACA staff can now accept the form via phone in person by mail or electronically The MC 210 A form may be signed virtually via electronic signature and telephonically recorded signature Staff may also accept the MC 210 A with a handwritten signature transmitted via fax or email
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
An applicantbeneficiary including a minor consent applicant may request retroactive MediCal for any of the three months preceding the month of application If not requested at application the request for retroactive MediCal coverage must be made within one year of the month for which retroactive coverage is requested Qualified Medicare Beneficiary QMB applicantsrecipients are not eligible to retroactive MediCal
The request for retroactive MediCal may be made
On the Statement of Facts SOF
On the MC 210A
By submitting a written request
By submitting a verbal request
Procedure
040210A Requesting for Retroactive MediCal Upon receipt of the request have the applicant complete the Supplement to the SOF for Retroactive CoverageRestoration MC 210 A form When the applicant requests retroactive MediCal only have the applicant complete the SOF for the earliest retroactive month and the MC 210 A for each additional retroactive month These may be completed with information the applicantbeneficiary provides over the phone in person or through any other avenue available for those applying for MediCal
040210B Retroactive MediCal for Presumptive Eligibility PE Recipients The PE program allows qualified providers to grant immediate temporary MediCal coverage to lowincome patients pending their formal MediCal application Because of the limited scope of benefits that PE covers most PE recipients will require retroactive MediCal to cover some services received during their PE eligibility period
When staff become aware that an applicant is a PE recipient provide the applicant with information on how to apply for MediCal and the timeframes for applying for retroactive MediCal coverage Inform PE recipients that they may apply for retroactive MediCal coverage within one year of the month for which retroactive coverage is needed Additionally they do not have to apply for or be approved for ongoing MediCal to apply for retroactive coverage
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Application for Retroactive MediCal
040210
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040210C Retroactive MediCal for County Medical Services CMS Recipients An application for retroactive MediCal must be completed for an applicant who is identified as having CMS coverage during any month in the retroactive period Review the applicants statement on the SOF to see if the applicant declares CMS coverage and also check for CMS eligibility on an Information Data Exchange IDX screen print see Desk Aid 39 for cases originating from Hospital Community Support Services HCSS to see if the applicant was in receipt of CMS in the retroactive period
Since the County can be reimbursed for medical expenses covered by CMS a CMS recipient who may have a disabling condition that potentially links them to MediCal must apply for and cooperate in completing an application for disability linked MediCal These applications must be referred to the State program Disability Determination Service Division DDSD Refer to MPG 0504 Encourage and assist the CMS recipient as needed to complete the application If the CMS recipient fails to cooperate in completing the MediCal application narrate the reason why the retroactive application was not completed If a CMS MediCal Referral form HHSA CMS5 was provided complete the form and forward to CMS as indicated on the form distribution
040210D Retroactive MediCal for Supplemental Security IncomeState Supplemental Program SSISSP Recipients Title 22 California Code of Regulations Section 50148 states that a request for retroactive MediCal may be made in conjunction with or after application for public assistance or MediCal An application for public assistance includes an application for SSISSP benefits A request for retroactive coverage must be made within one year of the month the eligible expenses were incurred
Based on this regulation the month of application is established along with the SSISSP application for retroactive MediCal purposes even if aid in this case SSISSP is never approved for the application month The approval of SSISSP benefits is not necessary for the determination of the threemonth retroactive MediCal eligibility as in any MediCal only application
Below are three forms of retroactive MediCal application that may be processed
1 Retroactive to SSI Approval Month An SSI recipient who requests MediCal coverage back to the month of SSI approval which may be several months prior to the request This kind of request should be made within six months of the decision or four months from the date of the first State Data Exchange SDX update
Since the State cannot establish eligibility in the MediCal Eligibility Data System MEDS for SSI recipients prior to their initial approval action
Obtain verification from the Social Security Administration SSA indicating the persons SSISSP date of eligibility and a request for MediCal coverage for that period
Attach the SSA verification to a 1428 HHSA with the appropriate section completed and submit them to the Family Resource Center FRC MEDS operator to establish eligibility for that period
Issue an immediate need paper card if the Benefits Identification Card BIC has not been received by the beneficiary and an immediate need situation occurs
Issue a Letter of Authorization MC 180 andor Eligibility Letter of Authorization LOAShare of Cost MC1802 if the retro period is over one year Refer to MPG 1403 for details on issuing a MC 180 LOA
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2 Retroactive to SSI Application Month An individual who is approved SSI with an effective date after the date of SSI application This occurs when the individual was not financially eligible for SSI during these months The SSI award letter or other verification of entitlement may show a disability onset date prior to the SSI effective date If the individual is determined disabled or there is other linkage in the retro period evaluate the individual for MediCal if otherwise eligible
3 Months Prior to SSI Application Month This type of request may require that you submit a disability referral to DDSD if no other MediCal linkage exists If an individual is approved or denied SSI and requests MediCal for the three months immediately preceding the month of SSI application
Complete the MC 210A form from information the customer provides over the phone in person or through any other avenue available for those applying for MediCal
Obtain verification of the SSI application date Such verification may be an awarddenial letter from SSA indicating the date of application and date of approvaldenial or a copy of the individuals original SSI application form
Before requesting an SSISSP award letter from the applicant first attempt to obtain the SSISSP information from the SDX report located on the SDX1 through SDX5 screens in MEDS If information is unavailable request a copy of the SSISSP Award Letter along with any additional information needed to make an eligibility determination from the SSISSP recipient
Note Do not ask an applicant for information that is already available to the County from the SDX report or that is unnecessary for a MediCal determination
The SDX screens can be accessed in MEDS by clearing the screen then typing SDX and entering the Social Security Number SSN of the individual The following provides a description of the data included in the screens
SDX Screens
SDX1CLIENT DATA
SDX2ADDRESS DATA
SDX3CLIENT INFORMATION
SDX4CLIENT INCOME STATUS DATA
SDX5CLIENT INCOMESTATUS DATA
Description
Contains MEDS identification ID number persons name client index number health insurance claim number BIC issue date birth date language spokenwritten and birthplace
Contains MEDS ID number persons name address and telephone number
Contains MEDS ID number persons name Title II Claim number SSI application date CA residency date and disability onset date
Contains MEDS ID number persons name unearned income and eligibility determination data
Contains MEDS ID number persons name eligible spouse SSN ineligible spouseparent data spouseparent earned income and unearned income
SSISSP recipients eligible under the Aged Disabled Federal Poverty Level AD FPL Program are eligible for MediCal in the month of application or in the month of the first day in which their SSISSP
County of San Diego Health and Human Services Agency HHSA
MediCal Program Guide
Application for Retroactive MediCal Number 040210 Page 4 of 6
eligibility criteria were met MEDS has been programmed to provide eligibility on this basis for the month of application
040210E Determining Retroactive MediCal Eligibility for SSISSP Applicants Pending SSA Disability Determination Screen the SSISSP applicant to any other MediCal program while the Social Security Disability Insurance SSDI application is pending at SSA
If it is determined that Then
the SSISSP applicant
is
Eligible for retroactive The effective date for MediCal eligibility is the first day of the SSA
MediCal under any application month and retroactive MediCal eligibility if found eligible
other MediCal program applies to any of the three months prior to the application month
Not eligible for retroactive MediCal under any other MedCal program Send a disability packet to DDSD for a disability determination The disability packet must include an evaluation request for the retroactive months Refer to MPG 0504 for more information on processing disability cases
040210F Processing Requests Received at Intake All requests for retroactive MediCal are assigned according to FRC policy Requests for retroactive MediCal received at application shall be processed as follows
Step Action
1 Complete the MC210A form from information the customer provides over the phone in
person or through any other avenue available for those applying for MediCal If only
retroactive MediCal is requested a SOF is completed for the earliest retroactive month and
a MC210A for each additional retroactive month
2 For income verification
If Then
no change is use income verification that is used to determine current month
indicated eligibility on the SOF for each of the retroactive months This would
also apply to selfemployment income provided it adequately reflects
actual monthly income
change in income request income verification for each retroactive month where a
is reported change in income is reported
3 Determine eligibility and the share of cost SOC
4 Generate and mail appropriate notices
Reminder Only one pay stub is required to verify income if it adequately reflects the actual retroactive months income You may request further income verification if income reported is inconsistent with the income verification provided
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040210G Processing Requests from MediCal Beneficiaries When a beneficiary requests retroactive MediCal after a case has been granted
Complete the MC 210A form with information the customer provides over the phone in person or through any other avenue available for those applying for MediCal
Image the MC 210A to the active case file
040210H Processing Previous Denied Months The application for retroactive MediCal will be denied when the applicant was previously denied for the requested months unless the application was denied due to
An erroneous denial
The applicants failure to cooperate was due to circumstances beyond the control of the applicant
040210I Cases Transitioning from Covered California CA Advanced Premium Tax Credits APTC to MediCal Beneficiaries who are enrolled in a Covered CA Qualified Health Plan QHP with APTC and are then transitioned to MediCal may request retroactive MediCal for the 3 months prior to the month of transition
When MediCal is granted retroactively for months that a beneficiary received APTC the MediCal beneficiary
Will not be required to repay QHP premiums for those months
Is not entitled to a refund for premiums paid for QHP coverage
Can claim the premiums paid during the months for which APTC payments were made
In addition the QHP is considered the primary payer and MediCal the secondary payer
040210J Beneficiary Reimbursement Process BRP Provide information to beneficiaries who have paid outofpocket expenses for MediCal covered services about the availability of the BRP also known as the Conlan process
Information about the BRP should be given to beneficiaries who have paid outofpocket expenses that
occurred in the following time periods
Time Period Description
Retroactive The 3month period prior to the month of application for the MediCal
program
Evaluation
Postapproval
From the date of application for the MediCal program until the date eligibility is established
The time period after eligibility is established
Beneficiaries who have such paid expenses as noted above should immediately contact the Beneficiary Service Center BSC at 916 4032007 TDD 916 6356491 or visit the website at httpwwwdhcscagovservicesmedicalPagesMediCalConlanaspx for more information The BSC provides the customer with the necessary forms and instructions for filing a claim
Program Impacts
None
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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References
MEPM LTR 274 ACWDL 0243 0827E 1131 1608 1707 MEDIL I 1416 1427 County Policy
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSA
This section is revised for the sunset review no policies or procedures were changed
MediCal Program Guide
Processing Applications Where a Faceto Face Interview is Requested Number 040211 Page 1 of 1
Revision Date
04012021
BackgroundApplicants have the option of completing the interactive interview in person
Purpose
Policy
A facetoface interview with the applicant or person completing the Statement of Facts SOF is not required as part of the application process except as noted in Article 4 Section 6 For applicants who choose to apply for MediCal benefits by attending the facetoface interview the SOF shall be completed and signed by the applicant during the interview appointment
Procedure During the facetoface interview determine the MediCal program under which the applicant should be processed and explain the eligibility requirements for that program Complete and review with the applicant the verification checklist which itemizes the verifications that the applicant must provide to determine eligibility as required by MPG 0407 When the Human Services Specialist HSS determines that additional informationverifications are necessary follow the procedures specified in MPG 0407 when making the request
Program Impacts
None
References
CCR Title XXII Sections 50159 and 50161 42CFR 435907f WI Code 1400537r ACWDLs 0335 0340 MEDIL I 1012
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Processing MailIn Applications
040212
1of 2
Revision Date
04012021
Background
Effective July 1 2000 the Department of Health Care Services DHCS implemented the MediCal mailin application process to make health care benefits more widely accessible to the uninsured
Purpose
This section is revised to provide a reference to section 040222 for information on which applications must and must not be run through the California Healthcare Eligibility Enrollment and Retention System CalHEERS Business Rules Engine BRE
Policy
Effective July 1 2000 applicants may request a mailin packet in person at a Family Resource Center FRC or by phone without any interview requirement To protect the applicants date of application and retroactive months of eligibility a SAWS 1 must be completed
Procedure
040212A MailIn Packet Give applicants who request a mailin application packet fifteen days from the date of the request to complete and return the application form At the time of the request a SAWS 1 will be completed either by the applicant if the request is made in person at an FRC or by Access staff if the request is by phone The date of receipt is the date the application packet is received by the County
Note The packet must be sent on the same day the request is made
040212B Packet Not Returned by the Applicant FRCs are encouraged to attempt a reminder phone contact prior to denying individuals who do not submit the application packet When the application packet is not received by the 15th day after the application date SAWS 1 date the assigned Human Services Specialist HSS will deny the application
040212C Packet Received Upon receipt of the application packet the Document Processing Center DPC staff will register the application in CalWIN assign to the appropriate FRC image the documents into the CalWIN Electronic Records Management System CERMS and enter appropriate case comments Once assigned to an HSS to process review the application for completeness
If the applicationis
Complete
Incomplete
Then
evaluate for eligibility and notify applicant of determination Complete the eligibility determination within the 45day or 90day period as specified in 040217
follow the two 10day timeline specified in MPG 040712 to request needed informationverification
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Processing MailIn Applications
040212
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HSSs are reminded that some applications must be run through the CalHEERS BRE to electronically verify attested information prior to requesting paper verifications see 040222 for information on which applications must and must not be run through the CalHEERS BRE
040212D Packet Received More than 10 Days After Denial If the application packet is returned more than ten days after the date of the denial
Complete a new SAWS 1 The SAWS 1 date is the date the application packet is received after the denial action
The intake scheduling person should enter the resubmitted application on the schedule as a new intake
The information reported on the Statement of Facts SOF must adequately and accurately reflect the familys or individuals situation in the month of application for the new SAWS 1
Confirm whether there have been changes in the household that may affect eligibility since the applicant last signed the SOF a phone contact is sufficient If there were no changes narrate in the case that no changes occurred If changes have occurred take any necessary actions enter case comments and request any nonelectronically verified information needed to establish eligibility
Assign the application to an HSS to process
Note
There is no limit to the number of times a SAWS 1 may be completed However the SOF must be dated by the applicant no more than 12 months prior to the application date
The redetermination date must not be more that twelve months from the customers signature on the SOF or SAWS 1 whichever is earlier
Program Impacts
None
References
ACWDL 0031 0031E 1229 1233 1816
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Request for MediCal from Other Public Assistance PA Recipients
040213
1of 2
Revision Date
04012021
Background
Counties have been instructed to simplify and expedite applications for other aid programs This often allows a customer to use an application for multiple programs such as MediCal
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
040213A Request from CalFresh Recipients A CalFresh customer may request a MediCal evaluation by indicating on the CalFresh statement of facts SOF including the CF 285 that they are interested in applying for MediCal
Requirement Description
Forms If there is no active or pending MediCal case collect the Request for Tax Household Information RFTHI
Based on the review of the CalFresh SOF mail out the out all necessary forms including but not limited to the Disability Determination Services Division DDSD packet and the Child Support packet
Income
Property
Other Use the most current verification of income from the CalFresh case in the MediCal determination if there is no reported change
If applicable use the most current verification of property from the CalFresh case if it is dated the month of the MediCal application or not subject to change
Use all other verification available from the CalFresh case in the MediCal determination
040213B Request from Other Public Assistance PA Program Recipients Complete an ex parte review as outlined in MPG 040711 whenever requests for MediCal from persons on other PA programs for example CalWORKs CalFresh Cash Assistance Program for Immigrants CAPI General Relief etc are received Use the SOF from the PA case record as the SOF for the MediCal request Do not surpass the 45day timeframe for processing applications while obtaining informationverification from other PA case records
For applicants subject to a property evaluation property limits must be met in the month of application The property determination will be valid for twelve months or until there is an eligibility review due to a change in family circumstances The MediCal applicant or Authorized Representatives AR signature must be on the SOF It is not necessary for the applicant to sign the SAWS 1 Complete and sign the SAWS 1 using the date that MediCal is requested The redetermination date will be twelve months from the date of the SAWS 1
Program Impacts
None
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Request for MediCal from Other Public Assistance PA Recipients 040213 Page 2 of 2
References Assembly Bill 59 and Senate Bill 493 ACWDL 0110
Sunset Date This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Processing Individuals Denied SSISSP Due to Excess Income
040215
1of 2
Revision Date
04012021
Background
Complete the MediCal eligibility determinations begun by the Social Security Administration SSA for individuals who were denied Supplemental Security IncomeState Supplemental Program SSISSP due to excess income
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
Complete the MediCal eligibility determinations begun by SSA based on data collected by SSA for individuals who were denied SSISSP due to excess income on or after July 1 2009 These denied SSISSP cases are new applications therefore initiate andor complete identity citizenship income property and disability evaluations and receive and review all necessary verifications to complete the eligibility determination
Procedure
040215A Application Date The date of the application for MediCal will be the most recent of the SSISSP application date or the date California residency began
SSISSP application dates may be more than a year old When the SSISSP application date is 11 months prior to the current month and eligibility is established in the application month and ongoing send an application packet
Submit a disability referral within 10 days of the date of application For purposes of meeting performance standards enter into case comments any delays between the SSISSP application date as shown on the State Data Exchange SDX MediCal Eligibility Data System MEDS screens and the date the disability referral was made
NOTE MediCal retroactive coverage is available to applicants referred by SSA
040215B Processing Guidelines Use the Daily MEDS Alert 9043 and the information received on the SDX MEDS screens to start the MediCal determination process for individuals denied SSISSP due to excess income by SSA
DPC Action
Step Action Using the daily MEDS alerts 9043 on Share Point from the Management Report folder complete the application registration process and assign case to the appropriate Family Resource Center FRC bank
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page Processing Individuals Denied SSISSP Due to Excess Income 040215
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The Document Processing Center DPC will code the application source SSISSP Excess Income Denial Select SSISSP Excess Inc Denial in the Source field of the Collect Applicant Information window during Application Registration
2
Mail the MediCal application packet as noted on 040202 The SOF will not be sent because the application for MediCal was made with the application for SSISSP 3
Enter case comments of actions taken
FRC Action All avenues of eligibility including Medicare Savings Program MSP eligibility shall be considered
Conduct an ex parte review on all unverified information and follow the two 10day contact requirements as specified in MPG 040712 to request needed informationverification
Program Impacts
None
References
ACWDL 0928
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSA
Whether or not the infant is Deemed Eligible DE the MediCal Statement of Facts SOF is never
MediCal Program Guide
Adding Newborns Number 040216 Page 1 of 1
Revision Date
04012021
Policy
required to add an infant to a MediCal case
Purpose
This section is revised for the sunset review no policies or procedures were changed
Procedure
040216A Procedures for NonDeemed Eligible Infants Infants who are not DE must have an application for a Social Security Number SSN and a statement of US citizenshipnoncitizen status completed to add them to a case
040216B Procedures for Deemed Eligible Infants No forms of any kind are required to activate a DE infant on MediCal during hisher first year An application is not needed until the infant turns one The infant is DE for one year from the date of birth if the mother of the newborn received MediCal zero SOC or where she has met her SOC at the time of birth and the infant maintains California residency
Determination for DE may occur at any time during an infants first year Once an infant is determined DE MediCal must be granted within ten calendar days of receiving notification The 10calendar day deadline may be extended only if there is not an active case and additional information is needed In this situation the DE infant must be added within 45 days Refer to MPG 0515 for detailed information on DE
Program Impacts
None
References
ACWDL 9166 0349 0917
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Eligibility Determination Timeframes
040217
1of 2
Revision Date
04012021
Background
All MediCal applicants are entitled to a timely eligibility determination
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
Make the applicants MediCal eligibility and share of cost SOC determination after the applicant has applied completed the Statement of Facts SOF and provided all essential information and verifications The eligibility determination is considered complete on the date the Notice of Action NOA is mailed to the applicant
Furthermore for denials evaluate the applicants potential eligibility for other programs and determine eligibility for any other programs for which the applicant appears eligible and desires assistance
Procedure
040217A Timelines The determination of eligibility and SOC is completed as quickly as possible but no later than
Fortyfive 45 days following the date the application is filed
Ninety 90 days following the date the application is filed when eligibility depends on establishing disability or blindness
040217B Extending Eligibility Determination Deadlines The 45 or 90day periods may be extended for any of the following reasons
The applicant has good cause and was unable to return the completed SOF supplemental forms or necessary verifications in time for the Human Services Specialist HSS to meet the promptness requirement
There has been a delay in the receipt of information necessary to determine eligibility and the delay is beyond the control of either the applicant or the HSS
The applicants guardian or other person acting on the applicants behalf has failed to provide the essential information requested by the HSS The extended eligibility determination period may not exceed three months from the date of application in this situation
The applicant demonstrated good faith effort to provide evidence citizenship and identity and reasonable opportunity period ROP was granted to the applicant
When the eligibility determination deadline is extended beyond the 45 or 90day periods document the reason for the extended deadline
040217C Good Cause Criteria Good cause as reference in section B includes but is not limited to
Physical or mental illness or incapacity of the applicant and authorized representative which prevents the return of the required information
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Eligibility Determination Timeframes
040217
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A level of literacy of the applicant and authorized representative which in conjunction with other social and language barriers prevents the applicantauthorized representative from meeting the established due date
For general information on good cause refer to MPG 0421
Program Impacts
None
References
CCR Title XXII Sections 50173 50175 50177 County Policy
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page Processing Low Income Subsidy LIS Applications for MediCal 040219
1of 3
Revision Date
04012021
Background
On July 15 2008 Congress enacted the Medicare Improvements for Patients and Providers Act of 2008 MIPPA One of the provisions under MIPPA requires the Social Security Administration SSA to refer consented Medicare Low Income Subsidy LIS applications for applicants who have consented to have their information shared to the counties to be evaluated for the Medicare Savings Programs in other words Qualified Medicare Beneficiary QMB Specified Low Income Medicare Beneficiary SLMB or Qualified Individual QI The evaluation includes MediCal and Medicare Savings Program MSP eligibility if the applicant provides their consent
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
The Medicare LIS Program also known as Extra Help is available to Medicare beneficiaries with limited income and resources Those who are LIS eligible will receive financial assistance to help pay for their Medicare Part D prescription drug costs
Some Medicare beneficiaries are automatically or deemed eligible for LIS based on their nocost MediCal SSI or MSP eligibility Those who are not deemed eligible may still qualify for LIS based on their income resources and household sizes
Nondeemed eligible Medicare beneficiaries may apply for LIS by submitting a LIS application to SSA by mail or online SSA will review their LIS application and notify the Medicare beneficiaries in writing of their LIS eligibility
Procedure
040219A Referral Process SSA forwards LIS applications where the applicant has consented to have their LIS application forwarded to the County for a MediCalMSP evaluation LIS applications are sent to the County via the MediCal Eligibility Data System MEDS Use the LIS application information shown on the LIS MEDS screens LIS 1 LIS 7 as an application and Statement of Facts SOF for MediCal Obtain the applicants information by viewing the LIS screens on MEDS
040219B Types of Application Two types of LIS applications will be received by the County from SSA
LIS Application
Description Type
Processed
LIS 1 screen will have a N or blank in the LIS Application Completed field
SSA has completed an eligibility determination for LIS Extra help
Applications contain information used by SSA in their LIS Extra Help determination
Application information has been verified by SSA
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Processing Low Income Subsidy LIS Applications for MediCal
040219
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SelfReferred
Will include a denial reason if SSA denied the LIS Extra Help application
LIS 1 screen will have a Y in the LIS Application Completed field
Applicant selfassess that they are ineligible to LIS and requests that the information be forwarded to the County for a MediCalMSP evaluation
SSA has not completed an eligibility determination for LIS Extra Help
Application information has not been verified by SSA
SSA will not transmit LIS applications to the County where the applicant indicated that they do not want their information forwarded to the County
040219C Application Date The date of application for MediCal is the date that the LIS application was filed with SSA This date is located on the LIS Application Date field on the LIS 1 screen However when a MediCal application date already exists for the individual in CalWIN determine which application date would be most beneficial to the applicant See the Application Date section of the LIS Applications Processing Guide 09 for clarification and examples
NOTE Retroactive coverage is available to applicants referred via an LIS application
040219D Processing Timeframe The determination for MediCal including MSP eligibility must be made within the 45day application processing timeline The 45day application processing timeline begins the date the County receives the alert one business day after the date shown on the CountyReferral Date field on the LIS 1 screen The date the County received the alert and the CountyReferralDate must be narrated in case comments
040219E MEDS Alerts All LIS application information received from SSA will be matched against the MEDS databased daily
to check for existing MSP and MediCal eligibility The following MEDS alerts will be generated
MEDS
Title and Description
Alerts
9055
9056
9057
9058
9059
MIPPA LIS Application Client Not Found on MEDS
Individuals who have no information on MEDS
MIPPA LIS No Current MediCal and MSP eligibility
Individuals who have no current MediCal and MSP eligibility on MEDS
MIPPA LIS Current MSP eligibility but No Current MediCal Eligibility
Individuals who have current MSP eligibility on MEDS
MIPPA LIS No Current MSP Eligibility but Current MediCal Eligibility
Individuals who have current MediCal eligibility on MEDS
MIPPA LIS Current MSP and MediCal Eligibility
Individuals who currently have both MediCal and MSP eligibility on MEDS
040219F Processing Guide The Daily LIS Application Report is available in SharePoint Processing Guide 09 for LIS Applications is available in the Eligibility Essentials site
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Processing Low Income Subsidy LIS Applications for MediCal 040219 Page 3 of 3
Program ImpactsNone
References ACWDL 05231004
Sunset Date This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSA
The National Voter Registration Act NVRA is a federal law that requires states to provide voter
MediCal Program Guide
National Voter Registration Act NVRA Number 040220 Page 1 of 1
Revision Date
04012021
Background
registration opportunities at all offices that provide public assistance and all offices that provide state funded programs and services to people with disabilities
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy NVRA requirements for Public Assistance Offices information can be found in the Eligibility Policy Procedure Guide EPPG
Other Program Impacts
CalWORKs CalFresh and the Cash Assistance Program for Immigrants CAPI must comply with NVRA requirements
References MEDIL I 1202 Senate Bill 35
Sunset Date This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
Processing of Electronic Applications
040222
1of 6
Revision Date
04012021
Background
To meet the guidelines of the Patient Protection and Affordable Care Act of 2010 ACA California established the Covered California CA Health Care Exchange As of October 2013 applications submitted through the Covered CA portal also known as California Health Eligibility Enrollment and Retention System CalHEERS are electronically sent to the CalWORKs Information Network CalWIN through External Referral
In December 2009 the California Department of Social Services CDSS and CalWIN Consortium along with several counties implemented My Benefits CalWIN MyBCW
Electronic applications
Alleviate the constraints of travel and office hours
Provide applicants an alternative means of applying for benefits
Simplify and expedite the application process by allowing the electronic submission of applications and verifications
Provide 24hour access to the screening and application process
Allow the applicant to scan and upload verification documents directly to the web site
Reduce Family Resource Center FRC lobby traffic
Enable CommunityBased Organizations CBOs with appropriate authorization to submit applications on behalf of the applicant
Purpose
This section has been updated to incorporate information about applications that must and must not be run through the CalHEERS Business Rule Engine BRE
Policy
An applicant may submit their application and verifications electronically to the County for processing The web address for MyBCW is wwwmybenefitscalwinorg The web address for Covered CA is wwwcoveredcacom Applications submitted online are transmitted to CalWIN through the External Referral process
MediCal applications received electronically will be processed in the same manner as mailin applications except the date of application will be established based on the guidelines in MPG 040201
Note All established application processing policies and procedures will apply unless otherwise specified in this section
Procedure
040222A Electronic Application Process All electronic MediCal applications submitted through MyBCW or Covered CA will be registered by the Document Processing Center DPC and assigned to the appropriate FRC to be processed
040222B Roles Related to the Electronic Application Process
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Processing of Electronic Applications
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The following is an overview of the roles and responsibilities for processing electronic applications
Role
DPC Office Assistant OA
FRC Human Services Specialist HSS
FRC Supervising Human Services Specialist SHSS
Responsibility
Retrieval clearance applicationregistration imaging and assignment of electronic applications and verifications
Process electronic applications
Accept pending the Disability Determination Services Division DDSD application where the eligibility determination has been completed and case is pending the DDSD decision
Image verifications according to the CalWIN Electronic Records Management System CERMS policy
Ensure Performance Standards are met by monitoring and tracking electronic application processing timeframes
040222C Requesting Verifications At initial application only request verifications after a CalHEERS BRE Electronic Health Information Transfer eHIT if appropriate and ex parte review If information is not verified via the Federal Hub or ex parte verifications are required Follow the established two 10day contact for request of verificationinformation as indicated in MPG 040712
Attested income that is electronically verified everified for Modified Adjusted Gross IncomeAdvance Premium Tax Credit MAGIAPTC proposes cannot be used for NonMAGI cases due to the share of cost SOC determination Request documentation of income if not verified by the Social Security Administration SSA or Employment Development Department EDD through the Income Eligibility Verification System IEVS Refer to MPG 040711 for ex parte review information
Note All Covered CA application referrals are run through the BRE prior to the County receiving the referral
040222D Verifications Submitted at the FRC or Electronically Follow the CERMS guidelines to image verifications received
040222E Processing MyBCW Applications MyBCW allows the applicant to submit the application and verifications online Current functionality does not require the applicant to provide all information necessary to determine eligibility for MediCal Refer to 040222C for requesting verification Send any supplemental forms with the Verification Check List VCL based on 040202
040222F Processing Covered CA Applications Applications received from Covered CA will receive one of three eHIT eligibility determination results from CalHEERS Eligible Conditionally Eligible or Pending Eligible and must be processed in CalWIN
CalHEERS Result Description
Eligible An individual will be determined Eligible if CalHEERS has electronically verified all MAGI eligibility criteria If the results are not questionable do not request additional information from the customer and accept the results If
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Processing of Electronic Applications
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the electronic determination appears to be incorrect process the case as described under Pending Eligible
Conditionally Eligible
An individual will be determined Conditionally Eligible if CalHEERS can electronically verify MediCal eligibility and the individual attests to having satisfactory citizenshipimmigration status or a Social Security Number SSN but the status cannot be verified
If the determination appears to be correct approve the eligibility results and allow a 90day Reasonable Opportunity Period ROP for citizenshipimmigrations status verification or 60day ROP for Social Security Number SSN verification based on MPG 040713 and 0411
If the determination appears incorrect process the case as described under Pending Eligible
An individual will be determined Pending Eligible if CalHEERS cannot electronically verify that the individual meets MediCal eligibility but the attested income is within the MediCal limit
Pending Eligible means that the verifications are required prior to approval of benefits
If Eligible or Conditionally Eligible but the results are questionable accept the MAGI eligibility results from CalHEERS and process the case as a change in circumstance allowing the MAGI beneficiary 30 days to provide the missing or questionable verification
Conduct an ex parte review on all unverified information and follow the two 10day contact requirement
Pending Eligible
For Pending Eligible applicants who provide the required verifications the CalHEERS BRE will determine eligibility as follows
Result
MAGI Eligible
Covered CA Eligible
Description
If the applicant is determined eligible for MAGI the applicant will be sent a Notice of Action NOA and will have their eligibility established for a 12month period
If the applicant is determined eligible for Covered CA coverage accept the determination and refer them to Covered CA Customer Service Representatives for plan selectionenrollment questions
Deny or discontinue the MediCal application for failure to provide if unable to make a final eligibility determination and the two 10day contact requirement is followed
Note If the applicant provides additional verificationinformation but it is not enough information to determine eligibility continue to work with the applicant in their preferred method of contact and language to collect the necessary information
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Processing of Electronic Applications
040222
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040222G Processing Transitioning Cases from APTC to MediCal During the Covered CA annual redetermination or a reported change in circumstance Covered CA enrollees that appear eligible for MediCal will be referred to MediCal for a final eligibility determination
Since the Covered CA enrollee is not an existing MediCal beneficiary the referral is treated as a new application for MediCal purposes If the Covered CA enrollee is eligible to MediCal the MediCal benefits are granted effective the first day of the month of transition
While the MediCal evaluation is in process the Covered CA enrollee will remain in their Covered CA qualifying health plan QHP and will be placed in a Carried Forward Status CFS hold This will include eligible and conditionally eligible APTCCost Sharing Reduction CSRCovered California Plan CCP individuals when a redetermination of eligibility results in a MAGI MediCal determination The individuals will continue on their Covered CA plan until a full MediCal eligibility determination has been made by the county and the CFS indicator in CalWIN is lifted by the Human Services Specialist HSS
CFS protects the Covered CA enrollee from having a gap in coverage until a full MediCal determination is completed Customers will receive the NOD64 Covered California Carry Forward notice informing them that they must continue to pay for their Covered CA QHP to avoid a gap in coverage
CFS applies to the following Covered CA transitioning case scenarios
Customer reports a change RAC and is determined MAGI MediCal Eligible Conditionally Eligible or Pending Eligible
During the Renewal Period the customer is determined MAGI MediCal Eligible Conditionally Eligible or Pending Eligible
During the Renewal Period the customer RAC after the renewal has been completed and is determined MAGI MediCal Eligible Conditionally Eligible or Pending Eligible
Applicant RAC after APTCCSRCCP eligibility has gone into effect and is determined MAGI MediCal Eligible Conditionally Eligible or Pending Eligible
CFS does not apply to the following Covered CA transitioning case scenarios
Special Enrollment Period SEP for APTCCSRCCPRAC
Open EnrollmentRAC and is determined MAGI MediCal Eligible
MediCal Access Program MCAP
For those who transition from Covered CA to MediCal their Covered CA QHP doctor may or may not be in their new MediCal health plan If required the beneficiary will need to select a new plan and will receive plan information from HCO
To complete the MediCal eligibility determination regardless of outcome lift the CFS flag in CalWIN
Note Evaluate Covered CA applications with CFS hold for MC eligibility as soon as possible because the consumer is paying their medical insurance premiums for Covered CA QHP even though they are potentially eligible for MediCal and they are not reimbursed for any medical insurance premiums paid during the CFS hold period
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
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Processing of Electronic Applications
040222
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040222H Remote Identity Proofing RIDP RIDP is a required process for online and telephonic MediCal or Covered CA applications that must be run through the Federal Hub and CalHEERS RIDP is not required for paper applications since the signature on the application satisfies the RIDP requirement
RIDP is mandatory for the primary applicant only Verify RIDP in either of the following ways
Complete an ex parte review to determine if acceptable identity documentation is on file to serve as RIDP verification
Request identity verification if adequate information is not on file
Refer to MPG 040706 for acceptable identity verifications
Note CalWIN cases will not be run through the CalHEERS BRE if RIDP requirement has not been met Refer to eHIT Bulletin 5 for RIDP processing in CalWIN
040222I Applications that must be run through CalHEERS BRE The CalHEERS BRE must be run for customers who meet any of the following criteria
A parent or caretakerrelative even if age 65 or over or receiving Medicare
Pregnant
Under age 19
1965 years old with no Medicare eligibility
Mixed MAGINonMAGI households
040222J Applications that must not be run through CalHEERS BRE The CalHEERS BRE is not be run if the entire household is eligible to
A Mega Mandatory Program
California Work Opportunity and Responsibilities to Kids CalWORKs
Refugee Cash Assistance RCA
NonMAGI MediCal with no eligibility to MAGI because of being aged blind or disabled and receiving Medicare and there is no dependent child or pregnant persons in the household
Note Review the application to prescreen for potential MAGI eligibility
040222K Referrals to Department of Health Care Services DHCS Investigations When unable to resolve any conflicting inconsistent or incomplete informationverification with the applicant initiate a fraud referral with the DHCS Investigations Branch Please see MediCal Processing Guide 19Fraud Prevention for procedural assistance
040222L Confidentiality Guidelines Process all requests for information in accordance with existing confidentiality guidelines Although representatives of the CBOs may assist the applicant with applying for MediCal they are not entitled to receive confidential case information An authorization for release of information or a signed appointment of representative must be obtained prior to releasing any confidential information
County of San Diego Health and Human Services Agency HHSA
CalWORKs CalFresh and General Relief GR applications may also be received through MyBCW
MediCal Program Guide
Processing of Electronic Applications Number 040222 Page 6 of 6
Other Program Impacts
It is mandatory that case comments contain adequate information to support the HSSs action
References
42CFR 435907f 42 CFR 435907 and 42 CFR435923 WI Code 1400537r 1400563 and 140145 MEDIL I 1012 1312 and 1510 ACWDL 0031 0807 1501 1608 1707 1816
Sunset Date
This policy will be reviewed for continuance by 04302024
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
NonMAGI Evaluation at Application
040223
1of 3
Revision Date
04012021
Background
This section provides guidance on when to evaluate for NonModified Adjusted Gross Income MAGI MediCal at application and the forms required for a NonMAGI evaluation at application Customers determined MAGI eligible may request a NonMAGI evaluation and if found NonMAGI eligible they must be given the option to select MAGI or NonMAGI
Purpose
This section is revised for the sunset review no policies or procedures were changed
Policy
As required by law perform a NonMAGI MediCal eligibility determination when an applicant
Requests a NonMAGI or full MediCal eligibility determination
Is exempted from the MAGI methodology
Is income eligible for Premium Tax Credits PTC is not income eligible for MAGIbased MediCal and indicated on the Single Streamlined Application potential eligibility for MediCal on the basis other than MAGI
Customers who are determined MAGI eligible may request a NonMAGI determination Evaluate for linkage through disability age or blindness and request the applicant or beneficiary to provide all information necessary to process a NonMAGI eligibility determination If found eligible for NonMAGI give the customer the option to select from MAGI or NonMAGI eligibility
Provide applicants potentially eligible for NonMAGI MediCal with the NonMAGI evaluation forms These forms will be used to collect the necessary data elements for a NonMAGI eligibility determination Do not discontinue MAGI eligible individuals from MAGI if the NonMAGI forms are not returned
Procedure
040223A Linkage to NonMAGI MediCal Potential eligibility for NonMAGI MediCal applies to individuals who are
Aged Blind or Disabled
Seeking Long Term Care LTC
Seeking services under Home and CommunityBased Services HCBS
Potentially eligible as Medically Needy
Requesting a NonMAGI or full MediCal evaluation
Do not deny NonMAGI only applicants for failure to provide tax household information as it is not needed to determine NonMAGI eligibility
Applying for Medicare Savings Programs MSP or Minor Consent does not require a MAGI evaluation
040203B NonMAGI Application Processing The following steps must be taken to evaluate for NonMAGI
County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number
Page
NonMAGI Evaluation at Application
040223
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Submission of these forms is not required applicants may submit this information over the phone or in their preferred method of communication Clearly narrate this information in case comments
Note Only request the MC 210 SI Income InKindHousing Verification when the situation requires this information to be submitted
040223D Advanced Premium Tax Credits APTC Evaluation The eligibility determination for APTC will happen concurrently with the MAGI determination If an applicant is determined income eligible to APTC they will fail for MAGI MediCal Send individuals potentially eligible for NonMAGI the NonMAGI evaluation forms for a NonMAGI determination
If an individual has MediCal with a SOC they have the option of having only SOC MediCal SOC MediCal and APTCCost Share Reduction CSR or only APTCCSR SOC MediCal does not meet Minimum Essential Coverage MEC
If the applicant is eligible to APTC benefits the APTC benefits will not be impacted if the applicant fails to provide NonMAGI MediCal verifications
Program Impacts
Automation
Collect the information from the MC 604 IPS form and enter appropriate information in CalWIN related to other income and property owned by the applicants
Go to the Case Individual Detail window in CalWIN mark Evaluate NonMAGI as Yes and redetermine eligibility
Forms and Document Capture The NonMAGI evaluation forms are available in Xerox and Eligibility Forms Repository
DPC staff will scan or manually login the barcoded MC 604 IPS form into the CalWIN Electronic Records Management System CERMS
References
ACWDL 1703 1726 1726E MEDIL I 1303 1304 1312 1402
Sunset Date
This policy will be reviewed for continuance by 04302024