County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal FMC Number 0507 Page 1 of 6 Revision Date 06012022 Background Prior to implementation of the Affordable Care Act ACA when a customers California Work Opportunity and Responsibility to Kids CalWORKs eligibility ended the Human Services Specialist HSS redetermined MediCal eligibility to evaluate if the customer still qualified for MediCal under Section 1931b When MedCal under Section 1931b with or without CalWORKs was discontinued due to an increase in earned income or hours of employment the HSS would evaluate for eligibility to Transitional MediCal TMC When the MediCal discontinuance was due to an increase in child or spousal support the HSS evaluated for FourMonth Continuing MediCal FMC With the implementation of ACA Modified Adjusted Gross Income MAGI methodology is used to determine eligibility for many MediCal groups As a result the section 1931b program was split into three groups consisting of the MAGI ParentCaretaker Relative group Mandatory Childrens group and certain individuals enrolled in the MAGI Pregnancy Coverage group Purpose The purpose of this section is to provide updated guidance regarding TMC and FMC policies for determining MediCal when CalWORKs is denied or discontinued under the ACA Policy When a customer is discontinued from the MAGI ParentCaretaker group CalWORKs Mandatory Childrens group or upon the end of the 12month postpartum period for the MAGI Pregnancy Coverage group the customer may be eligible for continued MediCal eligibility through TMC or FMC Note A household member between the ages of 18 to 26 years old who is eligible for the Former Foster Youth FFY program must be assigned the 4M aid code rather than be assessed for MAGI MediCal TMC or FMC Refer to MPG 051510 for policy guidance regarding the FFY program A Aid Codes with Potential TMC and FMC Eligibility The chart below illustrates aid codes in the Pregnancy group ParentCaretaker Relative group and Mandatory Childrens group which may be eligible for TMC and FMC Program MAGI ParentCaretaker Relative Full Scope MAGI ParentCaretaker Relative PregnancyRelated and Postpartum Emergency and LongTerm Care LTC services MAGI Expansion Child 619 years Full Scope MAGI Pregnant Women MAGI Pregnant Women PregnancyRelated and Postpartum Emergency and LTC services MAGI ACA Child 619 Years Full Scope MAGI ACA Child 16 Years Full Scope MAGI ACA Child 16 Years Emergency and LTC services MAGI ACA Infant 01 Year Full Scope Aid Code M3 M4 M5 M7 M8 P5 P7 P8 P9 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal Number Page FMC 0507 2 of 6 B Transitional MediCal TMC Eligibility TMC provides up to twelve months of continued MediCal eligibility There are two available periods of TMC An initial sixmonth extension period Refer to MediCal Program Guide MPG 0507C for guidance An additional sixmonth extension period Refer to MPG 0507D for guidance Eligibility Requirements for TMC for Adults To be eligible for TMC an adult customer must meet all the following criteria The customer is an aided adult on CalWORKs enrolled in the MAGI ParentCaretaker Relative group or the MAGI Pregnancy Coverage group in three of the six months immediately preceding the month of ineligibility o Months of retro MediCaleligibilitycounttowardsthe 3 months Discontinued solely due to an increase in earnings loss of earned income disregards or increased hours of employment o When multiple changes are reported the HSS must determine if the increase in earned income or hours of employment is the sole reason for the discontinuance Have a dependent child in the household A dependent child is an individual under the age of 18 or if 18 must be enrolled in school and expected to graduate by their 19th birthday o A dependent child can include a child who is receiving Supplemental Security IncomeState Supplementary Payments SSISSP or Adoption Assistance Children and TMC If a child remains eligible for a Mandatory Childrens group they are to remain in that coverage group If eligibility ends under the Mandatory Childrens group the HSS must evaluate for Continued Eligibility for Children CEC first When the CEC period ends the children must be placed in TMC with any eligible parentcaretaker relatives for the remainder of the TMC period Additional Household Members when TMC is Active The following individuals are eligible for the remainder of the extended eligibility period when being added to an active TMC case The other parent of the child returns to the family following a period of absence from the home Any children who are born adopted into the family or returning home after a period of absence from the home Note A child who is enrolled in TMC and becomes an adult during the TMC eligibility period may remain in TMC with their parentcaretaker relatives unless there is no other dependent child in the household Refer to MediCal Processing Guide 41 C Processing for the Initial Extended Eligibility Period of TMC for MAGI MediCal When a customer discontinues from the MAGI ParentCaretaker Relative group or the MAGI Pregnancy Coverage group HSS must evaluate the case for continued eligibility by taking the steps outlined below for these customers Refer to MediCal Processing Guide 41 for guidance on processing a TMC evaluation County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal FMC Number 0507 Page 3 of 6 D Second Extended Eligibility Period of TMC Once the initial extended eligibility period of TMC has expired customers may be eligible for the second extended eligibility period of TMC if the following conditions are met The customerwascontinuously aided forthe entire sixmonth initialextended eligibilityperiod ofTMC o Children who would have been aided under TMC but were aided under the Continuing Eligibilityfor Children CECorDeemed EligibilityDEfor Infants programsfor part or allthe initialTMC period are also eligible o Customers who were placed in Soft Pause or Edward v Kizer aid code 38 in lieu of a TMC aid are also eligible Earned income is at or below 202 percent of the Federal Poverty Level FPL o The HSS must determine countable earned income using MAGI MediCal rules o No separate deduction for childcare expenses needs to be included as the income limit takes this into account Have at least one dependent child in the household as outlined in MPG 0507A The family must be continuously employed with a gross monthly earned income at or below 202 percent of the FPL unless good cause exists o If the family reports a decrease in income or loss of employment an ex parte review must be completed to determine if the family is eligible for a more advantageous program If eligible HSS must enroll them into the more advantageous program Complete a quarterly report o The first quarterly report form MC 176 TMC must be submitted during the 4th month of the initial extended period by the 21st day of the month E Processing for the Second Extended Eligibility Period of TMC The HSS must conduct a MAGI MediCal eligibility determination by the end of the initial period of TMC with the information provided on the first MC 176 TMC quarterly report If the customer is determined to be ineligible for MAGI MediCal the HSS must evaluate for the second extended eligibility period of TMC Customers must submit quarterly reports timely to continue to be eligible for TMC Refer to MPG 0507Fforpolicyguidance onTMC quarterly reporting andMediCalProcessing Guide 41 forguidance on processing a second extended eligibilityevaluation for TMC Note If a customer is ineligible for the second extended eligibility period of TMC the HSS must evaluate for all other MediCal programs before discontinuing a customer from benefits and evaluating them for Advanced Premium Tax Credits Cost Sharing Reduction APTCCSR F Quarterly Reporting Families enrolled in TMC must report their income using form MC 176 TMC quarterly report The MC 176 TMC must be received timely unless there is good cause County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal FMC Number Page 0507 4 of 6 First Quarterly Report The first quarterly report is submitted during the initial extended eligibility period The report will be used to determine eligibilityfor the second extended eligibilityperiod of TMC There is no income test during the initial extended eligibility period and a customer cannot be terminated during this period for failure to submit the report Second and Third Quarterly Reports These quarterly reports are submitted during the second extended eligibility period of TMC and must be submitted timely to retain TMC eligibility If the reports are not submitted timely customers are allowed a 90day cure period Refer to MPG 0507J for guidance on determining TMC or FMC during the 90day cure period The table below outlines the reporting period and due date of each quarterly report Quarterly Report Reporting Period Due Date 1st Quarterly Report Months 13 of the initial extended eligibility period 21st day of month 4 2nd Quarterly Report Months 46 of the initial extended eligibility period 21st day of month 7 3rd Quarterly Report Months 79 of the second extended eligibility period 21st day of month 10 Good Cause Good cause exists when a customer cannot be reasonably expected to fulfill the reporting responsibility due to factors outside of their control Below are some examples of good cause Customer is suffering from a mental or physical condition that prevents timely and complete reporting Customer failed to submit the report timely due to administrative county error Other extenuating circumstances When a customer has good cause for not reporting timely the HSS must rescind the discontinuance Refer to MPG 0507J for policy guidance regarding 90day cures for TMC or FMC G Change of Circumstances RedeterminationsWhen a family reports any changes that would immediately discontinue eligibility for TMC such as a child aging out or the family exceeding the 202 percent FPL income limit in the second extended eligibility period of TMC HSSs must reevaluate the family as follows If a customer is Then Being discontinued from TMC Evaluate for other Consumer Protection Programs CPPs Refer to MPG 0422D for more information on CPPs Ineligible for other CPPs Evaluate for all other MediCal Programs Ineligible for all other MC programs Discontinue benefits and evaluate for APTCCSR Note If a customer is still eligible for MediCal HSSs must reset the redetermination date based on the effective date of the change County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal FMC Number 0507 Page 5 of 6 H Redetermination at the End of the Transitional MediCal Period At the end of the TMC period HSSs will complete a redetermination as outlined in MPG 041502G Once the redetermination is complete if the customer is eligible under another MediCal program HSS will approve the customer and reset the redetermination date based on the effective date of change If the customer is ineligible HSSs must evaluate for all other MediCal programs before discontinuing the customer and evaluating for APTCCSR I FourMonth Continuing FMC MediCal FMC provides customers with continued MediCal eligibility for up to four months if they are discontinued from one of the eligibility groups below due to an increase in spousal support CalWORKs MAGI ParentCaretaker Relative group MAGI Pregnancy Coverage group Mandatory Childrens group Note An increase in child support is no longer a link to FMC Eligibility Requirements for FMC To qualify for FMC a customer must meet all the following requirements An adult aided on CalWORKs or enrolled in the MAGI ParentCaretaker Relative group or the MAGI Pregnancy Coverage group in three of the six months immediately preceding the month of ineligibility o Months of retroactive MediCal coverage count towards the three months Be discontinued due to an increase in spousal support o If multiple changes are reported HSSs must determine if the increase in spousal support is part of the reason for the discontinuance If so then the family is eligible for FMC Have a dependent child as outlined in MPG 0507A Redetermination at the end of the FMC Period At the end of the FMC period HSSs must conduct a redetermination as outlined in MPG 041502G by completing an ex parte review If the customer is found to be eligible under another MediCal program HSSs must reset the redetermination date based on the effective date of change Change of Circumstances Redeterminations When a family reports any change in circumstances that would immediately discontinue FMC an HSS must immediately evaluate for CPPs If no eligibility is found under a CPP then an evaluation for all other MC programs must be completed before discontinuing the family from benefits and evaluating them for APTCCSR J Evaluating for TMC or FMC Eligibility During the 90day Cure Period Customers have 90 days after the discontinuance to provide missing information needed to complete an eligibilitydetermination AdditionallyHSSwilltreatthe informationasbeing received timelyifitisreceived during the 90day cure period K MediCal after CalWORKs is Denied or Discontinued County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Transitional MediCal TMC and FourMonth Continuing MediCal FMC Number 0507 Page 6 of 6 When a family or children are denied or discontinued from CalWORKs HSSs must determine if continued MediCal eligibility exists Refer to MediCal Processing Guide 40 for procedural guidance on evaluating MediCal when CalWORKs is denied or discontinued Note During the evaluation process customers may be transitioned into Edwards v Kizer aid code 38 while the evaluation for continued MediCal eligibility is being processed Refer to Desk Aid 121 for guidance on determining if an ex parte is required and whether a customer should be placed in aid code 38 L TMC and FMC Aid Codes Program TMCInitial Period TMCSecond Period FourMonth Continuing Full Benefits Aid Code 39 59 54 PregnancyRelated including dental and mental health Emergency and LongTerm Care Benefits 3T 5T 5W Action Staff must apply the policies in is MPG section when a customer is denied or discontinued from CalWORKs Program Impacts Refer to CalWORKs PG CPG 40100F for policy guidance on continuing benefits when CalWORKs ceases Automation Refer to HowTo 404 Establishing Prior Aid Code for Transitional MediCal Cases for guidance on entering the proper information necessary for CalWIN to determine TMC eligibility for TMC cases References ACWDLs 0136 0927 9166 9179 9619 1133 1405 1418 1428 1431 1441 1441E 1703 1923 2127 Sunset Date This policy will be reviewed for continuance by 06302025 Approval for Release Rick Wanne Director SelfSufficiency Services