ARTICLE 5
SECTION 17
TUBERCULOSIS TB PROGRAM
1 GENERAL
MEM
Proc 5N Section 13603 of the Omnibus Budget Reconciliation Act of 1993 OBRA 93 establishes an optional new program for persons infected with tuberculosis whose income and resources do not exceed the maximum amount for a disabled individual State law Chapter 147 Statutes of 1994 Assembly Bill 2377 specifies that this program be adopted Eligibility for this program was effective October 1 1994 MediCal clinics and providers who serve TB infected persons are encouraged to assist such
persons in applying for MediCal This is an alternative to the applicant applying directly at the
county welfare office These providers may help applicants complete all initial MediCal forms
used in the application process and may gather applicant verification This information will then
be forwarded to the county welfare department CWD for a MediCal determination
Individuals both adults and children eligible for the TB program are identified on MEDS under
aid code of 7H
2 ELIGIBILITY REQUIREMENTS
A To be eligible for the TB Program a person must
Be infected with TB This factor links a person to MediCal for the TB Program only
Not be a MediCal beneficiary whose coverage is mandated by federal laws AFDC SSI Other PA or Federal Poverty Level Programs
Be a United States citizen or an alien with satisfactory immigration status who would be eligible for full scope benefits
Have income and resources which do not exceed the maximum amount for a disabled individual under the Supplemental Security Income SSI program Income cannot exceed an amount referred to as the TB income standard See Article 11 Appendix A Assistance Standards Property can be no more than 2000 for an individual including a child When determining a childs property eligibility if two parents are in the home and neither is eligible to the TB program the parents are allowed 3000 as a deduction from their property before it is deemed to the TB child
Meet all other MediCal requirements ie residency cooperation verification etc
B TB Infected Definition
Infected with TB relates to a condition in which living tubercle bacilli are present in an individual without producing clinically active disease A TB infection is active when it produces diseases as demonstrated by clinical bacteriologic andor radiographic evidence
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The determination of whether an individual is TB infected shall only be made by a MediCal physician The Tuberculosis Application form includes a section for physicians to use to indicate TB infection
C MediCal Beneficiary With Coverage Mandated by Federal Law
The beneficiary cannot be eligible for MediCal under one of the programs listed below These individuals are currently eligible for full scope zero shareofcost MediCal benefits which includes TB coverage Workers will not be allowed to enter the TB aid code 7H onto the MediCal Eligibility Data Systems MEDS if the beneficiary is eligible for one of the programs listed below
1 California Work Opportunity and Responsibility to Kids CalWORKS Program
2 Supplemental Security IncomeState Supplementary Program
3 Other Public Assistance Other PA
4 One of the federal poverty level FPL programs
In addition a beneficiary eligible for full scope zero shareofcost MediCal under the MNMI program does not need coverage under the TB program
D United States Citizenship or Satisfactory Immigration Status SIS
A person applying for the TB program must be a United States citizen or an alien who would be eligible for full scope benefits if heshe were otherwise linked to MediCal Workers will follow the usual regulations procedures and guidelines for determining citizenshipalien status Undocumented aliens are ineligible for this program Persons who are eligible for restricted MediCal are ineligible for this program
E Income and Property Not Exceeding the Maximum Amount for a Disabled Individual
1 Whose Income and Property is Used
a Unmarried Adult If the adult is an unmarried applicant use only hisher own income and property
b Married If the applicant is married and living with hisher spouse use only the income received in the applicants own name For property only use the applicants separate property and onehalf of the community property
c Child A child is defined as an unmarried person under the age of 18
If the applicant is a child use his or her own income and property and the income and property of any of his or her parents who are not eligible for the TB program
If more than one child is applying for the TB program the parents allocation to the TB applicant children is divided among the potential TB applicant children
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Each unmarried person including a child applying for the TB program is evaluated separately If a married couple is applying TB eligibility is determined separately
3 SCOPE OF BENEFITS LIMITED TO TB RELATED SERVICES
The following services are available under the TB program
Physician specified clinics
Outpatient hospital services
Clinic services including specified clinics
Federally qualified health centers services
Case management services and
Services other than room and board to monitor prescribed drugs
4 MEDICAL PROVIDER RESPONSIBILITIES
A Tuberculosis Application Form MC 274 TB Appendix A
The Department of Health Services has developed a TB application Part A form which will be available only to county welfare departments CWDs and MediCal providers such as physicians and clinics This form is entitled the Application for MediCal Tuberculosis Program This form replaces the SAWS 1 only for persons applying for the TB program at a MediCal TB provider site
On the second page Part B of this application MediCal physicians or their designated staff must certify that the individual is infected with TB by indicating this person requires preventive therapy for tuberculosis infection or that the person requires treatment for active TB before submitting the application to the county
On the third page Part C of the application the client authorizes the clinic to act as their authorized representative This is the only acceptable authorized representative AR form for the TB program No other AR forms may be used
NOTE The effective date of the TB application will be the date the county receives it
B Clinic Activities
1 Clinics and providers are encouraged to help applicants complete the following forms and submit them to the county
MediCal TB Application MC 274 TB Parts A B C
MC 210 MediCal Statement of Facts
Statement of Citizenship Alienage and Immigration Status This can be on the statement of facts or sworn statement for US CitizensNationals Noncitizens will need to complete the MC 13 See MPG 425 for important requirements regarding citizennationalalien status declaration
MC 219 Rights and Responsibilities
MC 210A Supplement to Statement of Facts for Retroactive MediCal
ACWDL 0314
Providers will order these forms from the State Department of Health Services warehouse
5 2 FacetoFace Interview The required MediCal application facetoface interview can be conducted by the TB clinics or other providers acting on behalf of the CWDs During the interview the provider conducting the interview shall complete and explain the contents of the above described forms 3 Verification In addition TB clinics and other participating MediCal providers may gather necessary verifications For example providers may copy and forward to the CWD Social Security cards alien registration cards and other immigration documents for CWD verification of alien status Providers may also forward other items such as copies of wage stubs or bank statements for CWD verification of earned and unearned income and property DSS RESPONSIBILITIES
Each district will designate a TB Coordinator who will receive the TB applications and forms from MediCal providers Upon receipt of the completed application and additional forms the TB Coordinator will determine eligibility under the TB MediCal program If forms received are incomplete andor additional client information is needed the clinicprovider may be contacted for this information If the information can be obtained by telephone this would be the preferred method The worker may have to contact the clinic worker and sometimes participate in a conference call with the clinic worker and the MediCal client If the TB clinicprovider is unable or unwilling to assist in providing completed forms andor verifications the worker must attempt to contact the client to obtain any forms andor verifications needed to make an eligibility determination
When a TB application is received and potential eligibility for fullscope MediCal is identified the worker must inform the TB applicant If the applicant wishes to pursue the determination heshe must complete a SAWS1 and a facetoface interview If the person is actively infected a family member may apply for this individual If the person has no family member to apply on hisher behalf the worker will complete a SAWS1 to preserve the application date The worker will continue to process the TB application but delay the facetoface interview until the person can come into the office After that interview the worker can resume the eligibility determination for fullscope MediCal Beneficiaries will be notified in writing of their MediCal eligibility and of any changes made in their eligibility status A Notice of Action will be issued for approvals denials or discontinuance of eligibility Workers will use Eline action and NOA codes 107 for approval 127 for denial and 077 for discontinuance of eligibility to the TB program Timely notice requirements must be met MEM Proc 5N
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6 If the worker determines that the applicant is eligible for the TB program the worker will grant eligibility under Aid Code 7H PROPERTY METHODOLOGY
The TB Property Worksheets MC 278 for an adult and MC 279 for a child must be used A TB Property Limits The resource limit for an individual including a child is 2000 The resource limits do not increase even if the applicant andor his or her spouse have children living in the home When determining a childs property eligibility if two parents are in the home and neither is eligible to the TB program the parents are allowed 3000 as a deduction from their property before it is deemed to the TB child B Determination of Net Nonexempt Property Resources are determined according to Article 9 and Article 5 Section 14 Sneede v Kizer If the TB applicant is a child property is deemed to the child as follows 1 One parent in the home If there is only one parent living in the home who is not eligible for the TB program reduce the parents property by the property limit for one The remainder is deemed to the child ACWDL 9512
2 Two parents or one parent and a stepparent in the home If there are two parents living in the home and neither is eligible for the TB program reduce the parents property by the property limit for two The remainder is deemed to the child
If there is more than one child applying for the TB program the parents property is divided among the potential TB applicant children However as soon as a child is determined ineligible for the TB program the parents property must be redivided among the remaining children to determine their TB property eligibility even if their eligibility has already been determined C Resource Eligibility Net nonexempt property is compared to the appropriate TB property limit If net nonexempt property is less than or equal to the TB limit the applicant is TB property eligible
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2 Student Deduction Each ineligible child is allowed a student deduction for earned income of up to 400 per month but not to exceed 1620 per year if the ineligible child is regularly attending a school college university or a course of vocational training to prepare him for gainful employment 3 The remainder is each ineligible childs parental allocation 4 Total each ineligible childs parental allocation The total is the actual parental allocation 5 This allocation is applied first to the ineligible parents unearned income and then to hisher earned income Parental Deduction a Who may have this deduction This deduction is available to a parent or parents whose income is being deemed to a child whose income eligibility for the TB program is being determined
8 b Amount of the Deduction The amount of the deduction is the Federal Benefit Rate FBR for one if only one ineligible parent lives in the home with the child or it is the FBR for a couple if both ineligible parents live in the home with the child The FBR income standard is located in Article 11 Appendix A Assistance Standards 3 No Deeming From the Ineligible Spouse There will be no deeming from the ineligible spouse C Income Eligibility Compare the applicants net nonexempt income to the appropriate TB income standard If net nonexempt income exceeds the applicable standard the person is ineligible for the TB program ANNUAL REDETERMINATION
An annual redetermination is required for the TB program Redeterminations are handled similar to the initial application and the facetoface interview may be completed by the TB providerclinic A new TB certificate Part B would be required to document TB infection and the need for additional TBrelated services Part A of the MC 274 is not needed for the annual redetermination Clinic workers may line out Part A and Part C or indicate NA on each If the client designates the TB providerclinic as an authorized representative Part A can be lined out and completed Part B and Part C forwarded to the county MEM Proc 5N
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9 DUAL ELIGIBILITY
A An AFDCMN or ABDMN with a shareofcost may receive TB services as well as Dialysis and TPN Supplement beneficiaries
B A Qualified Medicare Beneficiary QMB or Specified Low Income Medicare Beneficiary SLMB may receive TB services
C Persons who are TB infected and in longterm care are not dual eligible because they are already receiving care for TB
Workers do not have to discontinue the TB program coverage if a person becomes eligible to zero SOC full scope coverage unless it is one of the following full scope or federally mandated aid codes
03 Adoption Assistance 10 Aged SSISSP 20 Blind SSISSP 3A CAAP CalWORKSFG 3C CAAP CalWORKSU 30 CalWORKSFG 35 CalWORKSU 39 Transitional MediCal 4C Voluntary AFDCFC 42 AFDCFCFederal 44 200Pregnant Citizen 47 200Infant Citizen 48 200Pregnant OBRA 5T Continuing TMCOBRA 5W 4Month Continuing OBRA 5X 2nd year TMC 5Y 2nd year TMC OBRA 54 4Month Continuing 59 Continuing TMC 6 months 60 Disability SSISSP 69 200Infant OBRA 7A 100Citizen Child 7C 100OBRA Child 72 133Citizen Child 74 133OBRA Child 8N 133Excess Prop OBRA 8P 133Excess Prop Child 8R 100Excess Prop Child 8T 100Excess Prop OBRA
MEDS will generate an alert message indicating these aid codes are INCOMPATIBLE WITH THE TB PROGRAM
10
RETROACTIVE BENEFITS
Up to three months of retroactive coverage is available The TB Application form asks the provider to indicate whether the applicant was infected three months prior to the date the form was completed If the application shows the person was infected at that time and heshe is otherwise eligible retroactive coverage is appropriate Workers are to use the MediCal Application for Retroactive Eligibility form MC 239D to approve and deny retroactive eligibility
11
PLASTIC BENEFITS IDENTIFICATION CARD BIC
Beneficiaries covered under the TB Program will use the Plastic Benefits Identification Card BIC for TBrelated services The message will be OUTPATIENT TBRELATED SERVICES ONLY AT NO SHARE OF COST
12
EXAMPLES TREATMENT OF INCOME AND PROPERTY
Example 1
Mr Smith age 47 is homeless He is not disabled He receives monthly unemployment insurance benefits UIB On October 15 1994 Mr Smith is diagnosed at the county MediCal clinic as being TB infected The clinic advises him of the TB program and he agrees to apply In October he will receive 207 UIB and will have no other income He has no property
Provider Activities
The clinic assists Mr Smith in completing the TB application and the MC 210 The clinic forwards these forms to the District TB coordinator
Worker Activities
The worker reviews the TB application A SAWS 1 is not used since the TB application form is used for those applying at a provider site The worker reviews the MC 210 and needs additional information from Mr Smith but Mr Smith has no address or telephone The worker contacts the clinics TB contact person and the clinic worker agrees to call the worker when Mr Smith next comes into the clinic The next day Mr Smith comes in for TB treatment at the clinic The worker Mr Smith and the clinic worker hold a telephone conference call and the worker is satisfied with the information now provided
Income is determined as if Mr Smith were disabled
The worker determines TB income eligibility Appendix B for October as follows
207 UIB
20 any income disregard
187 net nonexempt income
977 TB income standard for one in 1994
Mr Smiths net nonexempt income does not exceed the TB income standard He is income eligible
If the other TB program requirements are met the worker will find Mr Smith eligible for the TB program and establish MediCal TB benefits under aid code 7H for October
Example 2
On October 15 1994 Mr Jones who lives alone was determined TB infected at the county MediCal clinic The clinic explained about the TB program to him and Mr Jones agrees to apply The clinic informs him that he cannot work until the TB is no longer active If Mr Jones follows the prescribed regimen his TB should no longer be active by about November 1 Mr Jones will be on sick leave from July 16 through the end of July He earned 1205 through October 15 and will earn 1200 in sick leave pay through the remainder of October
Provider Activities
The clinic assists Mr Jones in completing the TB application and MC 210 Mr Jones provides the clinic with his October pay stubs The clinic forwards the forms and a copy of his pay stubs to the District TB Coordinator
Worker Activities
The worker reviews Mr Jones TB application and needs additional information about Mr Jones bank account The worker calls Mr Jones at his home and Mr Jones supplies his most recent bank statement The worker determines Mr Jones eligibility His property is determined to be less than 2000 the property limit for one person
Income is determined Appendix C as if Mr Jones were disabled His sick leave pay is earned income
2405 20 1225 1160 gross earned income any income deduction There is no unearned income to apply this against 65 and 12 earned income deduction 65 1160 net nonexempt income
977 TB standard for one in 1994
The worker compares Mr Jones net nonexempt income to 97700 the TB standard for one Mr Jones is ineligible due to excess income
Example 3
In November 1994 the county MediCal clinic determines Mr Brown to be TB infected active TB Mr Brown is married and lives with his wife They have no children Mrs Brown is TB infected dormant TB and the clinic will provide her with preventive TB therapy Although Mr Brown cannot work until his TB is no longer active Mrs Brown may continue to work since she does not have active TB The clinic worker explains about the TB program and they agree to apply
Mr and Mrs Brown both work In November Mr Brown will earn 1655 gross income and Mrs Brown will earn 1001 gross income They have one car and have a 2500 savings account all community property There is no other property
Provider Activities
The provider may choose to assist with the TB application or may refer Mrs Brown to the CWD If Mrs Brown is referred to the CWD the provider will have minimal activities in the TB application process Instead of completing the TB Application and MC 210 at the provider site Mrs Brown will be referred to the CWD where she will apply for the TB program and be given the regular MediCal application packet The provider will complete only Part B TB Referral Form of the TB application to confirm the TB infection An MC 274 Part B is needed for Mrs Brown and one for Mr Brown Mrs Brown will take these forms to the CWD when she applies
Worker Activities
The worker will process the application according to regular county intake procedures The worker will consider Mr and Mrs Brown as separate individuals Consider each persons separate property and half of the community property Appendix D1 and D2
Income is determined Appendix D3 as if Mr Brown were disabled
1655 Total earned income of Mr and Mrs Brown
20 Any income deduction There is no unearned income to apply this against
850 65 and 12 earned income deduction 65 785
785 Net nonexempt income
977 TB income standard in 1994
Mr Brown is income eligible
Income is determined as if Mrs Brown were disabled
1001 Gross earned income of Mrs Brown
20 Any income deduction There is no unearned income to apply this against
523 65 and 2 earned income deduction 65 458 458 Net nonexempt income 977 TB income standard in 1994
Mrs Brown is income eligible
Mr and Mrs Brown each have a property limit of 2000 Each has a community property share of 1250 Consider each persons separate property and half of community property The Browns are resource eligible
If Mr and Mrs Brown meet the other MediCal requirements ie residency cooperation etc for the TB program they will be put in aid code 7H
Example 4
The District TB Coordinator receives a TB application form and an MC 210 from the county MediCal clinic for Mr and Mrs Green who are homeless and cannot be contacted The worker is unable to determine whether the Greens are citizens or have satisfactory immigration status SIS The worker advises the clinic that additional information is needed The clinic discusses this with the Greens and the Greens inform the clinic that they are undocumented aliens Since the Greens do not meet the citizenshipSIS requirement for the TB program they are ineligible The worker sends a denial notice of action to the Greens via the clinic
Example 5
John Doe aged 16 moved back into his parents home in January after being a runaway for 8 months John and his two brothers are on MediCal with a share of cost Mr and Mrs Doe are on the County Medical Services Program In February John is diagnosed as TB infected No other treatment is prescribed for the remainder of the family
Mr and Mrs Doe are both employed Mr Doe earns 850 gross income per month and Mrs Doe earns 801 gross income per month They have one car and a 2500 savings account Mrs Doe agrees to request an eligibility determination for the TB program for John Since John is already on MediCal the provider only needs to complete Part B of the TB application form the MediCal Tuberculosis Program Referral Form which establishes TB infection The provider calls the District TB Coordinator and is told to mail the form directly to them
Worker Activities
Because John already is a MediCal beneficiary all TB requirements are met except for the income and property determination
Income Determination Appendix E1 John is treated as if he were disabled Income of the parents is considered but the parents income is reduced by any allocation to ineligible children who are the other children who are not applying under the TB program Assume the other children each have 100 unearned income
Determine the allocation to the ineligible children
1 The standard SSI allocation to each ineligible child in 1994 is 223
2 Subtract each ineligible childs own income
3 The remainder is each ineligible childs allocation
4 Total each ineligible childs allocation to determine the total allocation to ineligible
children Reduce the parents income by this amount after the other unearned and
earned deductions
Brother 1 Brother 2
Standard SSI allocation 223 223
Childs own income 100 100
Each childs allocation 123 123
Total allocation 246
Parental Income Deemed to John
1651 Mr and Mrs Does gross earned income
246 Allocation to ineligible children
20 Any income deduction Theres no unearned income to apply it against
725 65 and 12 earned income deduction 65 660
669 Parental Deduction for a couple in 1994 couple FBR
0 Parental income deemed to John
Johns TB Income Determination
0 Johns own income
0 Income from parents
0 Johns total income
97700 TB income standard for one in 1994
John is income eligible
Property Determination Appendix E2
2500 parents savings account
3000 parents property exclusion
0 parents property deemed to John
Since John has no property of his own he is property eligible The worker puts John into aid code 7H for February He also continues on regular MediCal with a shareofcost
Example 6
Mr Samuels is unmarried He lives with his 6 year old son Will and the mother of his child Mr Samuels and Will were diagnosed with active TB at the county MediCal clinic in October 1994 The childs mother needs no TB treatment Mr Samuels agrees to apply for the TB program for himself and Will Mr Samuels will earn 1535 gross income in October The mother will earn 2000 gross income in October Mr Samuels has a 2800 savings bond and the mother has a 5000 savings account Will has 100 per month unearned income
Eligibility is determined first for Mr Samuels If he is TB eligible none of his income or property will be deemed to Will when Wills TB eligibility is determined If Mr Samuels is not TB eligible his income and property will be deemed
Income determination for Mr Samuels Appendix F1
Mr Samuels is unmarried For purposes of the TB program only his income is used and compared to the TB standard for one
1535 20 790 725 gross earned income any income disregard there is no unearned income to apply it against 65 and 12 earned income disregard 65 725 net nonexempt income
977 TB income standard for one in 1994
Mr Samuels is income eligible Property Determination Appendix F2 for Mr Samuels Mr Samuels savings bond is a nonexempt resource The savings account of the childs mother is not considered Mr Samuels net nonexempt property of 2800 exceeds the 2000 TB property standard for an individual person Mr Samuels is ineligible for the TB program MEM Proc 5N
Income determination Appendix F3 for Will
Determine the income deemed to Will from his unmarried parents
0 3535 20 1790 669 1056 parents combined unearned income parents combined earned income any income disregard 65 and 12 earned income disregard 65 1725 parent deduction parental income deemed to Will
Determine Wills income
1056 80 1136 income from parents Wills own income 100 20 any income deduction Wills total income
977 TB standard for one in 1994
Will is income ineligible for the TB program
13 QUESTIONS AND ANSWERS
QUESTION 1 If the TB clinic sends an application to the county and the county finds this person eligible for fullscope benefits can the TB application still be used in lieu of the SAWS 1 or would the actual SAWS 1 have to be completed
ANSWER 1 The SAWS 1 would be required if the client is applying for fullscope MediCal benefits In addition the facetoface would also be required when the applicant is applying for fullscope MediCal benefits If this individual has infectious active TB then a family member who is not infected would apply at the county welfare office for this individual
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QUESTION 2 Will the clinics gather all client information and complete an application for each person applying and then forward all completed information to the counties
ANSWER 2 Clinics will assist TB applicants in completing the FORWARDING THEM BY MAIL to the TB Coordinatoralso forward verification of income property etc forms AND Clinics may
QUESTION 3 Will a TB application be taken for each individual when families are applying or will one application suffice
ANSWER 3 A TB application MC 274 TB must be completed for each individual applying for the TB Program If there are more than one family members applying for the TB program each member of the family must have hisher own TB application completed
QUESTION 4 Are family members who are NOT actively infected Dormant TB with TB required to go into the county welfare office to apply for the TB program themselves and other active TB infected family members
ANSWER 4 Other family members of an TB infected individual may go into the county welfare office and apply for benefits on behalf of this person or the family may apply at the clinic However if the individual or family desires fullscope MediCal benefits heshe or a family member must go into the county welfare office to apply A facetoface interview would be required
QUESTION 5 Once the District TB Coordinator receives and reviews the application and determines that additional information is necessary how will this information be obtained
ANSWER 5 If the TB Coordinator receives forms that are incomplete and needs additional client information they may contact the clinic or provider for this information If the information can be obtained by telephone this would be the preferred method of obtaining this information Counties at times may have to contact the clinic worker and sometime participate in a conference call with the clinic worker and the MediCal client Many clients will be homeless and without a phone
QUESTION 6 If an applicant claims to have Satisfactory Immigration Status SIS and then the worker finds this to be incorrect will this individual be discontinued immediately
ANSWER 6
QUESTION 7
ANSWER 7
QUESTION 8
ANSWER 8
QUESTION 9
ANSWER 9
QUESTION 10
ANSWER 10
QUESTION 11
The alien verification requirements for the TB program are the same as for the fullscope MediCal program When a TB applicant meets all other eligibility requirements the worker must grant eligibility while SAVE verification is pending If the Immigration and Naturalization Service SAVE response indicates this person does not have SIS the worker should terminate eligibility immediately subject to all notice of action requirements
Will faxes be appropriate to transmit client information from clinics to counties or must they be photocopies
Workers may accept faxes however clinics should subsequently forward the original document
When an applicant is homeless and he is found eligible for the TB MediCal program where should his card be sent Can it be sent to the clinic
The card may be sent wherever the client wishes it to be sent ie the clinic General Delivery a shelter a friends house
a
Can a TB applicant be eligible for the TB program and County Medical Services Program CMS
b
Can a TB applicant be eligible for the TB program and a different MediCal program
a
Yes the beneficiary may have dual eligibility with CMS
b
Yes as long as the beneficiary is not covered by a zero shareofcost MediCal program which covers TB services such as the ABDMN or AFDCMN with zero share of cost or coverage under a federal poverty level program for pregnant women infants or children
Can persons under age 21 living away from their parents home apply on their own
This would have to be determined according to the living situation of the individual The living situation of the individual would be looked at to determine whether their status is as an adult or child
a Is a TB application needed when a MediCal beneficiary with a shareofcost becomes TB infected and wishes to apply for the TB Program
b c What then would be the date of application for the TB Program Could there be a retro period
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ANSWER 11 a Only the certification MC 274 TB Part B is needed
b The date the person asks for coverage
c Yes
QUESTION 12 Will a physicians stamp be acceptable under this program
ANSWER 12 Yes A physicians stamp is acceptable Other staff members using the stamp should countersign with their own initials
QUESTION 13 Do deductions for guardianconservatorship fees and educational expenses apply to the TB program At this time there is no place for these deductions on the Eligibility worksheets MC 280 TB 994 or MC 281 994 If allowed how shall these be recorded ACWD 9512
ANSWER 13 Yes These deductions would apply To accommodate these deductions until the forms are corrected we suggest pen and ink changes to the MC 280 and the MC 281 and their related instructions
QUESTION 14 Does the ineligibility child mean an ineligible child living with his or her parents
ANSWER 14 Yes
QUESTION 15 If the TB clinicprovider is to act on behalf of the applicantbeneficiary would the TB grantingdenial Notice of Action NOA be sent to the TB clinic or provider
ANSWER 15 The choice is the clients It may be sent to the clinic or to any address the applicantbeneficiary chooses
QUESTION 16 When working with homeless applicants via a TB clinic or provider are workers required to meet the promptness requirements for determining eligibility for the TB program
ANSWER 16 Yes
QUESTION 17 If the TB applicant has other family members who want RESTRICTED MediCal benefits will the clinicprovider refer the family to the county welfare office to apply for MediCal
ANSWER 17 QUESTION 18 Yes This referral is made anytime family members want MediCal other than the MediCal TB program unless the family member who will go to the county has active TB Does the client provider check the restricted box for TB on the MC 13
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ANSWER 18 QUESTION 19 No They need to check the box labeled other and write in ATB in the space next to that box When determining income eligibility is the actual income used or is weeklybiweekly converted to a monthly amount
ANSWER 19 Actual income is used
QUESTION 20 If the clinic conducts the facetoface interview who should sign the MC 219 on behalf of the ET
ANSWER 20 The clinic staff person or provider who initially goes over the form with the client should sign the MC 219
QUESTION 21 Can the county hold a TB application forverification of actual income is pending at least a month while
ANSWER 21 Applications are not held but there must be verification before eligibility can be approved Workers must verify in the same manner that is used for any other MediCal case according to the promptness requirement
QUESTION 22 Under the TB program what is the definition of family member
ANSWER 22 Family member means the following persons living in the home
1 A child or sibling children 2 The parents married or unmarried of the sibling children 3 The stepparents of the sibling children 4 The separate children of family member means a single person of a married couple
QUESTION 23 Can a TB case be transferred to another county
ANSWER 23 This case would be transferred the same as any other MediCal case
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517A1
TB Application Part A
State of California Health and Welfare Agency Department of Health Services MEDICAL TUBERCULOSIS PROGRAM APPLICATION If you are applying only for the MediCal Tuberculosis Program please complete this form NOTE You must be a US citizen or have satisfactory immigration status to receive benefits under this program
1 PATIENTAPPLICANT NAME COUNTY USE ONLY
2 MAILING ADDRESS NumberStreet City ZIP Code Case Name
3 IF NO PERMANENT ADDRESS TELL US WHERE YOU CAN BE REACHED
4 TELEPHONE NUMBERS Home Work Message Case Number
5 DATE OF BIRTH Month Day Year 6 SOCIAL SECURITY NUMBER
7 THE LAW SAYS WE MUST GET YOUR ETHNIC GROUP AND PRIMARY LANGUAGE IF YOU DO NOT WANT TO COMPLETE THESE ITEMS THE COUNTY WILL DO IT FOR YOU THIS WILL NOT AFFECT YOUR ELIGIBILITY a Ethnic Group White Black Hispanic Filipino Chinese Hawaiian Asian Indian Laotian Cambodian Japanese American Indian Korean Guamanian Samoan Vietnamese or Alaskan Native Other Pacific Islander specify b Language English Cantonese Lao Tagalog Spanish Cambodian Vietnamese American Sign Other specify County of Application
County of Residence
CWD Records Cleared
Ethnic Group
Primary Language
If Applicant is Under 18 Years of Age ParentSpouse information
NAME
ADDRESS StreetNumber City ZIP Code
CERTIFICATION AND PERJURY STATEMENT I certify that I understand and agree that I have to comply with eligibility rules I understand that the statements I have made on this form may be checked and verified I declare under penalty of perjury under the laws of the United States of America and the State of California that the information I have given on this form is true correct and complete
SIGNATURE OR MARK OF APPLICANT OR AUTHORIZED REPRESENTATIVE DATE SIGNED
SIGNATURE OF INTERPRETER OR WITNESS TO APPLICANTS MARK
ORIGINAL County Welfare Department COPY Provider COPY Patient MC 274 TB 894 Part A Application
517A2
TB Application Part B
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517A3
TB Application Part C
State of California Health and Welfare Agency Department of Health Services
MEDICAL TUBERCULOSIS PROGRAM AUTHORIZATION FOR CLINIC ASSISTANCE
I hereby designate any staff member authorized by the clinic to perform intake andor treatment functions to assist me in my application for Tuberculosis Program benefits at no cost to me
This assignment enables the authorized staff of the clinic to
Submit requested verifications to the county welfare department
Assist me in the completion of the Application for MediCal Tuberculosis Program and the MC 210 Statement of Facts forms and
Obtain information from the county welfare department regarding the status of my application
I understand that I do not have to apply for MediCal benefits under this program and that I will not be denied treatment if I choose not to apply I also understand that I have the responsibility to complete and sign the Statement of Facts and to provide all requested verifications before my MediCal eligibility can be determined
I hereby state that I make this assignment voluntarily and that I may revoke it at any time by notifying my MediCal eligibility worker and the clinic
Signature of Applicant Signature of Authorized Clinic Staff Assistant
Date Name of Clinic
Clinic Address
Clinic Telephone Number
ORIGINAL County Welfare Department COPY Provider COPY Patient
MC 274 TB 894 Part C Clinic Assistant Assignment
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MPG Letter 289
517B
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM INCOME ELIGIBILITY WORK SHEET Use this form for an individual or applicant with spouse where both may be eligible for the TB Program If one individual is found to be ineligible then this process completes the determination for the ineligible spouse Example 1 Using 1994 Income Standards
CASE NAME Mr Smith CASE NUMBER
APPLICANTS NAME Mr Smith
TB INDIVIDUALS TOTAL COUNTABLE INCOME
a TB APPLICANT b TB SPOUSE
PART A UNEARNED INCOME
1 Applicants Gross Unearned Income 207
2 Subtract General Income Exclusion 20
3 Subtract Other Unearned Income Deductions 187
4 Total Countable Unearned Income
PART B EARNED INCOME
5 Applicants Earned Income
6 Subtract Balance of General Exclusion If Not Offset by Unearned Income Line 2
7 Remaining Earned Income
8 Subtract Work Expense Exclusion
9 Subtract Other Earned Income Deductions
10 Remaining Earned Income
11 Subtract OneHalf Remaining Earned Income
12 Total Countable Earned Income
13 Total Countable Income add lines 4 and 12 187
PART C TB ELIGIBILITY CALCULATION
14 Current TB Income Standard for Individual 977
15 Enter Total Countable Income line 13 187 TB Income Eligible
If line C15 is less than or equal to line C14 the Applicant is TB Income eligible
Eligibility Worker Signature Worker Number Computation Date County Use Only
MC 282 TB 795
517C
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM INCOME ELIGIBILITY WORK SHEET Use this form for an individual or applicant with spouse where both may be eligible for the TB Program If one individual is found to be ineligible then this process completes the determination for the ineligible spouse Example 2 Using 1994 Income Standards
CASE NAME Mr Jones CASE NUMBER
APPLICANTS NAME Mr Jones
TB INDIVIDUALS TOTAL COUNTABLE INCOME
a TB APPLICANT b TB SPOUSE
PART A UNEARNED INCOME
1 Applicants Gross Unearned Income
2 Subtract General Income Exclusion
3 Subtract Other Unearned Income Deductions
4 Total Countable Unearned Income
PART B EARNED INCOME
5 Applicants Earned Income 2405
6 Subtract Balance of General Exclusion If Not Offset by Unearned Income Line 2 20
7 Remaining Earned Income 2385
8 Subtract Work Expense Exclusion 65
9 Subtract Other Earned Income Deductions
10 Remaining Earned Income 2320
11 Subtract OneHalf Remaining Earned Income 1160
12 Total Countable Earned Income 1160
13 Total Countable Income add lines 4 and 12 1160
PART C TB ELIGIBILITY CALCULATION
14 Current TB Income Standard for Individual 977
15 Enter Total Countable Income line 13 1160 TB Income Ineligible
If line C15 is less than or equal to line C14 the Applicant is TB Income eligible
Eligibility Worker Signature Worker Number Computation Date County Use Only
MC 282 TB 795
MEDICAL PROGRAM GUIDE 517C
1195
MPG Letter 320
517D1
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM PROPERTY WORKSHEET ADULT 18 Years of Age and Older or Married Example 3
NAME Mrs Brown CASE NUMBER MONTH
STEP I Determine net nonexempt property in accordance with Article 9
STEP II A Only consider the net nonexempt property of the TB applicant do not consider the property of any other family members in the home B Net nonexempt property of TB applicant 1250 C Property limit for one person 2000 D Is line IIB less than or equal to line IIC Yes TB property requirement met No ineligible due to excess property Eligibility Worker Signature Worker Number MC 278 TB 795 Onehalf of Community Property TB Property Eligible
MEDICAL PROGRAM GUIDE 517D1
MPG Letter 320
517D2
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM PROPERTY WORKSHEET ADULT 18 Years of Age and Older or Married Example 3
NAME Mr Brown CASE NUMBER MONTH
STEP I Determine net nonexempt property in accordance with Article 9
STEP II A Only consider the net nonexempt property of the TB applicant do not consider the property of any other family members in the home B Net nonexempt property of TB applicant 1250 C Property limit for one person 2000 D Is line IIB less than or equal to line IIC Yes TB property requirement met No ineligible due to excess property Eligibility Worker Signature Worker Number MC 278 TB 795 Onehalf of Community Property TB Property Eligible
MEDICAL PROGRAM GUIDE 517D2
MPG Letter 320
517D3
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM INCOME ELIGIBILITY WORK SHEET Use this form for an individual or applicant with spouse where both may be eligible for the TB Program If one individual is found to be ineligible then this process completes the determination for the ineligible spouse Example 3 Using 1994 Income Standards
CASE NAME Mr Brown CASE NUMBER
APPLICANTS NAME Mr Brown
Mrs Brown TB INDIVIDUALS TOTAL COUNTABLE INCOME
a TB APPLICANT b TB SPOUSE
PART A UNEARNED INCOME Mr Brown Mrs Brown
1 Applicants Gross Unearned Income
2 Subtract General Income Exclusion
3 Subtract Other Unearned Income Deductions
4 Total Countable Unearned Income
PART B EARNED INCOME
5 Applicants Earned Income 1655 1001
6 Subtract Balance of General Exclusion If Not Offset by Unearned Income Line 2 20 20
7 Remaining Earned Income 1635 981
8 Subtract Work Expense Exclusion 65 65
9 Subtract Other Earned Income Deductions
10 Remaining Earned Income 1570 916
11 Subtract OneHalf Remaining Earned Income 785 458
12 Total Countable Earned Income 785 458
13 Total Countable Income add lines 4 and 12 785 458
PART C TB ELIGIBILITY CALCULATION
14 Current TB Income Standard for Individual 977 977
15 Enter Total Countable Income line 13 785 458
If line C15 is less than or equal to line C14 the Applicant is TB Income eligible Both are TB Income Eligible
Eligibility Worker Signature Worker Number Computation Date County Use Only
MC 282 TB 795
517E1
CHILD 1 CHILD 2 CHILD 3 CHILD 4
Name Name Name Name
223 223
100 100
State of California Health and Welfare Agency Department of Health Services
TUBERCULOSIS TB PROGRAM
FINANCIAL ELIGIBILITY WORK SHEET ELIGIBLE CHILD
Using 1994
Example 5 WITH INELIGIBLE PARENT OR PARENTS
Income Standards
CASE NAME CASE NUMBER
John Doe
APPLICANTS NAME
John Doe
PART I INELIGIBLE PARENTS UNEARNED INCOME
1
Parents unearned income do not include public assistance PA other PA or TB parents income Do not include parents income if spouse is PA other PA or TB 0
2
Allocation for ineligible children if no children enter zero in Part I2c Do not include TB applicant or TBeligible children
a
Standard SSI allocation Federal Benefit Rate FBR for a couple minus FBR for an individual
b
Minus childs income
123 123
c Total allocation 246
3 Remaining unearned income subtract line I2c from line I1 246
PART II INELIGIBLE PARENTS EARNED INCOME
1
Parents gross earned income 1651
2
Unused portion of allocation for ineligible children 246
3
Remaining earned income subtract II2 from II1 1405
IF THERE IS NO INCOME REMAINING AND I3 AND II3 ARE BOTH ZERO DO NOT DEEM GO TO PART IV IF THERE IS INCOME PROCEED WITH PART III
PART III COMBINED INCOMES Ineligible Parents
PART IV TB ELIGIBILITY CALCULATION Unearned Income
1 Deemed income from Part III15
0
1 Remaining unearned income after allocation or zero from I3 2 Eligible childs own OASDI income
0
2 A Subtract general income exclusion 3 Other unearned income
20 0
B Subtract other unearned income deductions 4 A Subtract general income exclusion
20
3 Countable unearned income to III11 B Subtract other unearned income deductions
0
5 Countable unearned income IV1 IV2 IV3 20
0
Earned Income
4 Remaining earned income from II3 6 A Childs countable earned income subtract 65 remainder
1405 0
5 Subtract balance of general income exclusion B Subtract other earned income deductions
20 0
6 Remainder 7 Total countable income
1385 0
7 A Subtract work expense exclusion 8 Current TB income standard
65 977
B Subtract other earned income deductions If line IV7 is less than or equal to line IV8 this person is income eligible
8 Remainder
1320
9 Subtract remainder
660
TB Income Eligible
10 Countable earned income to III12
660
Deemed Income
11
Countable unearned income from III3
12
Add countable earned income from III10
660
13 Total countable income from III11 III12
660
14 Subtract parent deduction
669
15 Deemed income Enter on Line IV1
0
Individual FBR if one ineligible parent lives with child couple FBR if both ineligible parents live with child
MC 280 TB 495
MEDICAL PROGRAM GUIDE 517E4 1195
MPG Letter 320
517E2
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM PROPERTY WORKSHEET CHILD Example 5
NAME John Doe CASE NUMBER MONTH
STEP I A There is no allocation of property from an ineligible parents if one or both parents is public assistance PA other PA or eligible for the TB program B Determine net nonexempt property in accordance with Article 9 1 car exempt
STEP II Ineligible Parental Allocation Only consider the net nonexempt property of the parents in the home do not consider the property of any other family members Parents net nonexempt property 2500 Property limit for one person if two parents enter property limit for two persons 3000 Subtract line A2 from line A1 enter 0 if negative Total Allocation 0 Divide line A3 by the number of TB children in the home TB Childs Share 0 TB Childs and Parents Resources Childs own net nonexempt property as determined under Article 9 0 Enter childs share of property from parents line A4 0 Add line B1 and B2 0 Enter the TB property limit for one person 2000 Is line B3 less than or equal to line B4 Yes TB property requirement met No ineligible due to excess property If more than one TB child in the home proceed to Section C More Than One TB Child in the Home Follow these steps if the child in Section B above is ineligible for any reason eg attainment of age 18 or due to excess property because the parental allocation when combined with the TB childs own net nonexempt property exceeds the TB property limit for one person Take the amount of property deemed from the parents line A3 and redivide it among the remaining number of TB children in the home line A4 Repeat Section B for each of the remaining TB children in the home to determine if the combined amount of the childs share of parental net nonexempt property and the childs own net nonexempt property line B3 is within the allowable TB property limit line B4 Eligibility Worker Signature Worker Number MC 279 TB 395 TB Property Eligible
MEDICAL PROGRAM GUIDE 517E5
MPG Letter 320
517F1
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM INCOME ELIGIBILITY WORK SHEET Use this form for an individual or applicant with spouse where both may be eligible for the TB Program If one individual is found to be ineligible then this process completes the determination for the ineligible spouse Example 6
CASE NAME Mr Samuels CASE NUMBER
APPLICANTS NAME Mr Samuels
TB INDIVIDUALS TOTAL COUNTABLE INCOME
a TB APPLICANT b TB SPOUSE
PART A UNEARNED INCOME
1 Applicants Gross Unearned Income
2 Subtract General Income Exclusion
3 Subtract Other Unearned Income Deductions
4 Total Countable Unearned Income
PART B EARNED INCOME
5 Applicants Earned Income 1535
6 Subtract Balance of General Exclusion If Not Offset by Unearned Income Line 2 20
7 Remaining Earned Income 1515
8 Subtract Work Expense Exclusion 65
9 Subtract Other Earned Income Deductions
10 Remaining Earned Income 1450
11 Subtract OneHalf Remaining Earned Income 725
12 Total Countable Earned Income 725
13 Total Countable Income add lines 4 and 12 725
PART C TB ELIGIBILITY CALCULATION
14 Current TB Income Standard for Individual 977
15 Enter Total Countable Income line 13 725
If line C15 is less than or equal to line C14 the Applicant is TB Income eligible TB Income Eligible
Eligibility Worker Signature Worker Number Computation Date County Use Only
MC 282 TB 795
517F2
State of California Health and Welfare Agency Department of Health Services TUBERCULOSIS TB PROGRAM PROPERTY WORKSHEET ADULT 18 Years of Age and Older or Married Example 6
NAME Mr Samuels CASE NUMBER MONTH
STEP I Determine net nonexempt property in accordance with Article 9
STEP II E Only consider the net nonexempt property of the TB applicant do not consider the property of any other family members in the home F Net nonexempt property of TB applicant 2800 G Property limit for one person 2000 H Is line IIB less than or equal to line IIC Yes TB property requirement met No ineligible due to excess property Eligibility Worker Signature Worker Number MC 278 TB 795 TB Property Ineligible
MEDICAL PROGRAM GUIDE 517F2
MPG Letter 320
517F3
MEDICAL PROGRAM GUIDE 517F3 MPG Letter 320