Table of
Contents
Article 20 Section 1 Performance Standards
TITLE MPG CITE
Overview 200101
Eligibility Determinations and Redeterminations 200102
MediCal to Healthy Families Bridging INACTIVE 200103
MEDS Alerts 200104
HFP to MediCal Transition 200105
Application Processing and Redetermination Performance Standards SelfCertification Monitoring Appendix A
200101 Overview
A General County Performance Standards CPS is an evaluation process used by DHCS Program Review Section PRS for review and verification of a County Welfare Department compliance with MediCal policies and procedures DHCS is required to monitor county performance based on the CPS evaluation process The monitoring includes evaluation of the county through a review of the selfcertification process for application processing annual redetermination processing and MedCal to Healthy Families bridging processing The PRS will also conduct independent performance reviews of the self certifications as well as the MEDS alert processing MEPM Article 25
Senate Bill X1 26 Chapter 9 Statutes of 2003 1st Extraordinary Session established the CPS for eligibility determinations and annual redeterminations Senate Bill 1103 Chapter 224 Statutes of 2004 established the CPS for MEDS Reconciliations and Alerts WI Code
Section 14154 c3D established the CPS for MediCal to Healthy Families Bridging Bridging
If the county does not meet the performance standards it may be subject to a two percent reduction in the county administration allocation
MPG Letter 667 409
B Compliance Requirements The table below is a summary of the performance standards and includes the percentage of cases that must meet the standards in order for the county to be in compliance with the CPS requirements MEPM Article 25
Performance Standard Components
Application processing Regular Applications within 45 days of application Applications based on disability within 90 days of application 90
Annual Redetermination RV processing RV form mailed to recipient by anniversary date RV completed within 60 of the last day of the annual redetermination month NOA mailed within 45 days of when redetermination form was due 90
Bridging INACTIVE The following must occur within 5 days of the share of cost determination for eligible 90
ACWDL 1123
children Notice sent informing family of Healthy Families Program HFP RV forms sent to HFP if parent consents Request to consent sent if parent has not consented
HFP to MediCal Transition Applications received from Single Point of Entry SPE complete not enrolled in Accelerated Enrollment AE or MediCal must be completed within 10 working days of receipt at the county 90
MEDS Alerts processing MEDS daily and renewal alerts MEDS reconciliationworker alerts 90 95
ACWDL
ACWDL 1229
MPG Letter 771 1212
C SelfCertification Schedule Review
ACWDL
Schedule
0342
ACWDL 0703 ACWDL 1233
Performance Standard Schedule
Application and RV processing Every two years beginning October 2009
Bridging INACTIVE Every two years beginning October 2008
HFP to MediCal Transition SemiAnnually beginning April 2013
MEDS Alerts processing There is no selfcertification process at this time
D Sampling Methodology
State Review DHCS Program Review Section PRS also completes independent performance evaluations of the CPS At this time they do have a specified schedule for these reviews PRS sends a notification of review letter two months in advance of the planned onsite review A confirmation letter will include a list of the cases requested for the review Entrance conferences are scheduled for the first day of the onsite review and the county receives a report of its performance at the exit conference
MPG LTR 667 409 ACWDL
Geographic Sampling ProjectGSP Prior to approval of the GSP pilot project the PRS annually reviewed random samples of MediCal cases for all 58 counties The number of MediCal Eligibility Quality Control MEQC case reviews selected for each county was proportionate to its share of the statewide MediCal beneficiary population Small counties had only limited numbers of
E Corrective Action Plans
cases reviewed annually These limited numbers of case reviews may not have accurately reflected the performance of these counties in determining MediCal eligibility The GSP sampling strategy provides for MEQC case reviews in the 25 largest counties in terms of MediCal population
ACWDL Minimum Sample Requirements 0845 The sample sizes for PRS review of self certification and independent performance reviews will normally be 75 cases for any CPS review However in some instances there may be fewer than 75 cases to select from for one or more of the selfcertification or independent reviews When it is determined that any one component of any one performance standard has less than 21 cases that component will not require a corrective action plan CAP if the performance is below the required threshold This applies to the review of self certifications independent PRS review and followup reviews associated with potential two percent sanctions
MPG LTR 667 409
When the county selfcertifies or when DHCS determines whether MEPM
Article 25
through review of a selfcertification or an independent performance review that a county has failed to meet the mandatory performance percentages the county is required to complete a CAP The CAP provides an opportunity for the county to implement changes and improvements It also allows time for the county to meet the mandatory performance requirements and avoid being subject to the two percent reduction in county funding
The CAP must contain a plan with interim benchmarks for improvement throughout the year that will be met by the county in order to avoid a reduction of two percent of its county administrative funds
MPG LTR 667 409
F Administrative Sanctions
If the county does not meet the CPS DHCS may reduce the allocation MEPM
Article 25
of county administration funds beginning in July of the year that the final corrective action plan review is completed Any funds reduced may be restored by DHCS if sufficient improvement has been made by the county in meeting the CPS during the year for which the funds were reduced
MPG LTR 667 409
200102 Eligibility Determinations and Redeterminations
A General DHCS established performance standards which measure whether counties are meeting the MediCal application and annual redetermination timelines mandated by Federal law ACWDL 0342
Federal law requires that Applications for MediCal must be processed within 90 days for applications that are disability based requiring a DDSD evaluation and 45 days for all other applications and Eligibility for MediCal must be reevaluated on a yearly basis
Note The process time can be extended if unusual circumstances occur and the worker cannot reach a determination of eligibility because of delays caused by the applicant DDSD examining physician or other factors not within the workers control
Counties are required to report to DHCS the percentage of applications and redeterminations which have been processed within the timeframes specified by Federal law The reported information will be evaluated for compliance and will require corrective action and counties will be subject to sanctions if not in compliance
MPG LTR 667 409
B Eligibility Determinations
The MediCal application performance standards require ACWDL
0342
General MediCal applications to be processed within 45 days of the application date and
Applications based on disability a DDSD evaluation is required to be processed within 90 days of the application date
Applications are excluded from the 4590day processing requirement if
The applicant provides partial informationverification is attempting to comply and requests additional time to provide or
DDSD has received the application prior to the 90 day timeframe but is unable to provide a determination within 90 days of the application date
MPG LTR 667 409
C The MediCal redetermination performance standards require ACWDL
Redetermin
ations Annual redetermination forms to be mailed to the beneficiary by the due date the first day of the month in which the redetermination is due Annual redeterminations which are complete and have been returned timely to be processed within 60 days starting from the last day of the annual redetermination month RV month Annual redeterminations for which the packets have not been returned to have a Notice of Action NOA mailed to the beneficiary within 45 days after the date the forms were due ACWDL 1123
For the purpose of these redetermination performance standards Complete means all questions on the RV form were answered all verifications were provided and no further action is required from the recipient Only County action is required because the County has the information necessary to make a determination Timely means that the recipient has returned the RV form by the due date specified on the RV notice Use an RV due in October for example October 1 100107 or by the last day of the month that the RV is to be completed by the recipient October 31 2007
Redeterminations will be excluded from the 60day requirement if Redetermination formsverifications are incomplete and the SB 87 process results in a delay or if the beneficiary requests additional time to provide and is given good cause Redetermination formsverifications are returned complete within 30 days of the discontinuance date
MPG LTR 736 911
D Required Actions Applications Workers are required to ACWDL 0342
Step Action
1 Complete the eligibility determination within the 45 day timeline
2 Document delays caused by unusual circumstances in the case file narrative
3 Complete entries in the automated system to assist in the monitoring and tracking of the performance standards see appendix A for monitoring and tracking information
Redeterminations
Workers are required to
Step Action
1 Ensure that RV forms are mailed to the beneficiary by the due date the first day of the month in which the RV is due
2 Process annual RVs that have been returned complete and timely within 60 days of the RV due date
3 Send a NOA to beneficiaries who do not return the intake packet within 45 days of the RV due date
4 Document the reasons for delays in processing the annual RV within 60 days of the RV due date in the case file narrative For example the forms were returned incomplete and the SB 87 process causes a delay
5 Complete entries in the automated system to assist in the monitoring and tracking of the performance standards see appendix A for monitoring and tracking information
MPG LTR 667 409
E See Appendix A for Monitoring and Tracking information for the
Monitoring application and redetermination performance standards and Tracking
MPG LTR 667 409
200103 MediCal to Healthy Families HFP Bridging INACTIVE
A Assembly Bill 1494 required the transition of HFP to MediCal ACWDL Inactive beginning 1113
The discontinuance of the Bridging Performance standard is effective 9112
MPG LTR 7XX 1212
200104 MEDS Alerts
A General
Unlike the CPS for eligibility and annual redeterminations which ACWDL require the counties to self report the CPS for the worker and error alerts require DHCS to make a finding of compliance
Performance standards require counties to submit quarterly reconciliation files Quarterly reconciliation submissions must be based upon a schedule determined by DHCS and in a format prescribed by DHCS The intent is to identify any discrepancies between eligibility files in the county records and eligibility as reflected in the MEDS Quarterly reconciliation performance will be continuously monitored by the MediCal Eligibility Division
Eight MEDS daily and renewal error alerts deemed to be critical alerts and three worker alerts were identified through this process and will be used to determine if counties are meeting worker and error alert performance standards
MPG LTR 667 409
B CPS for the worker and error alerts will be monitored by the Program ACWDL
0809
Error Alerts Review Section PRS MEDS daily and renewal error alerts subject to review are
Alert Number Alert Definition
1503 CLIENT INDEX NUMBERMEDSID CONFLICT
1504 CLIENT INDEX NUMBERMEDSID VS COUNTYIDMEDSID CONFLICT
1510 TRANSACTION FAILED MEDS NAMEBIRTHDATE MATCH CRITERIA
2005 TRANSACTION COUNTYID DOES NOT MATCH MEDS
9532 OVER 3 EDWARDS MONTHS MEDICAL DETERMINATION OVERDUE
9546 OVER 2 MONTHS ACCEL ENROLL APP DETERMINATION OVERDUE
9548 OVER 2 MONTHS EXTENDED ELIG MEDICAL DETERM OVERDUE
9550 ONGOING BURMAN ELIGIBLE MEDS ELIGIBILITY UPDATE
C MEDS Worker Alerts
Workers are required to process 90 percent of these error alerts within the following designated timeframes
The MEDS daily and renewal error alerts received on or before the tenth working day of the month must be processed in time for the change to be effective the beginning of the following month
The MEDS daily and renewal error alerts received after the tenth working day of the month must be processed in time for the change to be effective the beginning of the month after the following month
Some of the alerts listed above are not generated by a specific county action However the county must process the alert in order to initiate steps to identify and document the source of the error and initiate steps to address the error
For example alert number 9546 is created when a child is aided through the Accelerated Enrollment process under aid code 8E The alert identifies that the child has been in aid code 8E for over two months and an evaluation of ongoing MediCal eligibility is required An evaluation of this alert would include the determination of whether the county took timely action to process the alert within the guidelines specified above
MPG LTR 667 409
The reconciliation worker alerts subject to review are ACWDL
0809
Alert Number Alert Definition
6005 RECON RECORD ON MEDSNOT ON COUNTY RECON HOLD GENERATED
6006 DUP RECORDS ON COUNTY RECON FILE RECON HOLD GENERATED
6008 DUP RECORDS ON COUNTY RECON FILE NO MATCH ON MEDS
Workers are required to process 95 percent of worker alerts that stem from records that are on the county files but not on MEDS or on MEDS but not on the county files within the following timeframes
Reconciliation worker alerts received by the tenth working day of the month must be processed in time for the change to be effective the beginning of the following month
D DHCS monitoring
Reconciliation worker alerts received after the tenth working day of the month must be processed in time for the change to be effective the beginning of the month after the following month
MPG LTR 667 409
PRS has the responsibility for performing the evaluations for CPS The ACWDL
0809
first counties selected for review will be notified by DHCS The review will be initiated approximately two months after the county has been notified of the impending review The sample that will be used for the CPS evaluation will include all alerts from the daily renewal and quarterly reconciliation processes The specific dates for the alerts will depend on the actual dates determined for the onsite reviews
MPG LTR 667 409
E Worker Actions
Workers must review their MEDS alerts daily and process them within ACWDL
0809
the timelines specified above in sections B and C Guides for resolving critical MEDS alerts can be found on the CalWIN intranet at the following address
httpusplvucsd030calwinMediCalMEDSPerformanceStandardstabi d171Defaultaspx
MPG LTR 667 409
F Monthly Reports A listing of the critical alerts for each office is updated monthly and can be found on the county S drive at the following location
SENTERPRISEMEDS Alerts
MPG LTR 667 409
200105 HFP Transition Applications
As a result of this transition counties will receive applications from SPE that previously were sent to HFP for evaluation to that program As part of the transition the law requires that counties meet a new performance standard
MPG LTR 7XX 1212
B 90 of applications received complete and without client error from ACWDL
1229
Performance SPE that are not on accelerated enrollment or currently enrolled in Standard MediCal shall be processed within 10 working days of receipt
MPG LTR 7XX 1212
C Definitions
ACWDL
Processed
1229 There has been a disposition of the application by an eligibility worker certifying eligibility or ineligibility with a timely NOA
Complete and Without Client Error
All questions on the application or RV form are answered
determination
The worker has the required information to make a determination Start of Ten Day Timeframe The ten day time frame begins when the county receives and date
stamps the application MPG LTR 7XX
ACWDL
D
cases can be found in MPG Article C Processing Guide 03 TLICP
Timeframe MPG LTR 771 1212 Applications
Appendix A Application Processing and Redetermination Performance Standards SelfCertification Monitoring and Tracking
Required Action for Application
Application Processing Requirements
Applications shall be processed according to the application performance standards as stated in article 200102A The 4590day time period starts on the date of the application including mailin applications and those sent from SPE not the date of receipt
Application Coding Requirements
Workers will use the Special Indicators in CalWIN see Automation section below to identify
Disability based applications requires a DAPD evaluation
Applications not processed timely due to delays caused by the applicant who is attempting to comply
Applications not processed timely due to delays by the State
Craig vs Bonta applications
Narrative Entries
Workers shall utilize CalWIN Case Comments to document intake activities and reasons for applications not processed within the 45day or 90day requirement
Application Processing Reminders
To minimize delays and ensure timely processing of applications staff are reminded to
Complete the Collect DED Referrals and Results Detail window in CalWIN for disability based applications requires a DDSD evaluation Do not forget to indicate Pending in the Status field of the Disability Evaluation Division section for those pending DDSD evaluation
Activate MediCal benefits for children as soon as they are determined eligible to one of the Federal Poverty Level FPL programs Do not delay enrollment of children if parents request MediCal
Activate pregnancyonly MediCal for pregnant women under the 200 FPL Program as soon as eligibility is established Continue to evaluate for fullscope MediCal if the pregnant woman requests
Activate fullscope or LTC benefits for individuals claiming PRUCOL status and who are determined otherwise eligible prior to the 30day deadline in which the applicant must provide documentation of alien status
Complete the MC 223 Applicants Supplemental Statement of
Facts for MediCal if needed via an overthephone interview with the applicant and mail to the applicant for review and signature
Required Action for Ongoing Cases
Redetermination Processing Requirements
Redeterminations shall be processed according to the MediCal redetermination performance standards as stated in 200102C
Application Coding Requirements
Workers will use the Special Indicators in CalWIN see Automation section below to identify
Redeterminations that are received complete no pending verifications and timely
Narrative Entries
Workers shall utilize CalWIN Case Comments to document redetermination activities and reasons for redeterminations not processed within 60 days of the redetermination due date
Redetermina To minimize delays and ensure timely processing of redeterminations
tion staff are reminded that
Processing The most recent pay stub available to the beneficiary is acceptable
Reminders proof of income
The most recent bank statement available to the beneficiary is acceptable proof of current bank balance
Automation The following Special Indicators shall be used for all applications dated October 1 through October 31 2007 and all cases with an October 2007 redetermination date Special Indicators will be recorded on the Collect Case Special Indicators window as shown below
Type of Special Indicator Description When
MC PSDAPD Disabilitybased application DDSD required
MC PSCraig vs Bonta Craig vs Bonta application Open pended
MC PSClient Error App over 45 or 90 days Applicant caused By 45th90th day
MC PSState Delay Disabilitybased App over 90 days State caused By 90th day
MC PSRecd complete timely RV packet received in report month and is complete with no pending verifications By the last date of the report
Note Applications over 45 or 90 days without the aforementioned Special Indicators will be reviewed and recorded as worker error unless indicated otherwise