Article 5 Section 12 Special Zero ShareofCost Programs for Children and Pregnant Women
Table of
Contents
TITLE MPG CITE
Overview 051201
Income Disregard Program and the Asset Waiver Provision 051202
133 Program 051203
100 Program 051204
Targeted LowIncome Childrens Program 051205
Property Disregard 051206
Long Term Care 051207
Income Treatment and Deductions 051208
Miscellaneous 051209
Desk Aids and Processing Guidelines
RESOURCE TITLE
ProcessingGuidelines
TLICP CalWIN Entries
Desk Aid
Childrens Special Zero SOC Program Aid Codes
Period of Eligibility
Childrens Special Zero SOC Program Flow Chart
Childrens Special Zero SOC Q A
LMS Training
Targeted Low Income Training Type TLICP on the LMS search field to register and complete the training
051201 Overview
A Overview This section provides regulations for the following programs which are applicable to cases that contain children ages 019 andor pregnant ACWDL 1233
women
Income Disregard
133 Program
100 Program
Targeted Low Income Childrens Program TLICP
MPG LTR 771 1212
051202 Income Disregard
A Overview The Income Disregard Program provides zero shareofcost MediCal coverage to eligible infants under the age of one year and pregnant women To qualify for the Income Disregard Program the MFBU must have net nonexempt income that that exceeds the MediCal maintenance need level but is not over 200 of the Federal Poverty Level FPL MEM PCOC 5F
MPG LTR 316 1095
B PregnantWomen
ACWDL
Eligibility for pregnant women begins with the first day of the month of
0334
selfdeclaration of pregnancy The pregnant woman may request a retroactive MediCal evaluation see 051209B
Pregnant women who qualify for no SOC benefits receive pregnancyrelated services regardless of their citizenship or alien status Pregnancy services include
Prenatal care
Labor
Delivery
Postpartum care
Family planning
Pregnant women may also be eligible to nonpregnancy related services with a SOC under the MIMN program
If eligibility is maintained through the month of birth eligibility continues through the 60day postpartum period Benefits will be discontinued at the end of the month in which the 60day postpartum period ends
If a pregnant minor does not qualify under regular Income Disregard regulations they must be evaluated using the Parental Income Disregard provision
C Infants up to one year of age may be eligible to fullscope benefits or Infants up to
benefits limited to the treatment of emergency medical conditions
One Year of depending upon their citizenship status Eligibility begins at birth and
Age continues through the month of their first birthday if eligibility is otherwise maintained during this period
NOTE Under Continued Eligibility for pregnant women or Deemed Eligibility for infants eligibility cannot be ended during the pregnancy or for the infant prior to the first birthday due to an increase in income If the infant is active in the Income Disregard Program and loses eligibility evaluate the child for Deemed Eligibility or Continuous Eligibility for Children CEC prior to taking any negative action Approve for Deemed Eligibility or CEC if eligible
051203 133 Program
A
133
Program
ACWDL
The 133 program provides zero SOC MediCal coverage to otherwise
9034
eligible children beginning at age one up to end of the month of the 9061 childs 6th birthday
To qualify for this program the net nonexempt income of the MFBU must exceed the MediCal maintenance need level but not be over 133 of the FPL Scope of benefits will depend on their citizenship status The following aid codes will be used
Aid Code Scope of Benefits
72 Full Scope
74 Limited Scope
MPG LTR 534 1103
051204 100 Program
A
100
Program
ACWDL
The 100 Percent Program provides zero SOC Medical coverage to
9161
eligible children at age six to the end of the month of the childs 19th birthday
To qualify for this program the net nonexempt income of the MFBU must not exceed 100 percent of the federal poverty level Scope of benefits will depend on their citizenship status The following aid codes will be used
Aid Code Scope of Benefits
MPG LTR 534 1103
County of San Diego Health and Human Services Agency HHSAProgram Guide
Targeted LowIncome Childrens Program TLICP Number Page
051205 1 of 3
Issue Date
4232015
Effective Date
Upon Receipt
Background
TLICP is a property disregard program that provides coverage for children who would have previously been enrolled in the HFP Eligibility to the different programs is based on age The below chart describes how the age groups are determined
Begin End
At birth The end of the month of the childs 1st birthday
At age one The end of the month of the childs 6th birthday
At age six The end of the month of the childs 19th birthday
Continuous Eligibility for Children CEC applies to the TLICP refer to MPG 51505
A Aid Codes and Income Limits
To qualify for TLICP the net nonexempt income of the MFBU must be as follows
Age Group Percent Level Aid Code Premium
01 Above 200 up to 250 PREACA H1 No
01 Above 208 up to 266 T5 No
01 Above 208 up to 266 Undoc T0 No
16 Above 133 up to 150PREACA H2 No
16 Above 142 up to 160 T4 No
16 Above 142 up to 160 Undoc T9 No
16 Above 160 up to 266 T3 Yes
16 Above 150 up to 250PREACA H3 Yes
16 Above 160 up to 266 Undoc T8 Yes
619 Above 133 up to 160 T2 No
619 Above 133 up to 160 T7 No
619 Above 100 up to 150PREACA H4 No
619 Above 160 up to 266 T1 Yes
619 Above 160 up to 266 Undoc T6 Yes
619 Above 150 up to 250PREACA H5 Yes
Aid codes H3 and H5 are PreACA premium payment aid codes Aid codes T1 T3 T6 and T8 Are MAGI TLICP premium payment aid codes
County of San Diego Health and Human Services Agency HHSAProgram Guide
Targeted LowIncome Childrens Program TLICP Number Page
051205 2 of 3
There are no restricted scope aid codes for preaca TLICP If an applicant fails to provide citizenshipidentity documentation at the end of their reasonable opportunity to provide period they must be reevaluated for limited scope MediCal with a SOC
MAGI Based TLICP has aid codes for undocumented children
B Premiums
Premiums are 13 per child monthly with a maximum of 39 per family monthly When workers approve a beneficiary for one of the TLICP premium payment aid codes the information will be transmitted to MAXIMUS via MEDS Beneficiaries may pay premiums in the following forms
Cash check Western Union
Electronic Funds Transfer
Credit Card Transactions
MAXIMUS is the administrative vendor of premium payment collection and will be known as the MediCal Premium Payment Section MPPS The MPPS will
Maintain premium payment case files
Bill beneficiaries
Send overdue payment notices
Notify counties when a beneficiary on a premium payment aid code has not paid premiums for 60 days
Verify when a beneficiary previously discontinued for nonpayment of premiums has paid and should be reinstated
C
NonPayment of Premiums NPP Condition
The NonPayment of Premium Condition is when a beneficiary is two monthly payments past due A reminder letter is mailed by the MPPS prior to 60 days past due Upon receipt of notification of NPP discontinue the beneficiary with timely notice Beneficiaries are billed until they pay past due payments or are discontinued from TLICP Premium Payment is a condition of eligibility for premium payment aid codes No reevaluation of MediCal is required when a beneficiary is discontinued from a premium based aid code for NPP
D Reinstate TLICP Discontinued Due to NPP
Beneficiaries can reinstate TLICP prior to termination or within 30 days of termination by paying their past due premiums After 30 days discontinuance the customers must reapply If discontinued customers are determined eligible for TLICP with a premium again they will be billed for all past due premiums Procedures for reinstatement of premium based TLICP is in the NPP and Premium RefundWaiver Processing Guide sections C D and E
County of San Diego Health and Human Services Agency HHSAProgram Guide
Targeted LowIncome Childrens Program TLICP Number Page
051205 3 of 3
E Requests for Discontinuance of TLICP
The request for discontinuance must be in writing and documented in the case file
Discontinuances of TLICP can only be made for the future months and cannot be made retroactive to the clients request unless a change in circumstance reported timely makes the individual eligible for a nonpremium aid code
F
Premium RefundWaiver Requests
The MPPS must continue billing the beneficiary until the Premium aid code is discontinued in MEDS TLICP beneficiaries with premiums can request a waiver or refund of premiums in the following conditions
They are found retroactively eligible to a nonpremium aid code They can request a refund of the premiums paid for the months where they are eligible for a nonpremium aid code
A beneficiary requests discontinuance of a premium based aid code and the discontinuance is not effective the last day of the request month example client requests discontinuance in May 2014 but the worker does not take action until July 2014 the refund request would be for June 2014 and July 2014 paid premiums
Submit a premium refundwaiver request if the discontinuance is not processed by the end of the month of request even if the beneficiary has not paid because the MPPS will still bill for the months where the client shows active in MEDS on a premium aid code If the client goes back on a premium aid code within a year the MPPS will bill the beneficiary for past due payments Instructions for submitting Premium RefundWaiver requests can be found in the NPP and Premium RefundWaiver Processing Guide
G American IndianAlaskan Native Premium Waivers
American IndiansAlaskan Natives who are eligible to receive or have received service from an Indian Health Service Tribal 638 Urban Indian Health Program or through a referral to a Contracted Health Services are eligible to a premium waiver for TLICP Premiumbased aid codes Initiate the premium waiver process for these individuals following the directions in the NPP and Premium RefundWaiver Processing Guide section G
References
ACWDLs 1233 1429 1429E 1443 and 1510 MPG LTR 771
Sunset Date
This policy will be reviewed for continuance by 4232018
051206 Property Disregard
A Overview The Income Disregard 133 and 100 program offer a property disregard option that will be applied in the following situations ACWDLs 8950 89103
When the property reported exceed the MFBUs property limit In situations where a pregnant women request pregnancy related services and the only pending verifications are property verifications Property verifications will delay benefits for children ages 019 89104 9407 9528 9552 9806
Workers must inform applicants of the property disregard option at application or when made aware that the family is for a child age 019 or pregnant woman If the pregnant woman wants fullscope benefits for herself andor the rest of her family she must reduce her family assets to the property limit in order to establish non Asset Waiver Provision MediCal
eligibility
NOTE Workers must not require verification on any property listed on the MC 210 property utilization verification or completion of supplemental property forms
MPG LTR 555 0504
B The following aid codes must be used for property disregard cases Aid Codes
Aid Code Program Level of Benefits
47 200 Full Scope
69 200 Restricted
44 200 Pregnancy Full Scope
48 200 Pregnancy Restricted
8P 133 Full Scope
8N 133 Restricted
8R 100 Full Scope
8T 100 Restricted
051207 Long Term Care
A ACWDL
A child who is an inpatient receiving continuous services which begin
89105
Overview
before and continue beyond the age of eligibility to the following programs will be entitled to extended eligibility under the program they qualify until the end of the month in which the continuous stay ends as long as the family remains eligible
Income Disregard
133 Program
100 Program
TLICP
Inpatient services are defined as any medical facility in which the child stays over 24 hours including longterm care LTC and acute care facilities
Children receiving continuous inpatient services must be reevaluated for the 133 program at age six and at 6 month intervals until the continuous period ends Workers must set a case alert to reevaluate the child
Any MFBU with a shareofcost SOC that contains an LTC person must have the SOC listed for the LTC person A pregnant woman in LTC who is not disabled and is eligible under the special programs must have zero SOC Any SOC will be assigned to the other members of the MFBU who are not LTC Any nonpregnancy related services received by her in the LTC facility may be applied towards the MFBUs SOC
MPG LTR 771 1212
051208 Income Treatment and Deductions
A ACWDLs
This section includes the treatment of income for Income Disregard
8950
Income 133 100 and TLICP program Income from exempt property is
9407 counted in the budget except in the below situations
is unavailable in accordance with MPG Article 100104
exempted by specific court order or statute
Interest income from a revocable or irrevocable burial trust or reserve which is exempt as property shall not be counted if the family provides documentation that the burial trust or reserve meets the exemption criteria and that the interest income is left to accumulate and become part of the separate identifiable burial fund
Interest income from disaster or emergency assistance payments is also exempt
Rental income from real property is counted in the budget and must
B Deductions
be verified as follows
Applicantsrecipients must be provided the opportunity to state any expenses relate to rental income by completing the questions on the MC 210 SP that relate to rental expenses
The Asset Waiver applicantrecipient will not have to provide verification of the property other than what is necessary to establish the income and expense amounts
NOTE Workers must review IEVS for all applicants regardless if the applicantsrecipients meet the Asset Waiver provision requirements IEVS provides income information including interest income from property
MPG LTR 771 1212 ACWDL
This section includes the treatment of deductions for Income
8950
Disregard 133 100 and TLICP program Allowable income 9407 deductions are the same as AFDCMN programs including excluded child allocations outlined in MPG 100604 except for the following
Health insurance premiums
Deductions allowed for ABD persons under the MIMN programs MPG 100603
NOTE When these deductions are allowed in the MIMN case they must be added back when completing the budget evaluation for the programs mentioned above
MPG LTR 771 1212
C Parental Income Disregard Under the Parental Income Disregard Program provision income from a parent of a pregnant minor who live together in the home is to be disregarded if the pregnant minor is not eligible using regular Income Disregard rules ACWDL 8950 9407
This applies to all pregnant minors including a pregnant minor between the ages of 18 and 21 and claimed as a tax dependent by her parents even though she does not live in the home of the parents eg she is temporarily away at college
The Parental Income Disregard provision must be used if the parent refuses to provide verification of income but provides sufficient information about the minor
When the parental income is disregarded the parents will not be counted in the maintenance need level when comparing income to 200 of the FPL
D MediCal Family Budget Unit
ACWDL
Children age 019 and pregnant women in TLICP 100 133 and Income Disregard program will be included in the special program MFBU and The MIMN program MFBU with a shareofcost as an ineligible person
Property Disregard children 019 and pregnant women in 100 133 and Income Disregard Program will only be included in the special program MFBU
NOTE The child may link parents to AFDCMN for MediCal eligibility purposes
MPG LTR 771 1212
051209 Miscellaneous
A Adding Newborns No application forms are required to add a newborn to the MediCal case regardless of whether the child is Deemed Eligible or not See MPG 040216 for more information on adding newborns ACWDL 0345 0349
According to Deemed Eligibility rules an infant is to be placed in the same category of aid as the mother Therefore if the mother received MediCal in the month of birth see MPG 515 through the Income Disregard Program the newborn will be added to the Income Disregard Program case For more information see MPG 051502
If the mother did not meet her SOC in the month of birth a statement of citizenshipalien status and application for SSN must be obtained for the infant For more information see MPG 515 I dont think this applies any longer Need to research
MIMN MFBU
The newborn must be added to the MIMN MFBU as an ineligible person when heshe will be issued benefits through the Income Disregard MFBU If the entire MIMN MFBU is ineligible eg no linkage for parents no other children the newborns PDTL linkage code must be entered
MPG LTR 541 1103
B Retroactive Requests
The following programs may be applied in retroactive evaluations ACWDL
9407
Income Disregard
0349
133 Program
100 Program
TLICP
NOTE TLICP may not be applied to retroactive applications dated prior to 112013
In some cases a woman applicant may not be pregnant at the time of application but may have been pregnant or in the postpartum period for one or more of the retroactive months Likewise an infant may be over one year of age at the time of application but may have been under one year of age for all or part of the threemonth retroactive period These situations need to be evaluated for retroactive Deemed Eligibility Income Disregard and Asset Waiver benefits
MPG LTR 771 1212
C Retroactive Repayment of SOC
Beneficiaries who previously met or were obligated to pay their SOC and were subsequently determined eligible in the same month of eligibility for the Income Disregard program are entitled to an adjustment refundreduction of the billed amount If the family met its SOC but the beneficiary had no expenses for that month received no benefits heshe would not be eligible for a refund
If the beneficiary Then
had expenses in a month and the share of cost was not met the county should issue the appropriate Income Disregard program card
states that heshe does not wish a refund but prefers an adjustment to a future months SOC follow the procedures outlined in Article 12 of the MediCal Program Guide
Beneficiarys must be provided with the following
If the date of service Then the beneficiary should be given
Less than 12 months the SOC MediCal Provider Letter MC 1054 containing the Old SOC County ID and the New NonSOC County ID
Older than 12 months a retroactive MediCal card containing the original SOC county ID and an MC 1054
These documents must be given to the provider for processing Once the providers claim for services has been reimbursed by the fiscal intermediary the provider must refund the appropriate amount to the beneficiary if the met SOC was paid If the SOC was obligated but not paid the provider reduces the amount billed to the beneficiary by the appropriate amount
D Minor Consent
Pregnant minors who apply for minor consent services may qualify for either the Income Disregard or the Asset Waiver provision Pregnant minors are to be issued a no SOC limited service card under the appropriate aid code Remember minor consent applicants are never required to verify pregnancy
MPG LTR 541 1103
E Sneede
As in the other percentage programs workers are to determine Sneede MBUs first MBUs of children born after September 30 1983 who are at least six years old and who have a shareofcost should be evaluated for the 100 program
MPG LTR 414 1298
F The following MEDS alerts will generate MEDS Alerts
Alert Description
9524 Generated towards the end of the 11th month from which the MEDS record was established stating that the woman appears to be no longer eligible for the Income Disregard or Asset Waiver program The worker will be responsible for terminating the MEDS record If the woman becomes pregnant again within 12 months the worker can reactivate the MEDS record through a restoration of benefits however no subsequent alert will be generated
9525 Generated every 6 months beginning with the last month of eligibility to remind the worker to check the childs inpatient status send a notice of action or that a termination action should be taken if MEDS has no termination date
9526 Generated when the child is past the appropriate age and every 6 months thereafter when eligibility has not been reconfirmed by the worker It will inform the worker that eligibility has been terminated on MEDS