County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Procedures Number Page 040201 1 of 5 Revision Date 08012019 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 This section has been updated to add information about the date of application from Memo 1607 which is now obsolete 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 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 hisher 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 My BenefitsCalWIN or Covered California applying through the Perinatal Care Network making the request while receiving aid under another public assistance program County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Procedures Number Page 040201 2 of 5 040201C Processing Requests for a FacetoFace Interview When an applicant requests MediCal at an 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 applicationregistration 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 Encourage the applicant to attend the Health Care Options HCO presentation so that heshe can make an informed choice of health plan 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 the worker will does not attend and if no contact is made from the applicant to reschedule send a MediCal mailin application packet as outlined in MPG 040212 attends the facetoface interview follow procedures outlined in MPG 040211 040201D Processing Requests for a MailIn Application Whether the request for an application is by phone or in person the following actions will be taken to provide the applicant with the necessary information at the time of the request Step Action 1 Explain to the applicant that heshe can apply for MediCal as a mailin or attend a facetoface interview 2 Encourage the mailin applicant to attend a HCO presentation so that heshe can make an informed choice of health plan and inform the applicants that they will receive a HCO packet by mail 3 Ask the applicant if heshe would like to apply for CalFresh in addition to MediCal If the applicant is interested in applying for CalFresh in addition to MediCal or needs CalFresh expedited services explain to himher that a facetoface interview may provide himher with faster benefits and is advisable especially if heshe does not have access to a regular source of communication Inform all other applicants that they should expect an interview within 30 days and can choose to do so over the phone refer to the CalFresh Program Guide The CalFresh interview may be scheduled with the MediCal application to streamline the application process However the applicant may still apply for MediCal by mail if heshe chooses Upon inperson request for a mailin application County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number Page Application Procedures 040201 3of 5 Step Action 1 Ask the applicant to complete a SAWS 1 to preserve the application date Note Outstation staff will process the SAWS 1 requests received Complete the applicationregistration process and assign the pending case to the central pending case bank based on FRC procedures Provide the applicant with the MediCal application packet and form 1485 HHSA Form 1485 HHSA reminds the applicant of the requirement to complete the application process This must be provided without delay Encourage the applicant to attend the Health Care Options HCO presentation so that heshe can make an informed choice of health plan Complete case comments documenting all case actions taken and image the SAWS 1 Fifteen days after the SAWS 1 date determine if the application packet has been received If the application packet is Then assign the application to a worker 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 040201E Processing Requests for Mailin Requests Received at Access Access Required Actions When an applicant contacts Access to request a mailin application Step 1 Action Clear all individuals requesting MediCal If an active MediThen Cal case exists Inform the applicant of the existing case Notify the FRC of the request Update case and mail any required formsnotices does not exist Proceed to step 2 To establish the date of application complete a SAWS 1 as follows Sign and date using the date the application was requested Complete the County Use section using the date the application was requested Enter the date of birth for the person requesting MediCal in box 2 under the Social Security number on the SAWS 1 Note Since the SAWS 1 is not required with the SOF the SAWS 1 completed by Access will not include the applicants signature Mail the MediCal mailin application packet and include form 1485 HHSA and a selfaddressed envelope County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Procedures Number Page 040201 4 of 5 4 Complete the applicationregistration process 5 Image the SAWS 1 and assign the MediCal pending case to the appropriate FRC pending bank FRC Required Actions Fifteen days after the application date or the date the MediCal application was sent to the applicant whichever is later FRC staff will determine if the application has been received If the application packet is Then assign the application to a worker 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 040201F Date of Application The date of application for MediCal benefits will be established using the following guidelines If the request is made Then the date of application is the date the over the phone phone request is made in person SAWS 1 is signed by the applicant by mail County receives the MediCal application online through Covered CA application is submitted to Covered CA call center and the call is transferred to the County as a Quick Sort Transfer request was transferred by Covered California to the County even if a voice mail message is left for Access2Health staff to return Example Covered CA received a call from an applicant on Friday 12216 at 6 pm The call was Quick Sort transferred to San Diego County on the same day The date of application will be 12216 Example 2 Covered CA received a call from an applicant on Sunday 12416 The call was Quick Sort transferred to San Diego County but since the County was not open for business the applicant was able to leave a voice mail message The date of application will be 12416 online through MyBCW application is received If received after 5 PM the application date is the next business day 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Procedures Number Page 040201 5 of 5 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 References 42CFR 435907f WI 1400537r California Code of Regulations Section 50151 ACWDL 1228 0106 MEDIL I 1012 1202 1601 Sunset Date This policy will be reviewed for continuance by 08312022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number Page Application Packet 040202 2of 4 2044 HHSA 1664 HHSA HHSA HSD 7 0998 HHSA CF 285 16157A HHSA Civil Rights Information National Voter Registration Act NVRA Voter Preference Form California Voter Registration Form VRC Health Care Options San Diego Gas Electric CARE Program Form CalFresh Outreach Flyer for MediCal Applicants NonLTC 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 include 1468 HHSA MailIn Cover Letter CCFRM604 Application for Health Insurance Postage paid preaddressed return envelope For applicants requesting a 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 MSP only 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 MSP only applicants Form Number MC 018 MC 020 MC 219 Pub 68 Pub 13 MC 372 GEN 1365 2046 HHSA 1475 HHSA 0998 HHSA 1669 HHSA 2044 HHSA 1664 HHSA 16157A HHSA 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 MediCal What it Means to You Brochure Your Rights Under California Welfare Programs Pamphlet Breast and Cervical Cancer Treatment Program BCCTP Brochure Multilingual Notification Language Needs Determination Mental Health Managed Care Notice San Diego Gas Electric CARE Program Form CalFresh Outreach Flyer for MediCal Applicants NonLTC Only Public Charge Civil Rights Information National Voter Registration Act NVRA Voter Preference Form California Voter Registration Card VRC Text Messaging Service Agreement Traffic Flow Flyer County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Packet Number Page 040202 3 of 4 Your Opinion Counts Survey 040202C Supplemental Forms Supplemental forms will be mailed to the applicant after the completed MediCal application is submitted and the worker evaluates the applicants circumstances For applicants requesting a facetoface interview these forms may be provided to the applicant during the interview Case comments must be entered to support the workers actions Child Support Packet Provide the following forms to applicants requesting MediCal for a child born out of wedlock or with an absent parent Form Number Form Title CS 196 Child Support Services Program Notice CW 21 NA Child Support Notice and Agreement CW 21 Q Child Support Questionnaire Postage paid preaddressed return envelope NonMAGI Evaluation Packet NonMAGI evaluation forms must only be provided to MediCal applicants who are subject to a property evaluation for MediCal eligibility Form Number Form Title 14146 NonMAGI Cover Letter for Applicants Pub 10 NonMAGI MediCal Programs Brochure MC 604 IPS Additional Income and Property Information Needed for MediCal MC 007 MediCal General Property Limitations DHCS 7077 Notice Regarding Standards for MediCal Eligibility only if the individual is institutionalized or requesting nursing facility level of care DHCS 7077A Notice Regarding Transfer of a Home for Both a Married and Unmarried ApplicantBeneficiary APTCCSR Brochure Covered CA Can Help You Get Affordable Health Coverage Postage paid preaddressed return envelope Statement of Citizenship Alienage and Immigration Status MC 13 The Statement of Citizenship Alienage and Immigration Status MC 13 is no longer provided to all applicants at initial application The form is provided to applicants when appropriate 040202D Case Comments Staff must enter cases 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 Repository EFR 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application Packet Number Page 040202 4 of 4 References ACWDLs 0106 0712 0832 and 1701 MEDILs I 1202 1421 1454 1454E 1535 1536 and 1726 Sunset Date This policy will be reviewed for continuance on or by 09302020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Applicants Rights and Responsibilities Number Page 040203 1 of 4 Revision Date 07272017 Background All applicants must be informed of their rights and responsibilities The Rights and Responsibilities for MediCal form MC 219 is updated to reflect new rules and changes in accordance with the Affordable Care Act ACA This section has been updated to include information about new regulations pertaining to the ACA and has been updated to the new format Policy Each applicant must be informed of hisher 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 applicants include Copy of the Right and Responsibilities MC 219 form Information on general MediCal property limits MC 007 and MC 005 if applicable Income Eligibility Verification System IEVS Information Additionally the worker is required to evaluate the applicants potential eligibility to other PA programs such as CalWORKs CalFresh SSISSP and CMS Procedure 040203A Inform Applicant of Rights All MediCal applicants shall be provided with the following information Requirement Description MC 219 Rights and Responsibilities The MC 219 Important Information for Persons Requesting MediCal must be given to or sent to the applicant The worker must 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 Applicants who request MediCal after a CalFresh only application must be given the MC 219 MC 007 General Property Limits The MC Information Notice 007 must be given 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 Ways to Reduce Excess Property The worker shall provide options as to how excess property may be reduced and how adequate consideration may be obtained in order to establish eligibility in the month of application This shall be done as soon as there is an indication that the County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Applicants Rights and Responsibilities Number 040203 Page 2 of 4 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 Article 9 for more information on spend down IEVS The Single Streamlined Application informs MediCal applicants that their SSN will be used to access State information on income and resources The worker must explain to the applicant that the SSN will be used to match information provided to the State by employers EDD and financial institutions although applicants who are not US 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 SOC determination is correct and that the information may be verified through collateral contacts when discrepancies are found Orientation The applicant should be encouraged to attend Orientation Orientation is not required for MediCal 040203B Review of Potential Eligibility for Other PA Programs When reviewing the application the worker will evaluate the applicants apparent eligibility for CalWORKs CalFresh and SSISSI If the applicant appears eligible for Then the worker will CalWORKs andor CalFresh advise the applicant of hisher potential eligibility have the applicant modify the SAWS 1 if heshe wishes to apply for additional aids document in case comments that the applicant County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Applicants Rights and Responsibilities Number Page 040203 3 of 4 was advised of potential eligibility for the aids if the applicant does not want to apply for additional aids SSISSP refer the applicant to SSA if heshe 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 040203D Applicants Responsibilities Applicants or key persons are responsible for providing essential verifications and reporting certain changes in a timely manner Responsibilities include Complete all documents required in the application process or in the determination of continuing eligibility Provide all verifications requested by the worker needed to determine eligibility and SOC as specified in Article 4 Section 7 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 utilize other health coverage available to the individual or family Promptly notify any changes in residence from one county to another within the state ICT procedures are described in Article 3 Section 2 Complete all the forms necessary to process a medical support referral to the Department of Child Support Services Cooperate with the Department of Child Support Services with the Medical Support Enforcement Program 040203E Medical Support Referral MediCal applicants must cooperate with the Medical Support Enforcement Program when requesting MediCal for a child born out of wedlock or with an absent parent An applicantrecipient must complete all the forms necessary to process a medical support referral to the Family Support Division of the District Attorneys Office Refer to Article 4 Section 18 for forms and referral procedures A beneficiary who refuses to cooperate without good cause with the Medical Support Enforcement Program will be determined to be an ineligible member of the MFBU References MEM 50184 ACWDL 9198 MEDIL I 1309 1605 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Applicants Rights and Responsibilities Number Page 040203 4 of 4 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Acceptable Statement of Facts SOF Number Page 040204 1 of 2 Revision Date 07272017 Background A Statement of Facts SOF is required to determine an applicants eligibility to MediCal This section has been updated to include information about new regulations pertaining to the Affordable Care Act and has been updated to the new format Policy 040204A Acceptable SOF The following forms may be accepted as an application and SOF for MediCal Form Usage CCFRM604 Single Streamlined Application Serves as an application for MediCal benefits Does not require a SAWS 1 Electronic Statement of Facts from MyBenefitsCalWIN MyBCW or Covered California 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 Note The SOF may also be used to evaluate the consumer for Covered California Advance Premium Tax Credits APTC and Cost Share Reduction CSR Other Program Impacts None References California Code of Regulations Sections 50159 and 50161 42CFR 435907f WI 1400537r ACWDLs 0335 and 0340 Sunset Date This policy will be reviewed for continuance on or by 07312020 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Acceptable Statement of Facts SOF Number Page 040204 2 of 2 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Persons Who May Complete and Sign the SOF Number Page 040205 1 of 4 Revision Date 7272017 Background This section provides regulations regarding who may sign the statement of facts SOF The section was updated due to new regulations that allow an authorized representative or a tax filer to complete the statement of facts for an applicant Policy 040205A Who May Complete 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 the MediCal SOF Applicants Adults in the applicants household as defined by the household composition regulations Family An Authorized Representative For incompetent or incapacitated individuals someone who is acting responsibly on behalf of the applicant The tax filer for the household 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 worker can sign the SOF If the applicant can only make a mark a witness must also sign the SOF 040205B Competency The following individuals may complete the application for incompetent applicants Spouse Conservator guardian or executor if there is one A relative or person with knowledge of the case can be broadly interpreted the 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 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 hisher 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 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 worker may process the application with that individual acting on behalf of and as key person for the applicant When the SOF is completed and signed by a key person the worker must give himher form DHCS 7068 to complete When the applicant is in LTC the worker may reach an incompetence decision by one of the following methods Calling the LTC facility and inquiring as to the patients ability to handle hisher own affairs Obtaining a statement from the patients physician Visiting the facility to communicate with the individual Obtaining satisfactory evidence from family members which provides the worker with sufficient reason to believe that the LTC individual is incapable of handling hisher own affairs Such evidence may County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Persons Who May Complete and Sign the SOF Number Page 040205 2 of 4 include conservatorship documents or a written statement from a family member stating that the individual is unable to complete the application process 040205C Defining Knowledgeable Person When the SOF is completed and signed by someone other than the applicant or hisher 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 affairs The person must be able to answer vital income and property questions with a response other than unknown If the person signing the SOF willfully conceals or fails to report essential facts that person not the applicantbeneficiary 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 the worker shall determine whether another knowledgeable person such as a relative or an LTC representative if the applicant is in LTC If no such person is available the worker may 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 refer to MPG Article 4 Section 9 for diligent search procedures Complete and sign the SOF The SOF must be countersigned by another county representative who confirmed by personal contact the inability of the applicant to act on hisher own behalf The case workers supervisor may make a phone call to the facility to confirm the clients incompetency and countersign the SOF 040205E Child Applicants The following individuals may submit an application for a child Parents custodial or noncustodial Any adult in the 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 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 himher 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 hisher financial affairs or The applicant is a child applying for Minor Consent Services and meets the requirements specified in Article 4 Section 4 040205F Tax Dependents The following individuals may apply for tax dependents County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Persons Who May Complete and Sign the SOF Number Page 040205 3 of 4 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 An applicant has a key person assuming case management responsibilities due to the applicants mental condition but the representative is noncooperative not acting in the best interests of the applicant eg 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 the worker shall complete form 1478 HHSA PUBLIC ADMINISTRATORCRAIG V BONTA REFERRAL When completing the section where the form asks State examples of probable cause the worker is to write the reason why the beneficiary is unable to handle hisher own affairs The original of the 1478 HHSA is to be forwarded to Mail Stop O95 attention Craig Liaison A copy of the form is to be imaged 040205H NonCooperation of the Acting Individual LTC applicants shall not be denied MediCal solely due to the noncooperation of the individual acting on 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 in order 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 eg SSA VA etc Treat the income as unavailable and do not use in determining SOC if worker 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 References California Code of Regulations Sections 50159 and 50161 ACWDLs 1712 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Persons Who May Complete and Sign the SOF Number Page 040205 4 of 4 Sunset Date This policy will be reviewed for continuance on or by 7312020 Approval Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide When Someone Other than the Applicant Signs the SOF Number Page 040206 1 of 2 Revision Date 08012019 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 This section is added to include the instructions from Memo 1552 into the Program Guide 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 MPG 42 for MailIn applications 040206B Examples Example 1 Brother applied for MediCal on November 1 He is also requesting for his sister He claims they file taxes separately This application belongs to the brother since he signed the Single Streamlined Application Open the sister on her own case and preserve the request date using the receipt date Nov 1 on her application Send the sister a Single Streamlined Application including the MailIn packet Example 2 Mother applied for MediCal on November 15 and also requested for her 30year old son She claims that they file taxes separately County of San Diego Health and Human Services Agency HHSA MediCal Program Guide When Someone Other than the Applicant Signs the SOF Number Page 040206 2 of 2 This application belongs to the mother since she signed the Single Streamlined Application Open the son on his own case and preserve the request date using the receipt date Nov 15 on his application Send the son a Single Streamlined Application including the MailIn packet Other Programs Impacts None References DHCS Clarification Sunset Date This policy will be reviewed for continuance by 8312022 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Authorized Representative Number Page 040207 1 of 4 Revision Date 1012019 Background An applicant may appoint an individual or organization to assist himher with MediCal applications and redeterminations This section covers regulations relating to authorized representatives AR This section was updated to include information regarding new AR forms Policy 040207A Scope of Duties The MediCal applicantrecipient 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 process Review the case record with or without the applicantrecipient present with some limitations as stated in MPG 020107 Submit verification to and obtain information from 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 applicantrecipient in the application redetermination and ongoing MediCal processes Receive copies of notices The applicant or beneficiary 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 The AR authorization does NOT grant the AR the authority to access other programs or assign another AR to represent the applicant or beneficiary 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 NOTE A signed authorization is not required for the applicant to have someone accompany and assist himher in the application process ARs are appointed by competent beneficiaries only No AR appointment is required for an applicantbeneficiarys 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 or paper The AR section of the SAWS2 Plus ARs appointed via the MC 306 or other valid forms prior to 1012019 remain valid until they are cancelled by the applicant beneficiary or AR If an MC 306 is received beginning 1012019 contact the applicantbeneficiary and offer to assist the applicantbeneficiary to complete the MC 382 via the acceptable methods listed below If the AR is appointed by the Single Streamlined Application or the SAWS 2 Plus workers must attempt to contact the applicantbeneficiary in order to determine the scope of powers they wish to assign the AR by completing the MC 382 with the applicantbeneficiary and notate the attempt and result in the case file County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Authorized Representative Number Page 040207 2 of 4 If the worker cannot contact the applicantbeneficiary to determine the scope of duties the AR will have full authority except for automatically receiving copies of all notices 040207C Methods to designate an AR The AR appointment can be made by phone in person by mail or electronically To designate an AR accept electronic signatures including telephone recorded signatures as well as handwritten signatures transmitted via fax or email to appoint an AR or specify the scope of the ARs duties When completing the MC 382 over the phone Complete the form with the beneficiary and mark their preferences Read section D Acknowledgement and Signatures to the beneficiary 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 The AR is not required to sign the MC 382 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 workers can 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 applicantbeneficiary does not complete it When taking the 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 phone 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 an applicant beneficiary may have If there is conflicting information from different ARs the applicant beneficiary must clarify the information or appoint a lead AR 40207E Changes The AR or applicantbeneficiary may cancel the AR appointment at any time Only the applicantbeneficiary may change the scope of duties Changes can be completed over the phone electronically in person or in writing 040207F Notification At the initial appointment of an AR send the following to the AR and the applicantbeneficiary within TEN DAYS of receiving the information MC 380 Notice of Authorized Representative Appointment A copy of MC 382 Appointment of Authorized Representative Send a copy of the MC 219 Rights and Responsibilities for MediCal to the AR only County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Authorized Representative Number Page 040207 3 of 4 Narrate the above actions in the case file 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 Send a copy of the AR authorization with any disability packet sent to DDSD If received after the submission of the packet send the authorization with an MC 222 form 040207G Effective Dates The appointment of an AR remains in effect until the applicant or beneficiary cancels or modifies the authorization the acting AR informs the county that they are no longer acting as AR or there is a change in legal authority on which the authority was based The appointment is valid for 90 days after a denial or discontinuance unless The appointment is canceled by the AR or applicantbeneficiary The worker determines that good cause exists for the AR appointment to continue because its in the best interest of the applicantbeneficiary A fair hearing is filed The appointment will continue through the fair hearing process to ensure the AR can assist with reinstating benefits 040207H AR has 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 two forms of DPA 1 Durable Power of Attorney for Property Management DPAP which authorizes an attorneyinfact to handle an individuals financial affairs and 2 Durable Power of Attorney for Health Care DPAHC which empowers an attorneyinfact to make health care decision for the principal Scope of an AR with DPA The possession of a DPA does not confer any additional authority to act on an individuals behalf for the purpose of obtaining MediCal benefits Applicants should be made aware that the DPA is a very powerful document and may be used inappropriately by unscrupulous persons especially since the DPA eliminates the need for court supervised conservatorship The DPA should be reserved for situations where it is determined that the principal can safely and properly grant the desired authority to a trusted agent References ACWDLs 1712 1826 DSS Manual 22085 19005 Sunset Date This policy will be reviewed for continuance on or by 10312022 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Authorized Representative Number Page 040207 4 of 4 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Public Guardian Conservator or Representative key person Acting on Behalf of Incompetent Applicants Number Page 040208 1 of 2 Revision Date 09012019 Background The following section defines the roles and responsibilities of Public Guardians Conservators or Representatives acting on behalf of incompetent individuals This section was revised due to the release of ACWDL 1712 which changed the scope of duties for authorized representatives to include completing the application on behalf of the applicant 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 persons 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 hisher 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 applicantbeneficiary and will act responsibly on hisher behalf Worker should evaluate if the individual meets this criteria Note A Key PersonKnowledgeable Person cannot appoint an Authorized Representative AR without the signature of the applicantbeneficiary 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 applicantbeneficiary would be required to perform Designate an AR to assist himher as any other applicantbeneficiary may do and like any AR the functions of the designated AR would be restricted to those stipulated on the MC 306 form Act fully for the conservatee If the worker believes that the AR is not acting in the best interest of the conservator or the conservatee the worker will so advise the conservator and suggest that heshe revoke the MC 306 and appoint another AR if heshe so desires The conservator is however ultimately responsible for the applicantbeneficiary and is subject to being removed as the conservator if heshe acts irresponsibly The worker 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 applicantbeneficiary representative key person be aware of hisher ongoing responsibilities for timely reporting changes to income property health coverage or any other changes that may affect eligibility of the applicantbeneficiary whom heshe represents 040208D Required Forms DHCS 7068 Responsibilities of Public GuardiansConservators or ApplicantBeneficiary Representatives MC 219 Important Information for Persons Requesting MediCal County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Public Guardian Conservator or Representative key person Acting on Behalf of Incompetent Applicants Number Page 040208 2 of 2 Give or mail the required forms to the public guardian conservator or representative at initial application and at each redetermination The signature address and telephone number of the public guardian conservator or key person is required on the DHCS 7068 The signed form must be retained in case file and a copy given to the public guardian conservator or representative 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 040208E Mailing NoticesCorrespondence In cases where the applicantbeneficiary has been determined incompetent to handle hisher own affairs and there is a public guardian conservator or key person acting on hisher behalf all NOAs and correspondences must be mailed to the public guardian conservator or key person It is not necessary to send a copy of a NOA or correspondence to the incompetent MediCal applicant or beneficiary In cases where the public guardian conservator or key person has requested that a copy of the NOA be sent to the administrator of the LTC facility the worker may copy the original NOA and mail it to the LTC administrator The NOA back which provides Appeal information is not required References ACWDL 1712 Sunset Date This policy will be reviewed for continuance on or by 09302022 Approval Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Statement of CitizenshipAlien Status Number Page 040209 1 of 2 Revision Date 07272017 Background United States US citizenship and alien status is used to determine the level of benefits a MediCal applicant is potentially eligible for This section has been updated to include information about new regulations pertaining to the Affordable Care Act and has been updated to the new format Policy Applicants who claim to be US citizensnationals or to have satisfactory immigration status SIS on the application will have their citizenship or immigration status electronically verified via CalHEERS through the Federal Data Services Hub Additionally selfattestation of citizenship via telephonic signature and electronic signature for applications submitted online will be an acceptable form of attestation MediCal eligibility should not be delayed denied 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 citizensnationals 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 is 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 040209C Reasonable Opportunity Period ROP Otherwise eligible applicant attesting to citizenshipsatisfactory immigration status pending verification of their status will be granted full scope MediCal benefits during the 90 day ROP to provide County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Statement of CitizenshipAlien Status Number Page 040209 2 of 2 This policy will be reviewed for continuance on or by 07312020 Approval Release Rick Wanne Director Eligibility Operations If verification is Then submitted which states SIS or applicants status is verified by current policy fullscope benefits continue provided or final determination is received but does not provide SIS reduce benefits to the appropriate level with adequate and timely noticenot submitted Note Former Foster Youth FFY 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 90 day ROP 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 over age 18 reduce benefits to the appropriate scope with proper notice If under age 19 remains fullscope MediCal based on Senate Bill 75 If FFY is age 18 up to age 26 remains fullscope MediCal Program Impacts No impact to other programs References ACWDL 1441 1532 1612 1701 MEDIL I 1421 Sunset Date County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application for Retroactive MediCal Number Page 040210 1 of 5 Revision Date 07272017 Background Prior to the passage of the Affordable Care Act ACA individuals requesting retroactive coverage MediCal coverage were required to complete and submit the Supplement to Statement of Facts for Retroactive CoverageRestoration MC 201 A form This section has been updated to include information about new regulations pertaining to the ACA and has been updated to the new format 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 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 Statement of Facts 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 you become aware that an applicant is a PE recipient you must provide the applicant with information on how to apply for MediCal and the timeframes for applying for retroactive MediCal coverage PE recipients shall be informed 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 in order to apply for retroactive coverage 040210C Retroactive MediCal for 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 You will need to review the applicants statement on the 162A HHSA and SOF to see if the applicant declares CMS coverage and also check for CMS eligibility on an IDX screen print see Desk Aid 39 for cases originating from hospital out station HOS to see whether 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 himher to MediCal must apply for and cooperate in completing an County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application for Retroactive MediCal Number Page 040210 2 of 5 application for disability linked MediCal These applications must be referred to DDSD Refer to Article 5 Section 4 The CMS recipient should be encouraged and assisted as needed to complete the application If the CMS recipient fails to cooperate in completing the MediCal application you must 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 SSI 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 three month 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 SDX update Since the State cannot establish eligibility in MEDS for SSI recipients prior to their initial approval action obtain verification from SSA indicating the persons SSISSP date of eligibility and a request for MediCal coverage for that period of time attach the SSA verification to a 1428 HHSA with the appropriate section completed and submit them to the FRC MEDS operator to establish eligibility for that period issue an immediate need paper card IF the BIC has not been received by the beneficiary and an immediate need situation occurs issue a MC 180 LOA if the retro period is over one year Refer to Article 14 Section 3 for details on issuing a MC 180 LOA 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 the individual shall be evaluated 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 MC210A form from information the applicantbeneficiary 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 etc County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application for Retroactive MediCal Number Page 040210 3 of 5 Before requesting an SSISSP award letter from the applicant you must first attempt to obtain the SSISSP information from the SDX report located on the ISDX1 through ISDX5 screens in MEDS If information is unavailable request from the SSISSP recipient a copy of the SSISSP Award Letter along with any additional information needed to make an eligibility determination 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 ISDX screens can be accessed in MEDS by clearing the screen then typing ISDX and entering the SSN of the individual The following provides a description of the data included in the screens SDX Screens Description SDX1CLIENT DATA Contains MEDS identification ID number persons name client index number health insurance claim number BIC issue date birth date language spokenwritten and birthplace SDX2ADDRESS DATA Contains MEDS ID number persons name address and telephone number SDX3CLIENT INFORMATION Contains MEDS ID number persons name Title II Claim number SSI application date CA residency date and disability onset date SDX4CLIENT INCOME STATUS DATA Contains MEDS ID number persons name unearned income and eligibility determination data SDX5CLIENT INCOMESTATUS DATA Contains MEDS ID number persons name eligible spouse SSN ineligible spouseparent data spouseparent earned income and unearned income SSISSP recipients eligible under the AD FPL Program are eligible for MediCal in the month of application or in the month of the first day in which their SSISSP 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 SSDI application is pending at SSA If it is determined that the SSISSP applicant is Then Eligible for retroactive MediCal under any other MediCal program The effective date for MediCal eligibility is the first day of the SSA application month and retroactive MediCal eligibility if found eligible applies to anyall 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 shall include an evaluation request for the retroactive months Refer to Article 5 Section 4 for more information on processing disability cases Beneficiary Reimbursement Process Provide information to SSISSP applicants who have paid outofpocket expenses for MediCal covered services about the availability of the Beneficiary Reimbursement Process BRP Information about the BRP should be given to SSISSP applicants who have paid outofpocket expenses that occurred in the following time periods County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application for Retroactive MediCal Number Page 040210 4 of 5 Time Period Description Retroactive Period The 3month period prior to the month of application to the MediCal program Evaluation Period From the date of application for the MediCal program until the date eligibility is established Postapproval Period The time period after eligibility is established SSISSP applicants who have such paid expenses as noted above should immediately contact the Beneficiary Service Center at 916 4032007 or visit the website at this link httpwwwdhcscagovservicesmedicalPagesMediCalConlanaspx 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 applicantbeneficiary 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 indicated utilize income verification that is used to determine current month 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 is reported request income verification for each retroactive month where a change in income is reported 3 Determine eligibility and SOC 4 Generate and mail appropriate notices Reminder Only one pay stub is required to verify income as long as it adequately reflects the actual retroactive months income You may request further income verification if income reported is inconsistent with the income verification provided 040210G Processing Requests from MediCal Beneficiaries When a beneficiary requests retroactive MediCal after a case has been granted Complete the MC210A form from information the applicantbeneficiary 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 that Transition from Covered CA Advanced Premium Tax Credits APTC to MediCal Beneficiaries who are enrolled in a Covered California 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Application for Retroactive MediCal Number Page 040210 5 of 5 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 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 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing Applications Where a Faceto Face Interview is Requested Number Page 040211 1 of 1 Revision Date 07272017 Background Applicants have the option of completing the interactive interview in person This section has been updated to the new format 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 that 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 the worker will determine the MediCal program under which the applicant should be processed and explain the eligibility requirements for that program The worker will complete and review with the applicant the verification checklist which itemizes the verifications that the applicant must provide in order to determine eligibility as required by Article 4 Section 7 When the worker determines that additional informationverifications are necessary the worker must follow the procedures specified in Article 4 Section 7 when making the request References California Code of Regulations Sections 50159 and 50161 42CFR 435907f WI 1400537r ACWDLs 0335 and 0340 MEDIL I 1012 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing MailIn Applications Number Page 040212 1 of 2 Revision Date 07272017 Background Effective July 1 2000 DHCS implemented the MediCal mailin application in order to make health care benefits more widely accessible to the uninsured This section has been updated to include information about new regulations pertaining to the Affordable Care Act and has been updated to the new format Policy Effective July 1 2000 applicants may request a mailin packet in person at a FRC or by phone without any interview requirement To protect the applicants date of application and retro months of eligibility a SAWS 1 will need to be completed Procedure 040212A MailIn Packet Applicants who request a mailin application packet shall be given 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 a 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 worker will deny the application 040212C Packet Received Upon receipt of the application packet DPC will register the application in CalWIN assign to the appropriate FRC image the documents in CERMS and enter appropriate case comments Once assigned to a worker to process the worker shall review the application for completeness If the application is Then the worker will complete evaluate for eligibility and notify applicant of determination Eligibility determination shall be completed within the 45 days or 90 days period as specified in Article 4 Section 217 incomplete follow the two 10day timeline specified in Article 4 Section 0712 to request needed informationverification Workers are reminded that an application must be run through the BRE to electronically verify attested information prior to requesting paper verifications 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 shall be 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing MailIn Applications Number Page 040212 2 of 2 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 any necessary actions must be taken case commented entered and request any nonelectronic verified verifications needed to establish eligibility Assign the application to a worker 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 clients signature on the SOF or SAWS 1 whichever is earlier References ACWDL 0031 0031E 1229 and 1233 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Request for MediCal from Other PA Recipients Number Page 040213 1 of 2 Revision Date 07272017 Background Counties have been instructed to simplify and expedite applications for other aid programs This often allows an applicant or recipient to use an application for multiple programs such as MediCal This section has been updated to the new format Policy 040213A Request from CalFresh Recipients A CalFresh applicant or recipient 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 staff will collect the Request for Tax Household Information RFTHI Based on the review of the CalFresh SOF staff will mail out the out all necessary forms including but not limited to the DDSD packet and the Child Support packet Income The most current verification of income from the CalFresh case will be used in the MediCal determination as long as there is no reported change Property If applicable the most current verification of property from the CalFresh case will be used as long as it is dated the month of the MediCal application or not subject to change Other All other verification available from the CalFresh case will be used in the MediCal determination 040213B Request from Other PA Program Recipients Staff shall complete an ex parte review as outlined in Article 4 Section 7 whenever they receive requests for MediCal from persons on other PA programs eg CalWORKs CalFresh CAPI General Relief etc The SOF from the PA case record is to be used as the SOF for the MediCal request Workers must 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 ARs signature must be on the SOF It is not necessary for the applicant to sign the SAWS 1 Workers may 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 References Assembly Bill 59 and Senate Bill 493 ACWDL 0110 Sunset Date This policy will be reviewed for continuance on or by 07312020 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Request for MediCal from Other PA Recipients Number Page 040213 2 of 2 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing National School Lunch Program NSLP Applications for MediCal Number Page 040214 1 of 1 This section is obsolete Note For NSLP regulation go to SElig OpsRArchived Program MaterialMediCal References ACWDL 0335 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing Individuals Denied SSISSP Due to Excess Income Number Page 040215 1 of 2 Revision Date 07272017 Background With the issuance of ACWDL 0928 Counties will complete the MediCal eligibility determinations begun by the Social Security Administration SSA for individuals who were denied SSISSP due to excess income This section has been updated to the new format Policy Staff will 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 workers may have to initiate andor complete identity citizenship income property and disability evaluations and receive and review all necessary verifications in order 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 applications dates may be more than a year old When the SSISSP application date is 11 months prior to the current month and workers have established eligibility in the application month and ongoing workers shall send an application packet Workers are required to submit a disability referral within 10 days of the date of application For purposes of meeting performance standards the worker shall enter into case comments any delays between the SSISSP application date as shown on the SDX MEDS screens and the date the disability referral was made NOTE MediCal retroactive coverage is available to applicants referred by SSA 040215B Processing Guidelines The Daily MEDS Alert 9043 and the information received on the SDX MEDS screens shall be used to start the MediCal determination process for individuals denied SSISSP due to excess income by the Social Security Administration DPC Action Step Action 1 Using the daily MEDS alerts 9043 on Share Point from the Management Report folder complete the applicationregistration process and assign case to the appropriate FRC bank DPC willl 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing Individuals Denied SSISSP Due to Excess Income Number Page 040215 2 of 2 All avenues of eligibility including Medicare Savings Program eligibility shall be considered Staff must conduct an ex parte review on all unverified information and follow the two 10day contact requirements as specified in Article 4 Section 0712 to request needed informationverification References ACWDL 0928 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Adding Newborns Number Page 040216 1 of 1 Revision Date 07272017 Policy Whether or not the infant is deemed eligible DE the MediCal statement of facts SOF is never required to add an infant to a MediCal case This section has been updated to the new format Procedure 040216A Procedures for NonDeemed Eligible Infants Infants who are not DE must have an application for a SSN and a statement of US citizenshipalien status completed in order to add them to the 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 as long as 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 10 calendar days 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 Article 5 Section 15 for detailed information on DE References ACWDL 9166 0349 0917 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Eligibility Determination Timeframes Number Page 040217 1 of 2 Revision Date 07272017 Background All MediCal applicants are entitled to a timely eligibility determination This section has been updated to the new format Policy The applicants MediCal eligibility and shareofcost SOC determination shall be made 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 the worker will 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 worker 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 worker The applicants guardian or other person acting on the applicants behalf has failed to provide the essential information requested by the worker 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 period was granted to the applicant When the eligibility determination deadline is extended beyond the 45 or 90day periods the worker must 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 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 Article 4 Section 21 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Eligibility Determination Timeframes Number Page 040217 2 of 2 References MEM 50173 50177 CCR Title 22 Section 50175 County Policy Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Referral to Health Families Number Page 040218 1 of 1 This section is obsolete Note For Healthy Families regulation go to SElig OpsRArchived Program MaterialMediCal References ACWDL 0305 0340 1233 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing Low Income Subsidy LIS Applications for MediCal Number Page 040219 1 of 2 Revision Date 07272017 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 SSA to refer consented Medicare LIS applications for applicants who have consented to have their information shared to the counties to be evaluated for the Medicare Savings Programs MSP ie QMB SLMB or QI1 The evaluation includes MediCal and MSP eligibility if the applicant provides hisher consent This section has been updated to the new format 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 hisher LIS application forwarded to the County for a MediCalMSP evaluation LIS applications are sent to the County via MEDS The LIS application information shown on the LIS MEDS screens LIS 1 LIS 7 shall be used as an application and SOF for MediCal The worker will 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 Type Description Processed LIS 1 screen will have a N or blank in the LIS Application Completed field SSA has completed and 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 Will include a denial reason if SSA denied the LIS Extra Help application SelfReferred LIS 1 screen will have a Y in the LIS Application Completed field Applicant selfassess that heshe is 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 to the County LIS applications where the applicant indicated that heshe does not want hisher information forwarded to the County County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing Low Income Subsidy LIS Applications for MediCal Number Page 040219 2 of 2 040219C Application Date The date of application for MediCal shall be 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 the worker must determine which application date would be most beneficial to the applicant See the Application Date section of the LIS Applications Processing for clarification and samples 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 Workers must narrate in Case Comment the date the County received the alert and the CountyReferralDate 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 Alerts Title and Description 9055 MIPPA LIS Application Client Not Found on MEDS Individuals who have no information on MEDS 9056 MIPPA LIS No Current MediCal and MSP eligibility Individuals who have no current MediCal and MSP eligibility on MEDS 9057 MIPPA LIS Current MSP eligibility but No Current MediCal Eligibility Individuals who have current MSP eligibility on MEDS 9058 MIPPA LIS No Current MSP Eligibility but Current MediCal Eligibility Individuals who have current MediCal eligibility on MEDS 9059 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 for LIS Applications is available in the Eligibility Essentials site References ACWDL 0523 and 1004 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide National Voter Registration Act NVRA Number Page 040220 1 of 1 Revision Date 07272017 Background NVRA is a federal law that requires states to provide voter registration opportunities at all offices that provide public assistance and all offices that provide state funded programs and services to persons with disabilities This section has been updated to the new format Policy NVRA requirements for Public Assistance Offices information can be found in the Eligibility Policy Procedure Guide EPPG Other Program Impacts CalWORKs CalFresh and CAPI shall comply with NVRA requirements References MEDIL I 1202 SB 35 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Express Lane Enrollment ELE for CalFresh Eligible Adults and Children Number Page 040221 1 of 1 Revision Date 07272017 Background CalFresh applicants can request a MediCal evaluation on the CalFresh application CF 285 CalFresh recipients typically have verified income within MediCal financial eligibility limits This section has been updated to the new format Policy The Department of Health Care Services DHCS received federal approval to quickly enroll CalFresh recipients who meet certain criteria in zero share of cost SOC MediCal without a new application or redetermination through June 30 2017 CalFresh recipients who meet the following criteria are eligible to ELE Under age 65 Not blind or disabled Not currently enrolled in MediCal Citizens or Legal Permanent Resident aliens Procedure Follow the procedures in Processing Guide 14 Express Lane Enrollment when processing ELE requests Other Program Impacts None References ACWDL 1406 1406E 1427 and 1436 MEDIL I 1620 Sunset Date This policy will be reviewed for continuance on or by 12312019 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing of Electronic Applications Number Page 040222 1 of 5 Revision Date 07272017 Effective Date Upon receipt Background San Diego County uses two types of electronic applications My Benefits CalWIN MyBCW and Covered CA applications This section has been updated to include information about Covered California electronic applications and Carry Forward Status To meet the guidelines of the Patient Protection and Affordable Care Act of 2010 ACA California established the Covered California Health Care Exchange In October 2013 applications submitted through the Covered CA portal also known as CalHEERS short for California Health Eligibility Enrollment and Retention System are electronically sent to CalWIN through External Referral In December 2009 the Department of Social Services DSS and the California Welfare Client Data Systems CalWIN Consortium and several counties implemented MyBenefits 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 FRC lobby traffic enable CommunityBased Organizations CBOs to submit applications on behalf of the applicant Policy An applicant may submit their application and verifications electronically to the County for processing The web address for My Benefits CalWIN is wwwmybenefitscalwinorg The web address for Covered California 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 on 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 California 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 The following is an overview of the roles and responsibilities for processing an electronic application Role Responsibility DPC Office Retrieval clearance applicationregistration image and assignment of electronic County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number Page Processing of Electronic Applications 040222 2of 5 Assistant OA FRC Worker FRC Supervisor applications and verifications Process electronic applications Accept pending DDSD applications where the eligibility determination has been completed and case is pending the DDSD decision Image verifications according to the CERMS policy Ensure Performance Standards are met by monitoring and tracking electronic application processing timeframes 040222C Requesting Verifications At initial application verifications must only be requested after a CalHEERS BRE eHIT and ex parte review Consumers are not initially required to provide supporting verification of information until after an attempt has been made to electronically verify through the Federal Data Services Hub Federal Hub If information is not verified via the Federal Hub or ex parte verifications are required No application may be denied until it has been run at leastone time through the Federal Hub during a time when the Federal Hub is available Staff will follow the established two 10day contact for request of verificationinformation Attested income that is everified for MAGIAPTC proposes cannot be used for NonMAGI cases due to the shareofcost SOC determination Staff must request documentation of income if not verified by the Social Security Administration SSA or Employment Development Department EDD through an Income Eligibility Verification System IEVS Refer to MPG 040712 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 FRCs will follow the CERMS guidelines to image verifications received 040222E Processing My BCW 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 VCL based on 040202 Note At this time the MediCal redeterminations cannot be completed on MyBCW 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 Eligible Conditionally Eligible Description An individual will be determined Eligible if CalHEERS has electronically verified all MAGI eligibility criteria If the results are not questionable staff shall not request additional information from the consumer and will accept the results If the electronic determination appears to be incorrect staff should process the case as described under Pending 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 staff shall approve the eligibility results and allow 90days ROP for citizenship immigrations status verification or 60days ROP for SSN verification based on MPG 040713 and 0411 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing of Electronic Applications Number Page 040222 3 of 5 If the determination appears incorrect staff should process the case as described under Pending Eligible 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 staff must 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 Staff must conduct an ex parte review on all unverified information and follow the two 10day contact requirement For Pending Eligible applicants who provide the required verifications the CalHEERS BRE will determine eligibility as follows Result Description MAGI Eligible If the applicant is determined eligible for MAGI the applicant will be sent a NOA and shall have hisher eligibility established for a 12month period Covered CA Eligible If the applicant is determined eligible for Covered CA coverage staff will accept the determination and inform the applicant that Health Care Options HCO is available to assist with Covered CA health plan enrollment To inform the applicants about HCO staff may mail HSD 51 flyer Staff may refer the consumer with plan selectionenrollment questions to Covered CA Customer Service Representatives The MediCal application will be denied or discontinued for failure to provide if staff is unable to make a final eligibility determination and the two 10day contact requirements is followed Note If the applicant provides additional verificationinformation but it is not enough information to determine eligibility staff shall continue to work with the consumer in their preferred method of contact and language to collect the necessary information 040222 G Processing Transitioning Cases from Advance Premium Tax Credit 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing of Electronic Applications Number Page 040222 4 of 5 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 eligibility worker CFS protects the Covered CA enrollee from having a gap in coverage until a full MediCal determination is completed Consumers will receive the NOD 64 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 Consumer reports a change RAC and is determined MAGI MediCal Eligible Pending Eligible or Pending Consumer Renewal Period and is determined MAGI MediCal Eligible Pending Eligible or Pending Consumer Renewal Period and RAC after Renewal is complete and is determined MAGI MediCal Eligible Pending Eligible or Pending Applicant RAC after APTCCSRCCP eligibility has gone into effect and is determined MAGI MediCal Eligible Pending Eligible or Pending 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 his or her new MediCal health plan If required the beneficiary will need to select a new plan and will receive plan information from Health Care Options To complete the MediCal eligibility determination regardless of outcome the eligibility worker will need to lift the CFS flag in CalWIN Note Covered CA applications with CFS hold must be evaluated for MC eligibility as soon as possible because the consumer is paying hisher 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 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 Staff will 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Processing of Electronic Applications Number Page 040222 5 of 5 040222H Referrals to DHCS Investigations When unable to resolve any conflicting inconsistent or incomplete informationverification with the applicant initiate a fraud referral with the DHCS Investigations Branch 040222I Confidentiality Guidelines All requests for information will be processed in accordance with existing confidentiality guidelines Although representatives of the Community Based Organizations may assist the applicant with submitting an application for MediCal heshe is 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 Other Program Impacts CalWORKs and CalFresh applications may also be received through MyBCW It is mandatory that case comments contain adequate information to support the workers action References 42CFR 435907f WI 1400537r MEDIL I 1012 1312 and 1510 ACWDL 0031 0807 1501 1608 1707 Sunset Date This policy will be reviewed for continuance on or by 07312020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide NonMAGI Evaluation at Application Number Page 040223 1 of 3 Revision Date 11282017 Background This section provides guidance on when to evaluate for NonMAGI MediCal at application and the forms required for a NonMAGI evaluation at application This section has been updated to include information from ACWDL 1726 and 1726E which states that applicantsbeneficiaries 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 To inform staff when to evaluate for NonMAGI MediCal and the forms required for a NonMAGI evaluation at application Policy As required by law a NonMAGI MediCal eligibility determination shall be performed 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 Applicantsbeneficiaries who are determined MAGI eligible may request a NonMAGI determination Staff will 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 the applicant or beneficiary must be given the option to select from MAGI or NonMAGI eligibility Applicants potentially eligible for NonMAGI MediCal will be provided with the NonMAGI evaluation forms These forms will be used to collect the necessary data elements for a NonMAGI eligibility determination MAGI eligible individuals must not be discontinued from MAGI if the NonMAGI forms are not returned Procedure 040223A Linkage to NonMAGI MediCal Potential eligibility for NonMAGI MediCal applies to Aged Blind or Disabled individuals Seeking Long Term Care Individuals seeking services under Home and Community Based Waiver HCBW Individuals potentially eligible as Medically Needy Applicants requesting a NonMAGI or full MediCal evaluation Staff should 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 Step Action 1 Complete an ex parte review County of San Diego Health and Human Services Agency HHSA MediCal Program Guide NonMAGI Evaluation at Application Number Page 040223 2 of 3 2 If ex parte is successful authorize case If ex parte is unsuccessful o Provide the NonMAGI evaluation forms to the applicant o Enter case comments explaining actions taken o Follow established intake processing timeframes for the pending NonMAGI verifications Note Request only information or documents not already available or identified in the case 3 Depending on the response If the applicant Then Is MAGI eligible and does not provide the NonMAGI evaluation verifications after following the twocontact requirements leave in appropriate MAGI aid code deny NonMAGI MediCal timely issue the appropriate NonMAGI denial NOA and enter case comments does not provide the verifications after following the twocontact requirements deny the individual or case in CalWIN timely issue the appropriate denial NOA and enter case comments provides the verifications Update verifications in CalWIN Evaluate for NonMAGI MediCal Authorize appropriate benefits Timely issue adequate NOA and enter case comments Note Attested income that is everified for MAGIAPTC purposes cannot be used for the NonMAGI MediCal evaluation due to the Share of Cost SOC determination Staff must only request verification of income that is not verified by the Social Security Administration SSA or Employment Development Department EDD through an Income Eligibility Verification System IEVS 040223C NonMAGI MediCal Evaluation Forms For a NonMAGI evaluation applicants will be provided with NonMAGI MediCal evaluation forms These forms will be used to collect the necessary data elements for NonMAGI MediCal eligibility determinations The following forms are sent to applicants for a NonMAGI evaluation Form Title 14146 NonMAGI Cover Letter for Applicants MC 604 IPS Additional Income and Property Information Needed for MediCal MC 007 MediCal General Property Standards DHCS 7077 Notice Regarding Standards for MediCal Eligibility DHCS 7077A Notice Regarding Transfer of a Home for Both a Married and Unmarried ApplicantBeneficiary Pub 10 NonMAGI MediCal Programs Brochure County of San Diego Health and Human Services Agency HHSA MediCal Program Guide NonMAGI Evaluation at Application Number Page 040223 3 of 3 Submission of these forms is not required applicants may submit this information over the phone or in their preferred method of communication Staff must clearly narrate this information in case comments Note The MC 210 SI Income InKindHousing Verification should only be requested 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 Individuals potentially eligible for NonMAGI must still be sent the NonMAGI evaluation forms for a NonMAGI determination If an individual has MediCal with a share of cost 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 Staff must 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 CERMS References ACWDL 1703 1726 1726E MEDIL I 1303 1304 1312 and 1402 Sunset Date This policy will be reviewed for continuance on or by 11302020