10. redeterminations · revised: 11/30/16 update # 15-34 page 10-2 medi-cal handbook...

Medi-Cal Handbook page 10-1Redeterminations

10. Redeterminations

Title 42, Code of Federal Regulations, Section 435.916 (a) requires counties to redetermine the eligibility of Medicaid [Medi-Cal (MC) in California] clients with respect to circumstances that may change at least once every 12 months. Welfare and Institutions Code (W&I) Section 14012 states that redetermination must be completed annually and may be required at other times in accordance with general standards established by the Department of Health Care Services (DHCS).

The client must not be requested to provide information that is not relevant to ongoing eligibility or that has already been provided with respect to eligibility criteria not subject to change (i.e. date of birth, social security number, or U.S. citizenship).

10.1 Frequency & Timeliness

• Individuals or families receiving MC must have an eligibility redetermination (RD) within 12 months of:

• An approval of eligibility on any application, reapplication, or restoration which requires a Statement of Facts, or

• The last annual RD, or

• A Change in Circumstance (CIC) that triggers an eligibility redetermination.

• The first RD must be completed by the last day of the twelfth month counting from the application month as the first month of eligibility. Each RD date after that is set for 12 months.

• If the client submits the MC RD on the last day of the 12th month, it is considered timely.

• The client is not required to complete the RD sooner than the eleventh month following the initial application, reapplication or most recent RD.

• The RD due month does not change if the RD is completed early.

Update # 15-34 Revised: 11/30/16

2 Medi-Cal HandbookRedeterminations

Note:Each case record must contain adequate information with supporting documents to verify an individual's eligibility. All reported eligibility information must be consistent with verifications, case history, and case documents.

10.1.1 MC RD Due Date

The annual MC RD due date is set from the first day of the application month in most cases. The following five examples describe when the RD is due in specific situations.

Example:Applicant is eligible from the first day of the application month.

Application date 1/21/2016

Application approved 2/15/2016 (MC eligibility is effective 1/2016)

Eligibility effective date 1/1/2016

12th month ends (RD due) 12/31/2016

1/2016 2/2016 3/2016 to 11/2016 12/2016

Month 1 Month 2 Months 3 to 11 Month12

Application Month Approval Month RD Due Month

Eligible Eligible Eligible Eligible

Initial 12-month Period

New 12-month Period

New 12 month period begins 1/2017

Next MC RD due 12/2017

1/2017 2/2017 to 11/2017 12/2017

Month 1 Months 2 to 11 Month 12

New 12-month begins Eligible Next RD Due

Revised: 11/30/16 Update # 15-34


Example:Applicant is eligible for retroactive benefits.

The RD due month is set from the application month, even if the person is granted retroactive benefits for any of the three months before the application month.


Retro MC Requested 11/2015 & 12/2015

Application approved on 2/12/2016 (MC eligibility effective 11/2015)

Eligibility exists for both Retro months (11/2015 & 12/2015) and application month (1/2016)

12th month ends (RD due) 12/31/2016

Initial 12-Month Period with Retroactive Months

11/2015 12/2015 1/2016 2/2016 3/2016 to 11/2016 12/2016

Retro Month Retro Month Month 1 Month 2 Months 3 to 11 Month 12

Retro Eligibility

Retro Eligibility

Application Month Eligible

Approval Month Eligible

Eligible First RD Due

The retroactive months of 11/2015 and 12/2015 are not counted in the 12-month period because the application was received in 1/2016. The new 12 month period is 1/2016 - 12/2016.

Example:Applicant is not eligible in the month of application.

If the applicant does not meet all of the eligibility criteria during the month of application, the RD month is set from the first month in which the applicant meets all eligibility criteria. The first month in which the applicant meets all eligibility criteria is the initial month of eligibility. For example, a Non-MAGI MC applicant who has excess property in the month of application will have to spend down before eligibility criteria are met..


No eligibility for 1/2017 & 2/2017

Application approved on 3/2/2017 (MC eligibility effective for 3/2017 & forward)




01/2017 02/2017 03/2017 04/2017 to 01/2018 02/2018

MC ineligible MC ineligible First Eligible Month Eligible First RD due

New 12-month Period

New 12 month period begins 3/2017 - 2/2018


Example:Family members have different initial eligibility dates

There are situations where one application covers one or more tax households and/or household members who are eligible in the month of application, and others who do not meet eligibility criteria until a later month or are added to the case during the 12-month period.

In these situations, the household members who were determined eligible first will set the MC RD due date for all household members in the case. New members who are added to the case do not get their own separate MC RD due date from other members already in the case. The change in income is considered a CIC. [Refer to “Change in Circumstance,” page 10-47].


Application approved for two children in OTLIC program

1/2016

Parents are not eligible for MAGI MC in 1/2016 due to income. Parents report decreased income in 2/2016

Parents become eligible for MAGI MC due to decreased income

2/2016

Original 12th month ends 12/31/2016

Original MC RD due for all household members 12/2016

New MC RD due date because of CIC (Report of decreased income allows the parents to receive MC eligibility)

2/2017

Initial month of eligibility 3/2017

12th month ends (RD due) 2/2018



1/2016 2/2016 3/2016 to 11/2016 12/2016 2/2017

Month 1 Month 2 Months 3 to 11 Month 12

Application Month; Children are eligible; Parents are over income for MAGI MC.

Parents are eligible due to less income

All household members are eligible

MC RD due for parents & children

New MC RD due date because of CIC

New 12-month Period

New 12 month period begins 2/2016 - 2/2017


.

Example:A household with two children eligible for the CEC program and a third child moves into the home. The household now has three children with different CEC periods.

Application date for parents (Aria & Enzo), child #1 (Lucas) & child #2 (Emma)

1/21/2016

Application approved 2/2/2016 (MC eligibility effective 1/2016)

Child #3 (Chloe) was on MC in another household with a CEC period from

4/2016 - 3/2017

Chloe moves into the home 5/2016

Original MC RD due 12/2016

New MC RD due date because of CIC (Adding Chloe to the home)

5/2017

CEC period for Chloe, Lucas & Emma 6/2016-5/2017

New MC RD due date because of CIC (Adding Chloe to the home)

5/2017


1/2016 2/20163/2016 to

4/2016 5/20166/2016 to 11/2016 12/2016 5/2017

Month 1 Month 2 Month 3 to 4 Month 5 Months 6 to 11 Month 12



The CEC period for Chloe continues until 3/2017 even if eligibility changes for the other household members at the annual RD. At the end of Chloe's CEC period, an ex parte eligibility review must be completed for Chloe.

10.1.2 MC RD Due Date for DDSD

During the application process, if the applicant alleges a disability, forward the disability packet to the Disability Determination Service Division (DDSD) for a disability evaluation. The county has 90 days to make a final eligibility decision for applications based on disability, excluding delays by the State. When the decision is received confirming an applicant's disability, then complete the MC eligibility process. The applicant is determined eligible for MC effective the first day of the month of application. The MC RD must be completed by the last day of the 12th month.

If MAGI MC eligibility exists, approve the individual with a MAGI MC aid code and still forward the packet to the DDSD for a disability evaluation.

Example:.

Application Date 1/5/2017

DDSD Packet Sent 1/14/2017

DDSD Approval Decision 3/10/2017

Eligibility Effective Month 1/2017

12th Month Ends (RD Due): 12/2017

Next MC RD 12/2018

A client applies for MC on 1/5/2017 and claims disability.

App. month for parents, Lucas & Emma eligible with no share of cost (SOC)

App. approval month

MC eligible Chloe returns home with own CEC period

MC eligible

New CEC for all children

Annual RD Due for household, CEC ends for Lucas & Emma

MC RD due

1/2016 2/20163/2016 to

4/2016 5/20166/2016 to 11/2016 12/2016 5/2017



If the DDSD decision approving disability is received after 90 days, but prior to the last day of the 11th month, complete the normal RD process. Mail the RD packet to the client and allow 30 days for the client to provide the necessary information. The RD must be completed by the last day of the 12th month.

Example:A client applies for MC on 1/5/2016. The EW mails the DDSD referral packet on 1/12/2016, but DDSD provides a decision after 90 days.


DDSD Referral Packet Sent 1/12/2016


Eligibility Completed 8/20/2016


12th Month Ends (RD Due) 12/2016

Next MC RD 12/2017

DDSD Evaluation is received after the 11th month

There are instances where receipt of the disability decision extends beyond the 11th month from the date of application. The county has 90 days to make a final eligibility determination for applications based on disability, excluding delays by the State. If the DDSD decision confirming disability is received after the 11th month, do NOT complete the normal annual RD process. Instead, review the case and determine if an eligibility determination can be made based on the information in the case or other available information. If there is insufficient information, contact the client to find out if there were changes that occurred that impact eligibility since the application date.

DO NOT send the MC RD forms to obtain updated information. If the applicant is determined MC eligible as of the application date, then the beginning date of eligibility is the first day of the application month. The RD due month is set 12 months from the date the applicant is determined eligible for MC.

Note:Follow the two contact policy. [Refer to “Two Contact Requirement,” page 12-2 for additional information regarding the two contact policy for MC.]




DDSD Packet Sent 1/12/2016

First MC RD due: 12/2016


County Received DDSD Decision 6/15/2017

Eligibility Completed 8/15/2017

12-month period: 8/2017 to 7/2018


First MC RD Due 7/2017

Next MC RD Due 7/2018

Example:

Note:If the case is originally approved under Presumptive Disability (PD) as of January 2016 pending the disability determination from DDSD, the RD is still in December 2016 on the PD case.

10.1.3 MC RD and CalWORKs

If the CalWORKs (CW) application is approved, the MC RD date changes. The EW will determine eligibility for all family members using the new information contained on the CW application and update the eligibility status of the entire case as follows:

• If all family members are approved for CW, then the MC only case no longer exists and the RD date is set based on the CW application month.

• If there are family members who remain MC only eligible, the next MC RD date will be set 12 months from the CW application month.

When a client is receiving MC and later applies for CW, but is denied CW, the MC RD due date does not necessarily change. However, if the client reports on the CalWORKs application a change in a data element that requires a redetermination of eligibility for MC the MC RD due date may be reset to a new 12-month period. [Refer to “Change in Circumstance,” page 10-47]

Reminder:When processing a CW application, the MC program must be reevaluated.



MC RD Date when the CalWORKs Case is Discontinued

When a client is discontinued from CW for failure to complete the annual RD, the individuals are placed into aid code 38 pending a MC only determination. During this timeframe:

• The case will have an overdue annual RD while the clients continue to receive MC benefits.

• Follow the ex parte process (all available information within 90 days can be used to make a MC eligibility evaluation).

• If there is not enough information from the ex parte process to complete a MC eligibility determination, then mail out the appropriate MC RD forms to the client during the month after the CW case is discontinued using the same procedures required for processing a MC RD.

• Transition the case to ACA (if necessary).

• The client must be given at least 30 days to return the MC RD forms or provide the requested information. The ex parte process applies if the MC RD forms are returned or the information is provided timely, but are incomplete.

• Upon completion of the MC RD, a new 12-month period is set as follows:

10/2016 11/2016 12/2016 1/2017 2/2017 to 11/2017 12/2017

CW RD disc. for no RD

MC RD pending (aid code 38)

MC RD completed (aid code 38)

New 12-Month period begins

MC eligible MC RD Due

Note:If there are children in this household, the CEC period for the children is 1/2016 - 12/2016.

10.1.4 MC RD and Former Foster Youth

Former Foster Youth (FFY) clients do not have to meet income and property rules and do not have a SOC. The only requirements for an annual MC RD under the FFY program is confirmation of:

• The FFY wants MC to continue, and

• California residency.



EWs may obtain this information by contacting the client by telephone or mailing the MC 250A.

[Refer to “Foster Care MC RD Forms,” page 10-14 for additional information.]

FFY should not receive any of the MC RD forms such as MC 216, MC 210 RV, etc., unless they are part of a household where other household members must complete a Non-Foster Care MC evaluation to continue their MC benefits.

FFY up to age 26 must not be discontinued due to a loss of contact or for not responding to the county at annual MC RD.

10.2 MC RD Forms

In general, all MC only clients are required to complete an annual MC RD, with the exception of the following groups:

• FFY in aid code 4M

• Clients receiving MC through public cash assistance programs:• CalWORKs• Supplemental Security Income/State Supplementary Payment (SSI/SSP)• Foster Care [Refer to “Foster Care MC RD Forms,” page 10-14], or• Adoption Assistance Program (AAP).

10.2.1 MC RD Packets

There are four different sets of forms based on the case type for MC RDs:

(1) The MAGI MC RD packet for cases with information that was not e-verified through the Federal HUB.

(2) The Mixed Medi-Cal (both MAGI and Non-MAGI) MC RD packet.

(3) The Non-MAGI MC RD packet.

(4) The LTC MC RD packet..



Clients should NOT be discontinued for not returning the MC RD packet, if the information has been provided. Clients can provide the information requested in the packet by mail, by fax, by email, in person, or over the phone.

Note:Please follow the reprint process, “Reprinting MC RD forms,” page 10-90, if the packet needs to be resent to the client.

MAGI MC RD Packet

For MAGI MC only cases, when information is not e-verified the following form will be mailed to the clients:

Form Number Form Name Description of Form

MC 216 Medi-Cal Renewal Form

The pre-populated MC 216 will be auto-generated and sent by CalWIN. CalWIN will pre-populate case information on the form.

NOTE: The additional informational forms listed on 10.2.2 - “Informational MC RD Forms,” page 10-13, are also sent to the client.

Non-MAGI MC RD Packet

The Non-MAGI MC only MC RD packet (non-LTC) consists of the following forms:


MC 210 RV Medi-Cal Annual Redetermination form

The MC 210 RV is the main MC RD form for Non-MAGI MC individuals.

MC 210 PS Property Supplement

The MC 210 PS is a separate form for Non-MAGI MC to provide property related information. This form is auto-triggered when the MC 210 RV is generated in CalWIN.


Mixed MC RD Packet

A Mixed MC case consists of both individuals who are MAGI MC eligible and Non-MAGI MC eligible (i.e. a 68-year-old spouse on an ABD program and his/her 60-year-old spouse on MAGI MC).



The following forms will be mailed to the clients:


MC 216 Medi-Cal Renewal Form

The pre-populated MC 216 will be auto-generated and sent by CalWIN. CalWIN will pre-populate case information on the form.

MC 604 IPS Evaluation for Non-MAGI MC

The MC 604 IPS requests the necessary Non-MAGI MC property, income, and income deduction information to evaluate for Non-MAGI MC eligibility if this information was not previously obtained through the ex parte review or is not current for individuals who are:


Long Term Care MC RD Packet

The LTC MC RD Packet consists of the following forms:


MC 210 RV Notice

Medi-Cal Annual Redetermination Notice

This cover letter explains to a MC client the change to the annual MC annual RD process due to ACA. The informing notice also contains the following information:

• Purpose of the annual MC RD.

• Requirements of the annual MC RD, and

• The due date when required forms must be completed/returned for MC benefits to continue.

• Completing the annual MC RD in a timely manner will ensure continuous coverage if all eligibility factors are met, and

• Non-cooperation may cause interruption/termination of MC benefits.

MC 262 Redetermination for Medi-Cal Beneficiaries (LTC)

The MC 262 is used for clients in Long Term Care.


• No longer eligible for MAGI MC, or

• Non-MAGI in a Mixed MC case (MAGI MC and Non-MAGI MC case members.)



Additional forms that were previously sent with the LTC MC RD packet will continue to be sent. The following are the LTC MC RD supplemental forms:

Form Number Form Name

DHCS 7068 Responsibilities of Guardian/ Conservator or Applicant/ Beneficiary Representative

NOTE: This supplemental form is required for clients with an Authorized Representative (AR).

MC 004 Nursing Home Patient Information

MC 019 Medi-Cal Information for Beneficiaries

MC 18 Important Notice About Your Medi-Cal Benefits

MC 210 PS Property Supplement

MC 219 Important Information for Persons Requesting Medi-Cal

NOTE: A returned, signed copy of the MC 219 is not required; however case comments that the form was sent must still be entered in CalWIN.

Pub 13 Your Rights Under California Welfare Programs

SCD 508 National Voter Registration Interest Form

SCD 1264 Language Survey- Interpreter/ Translation Request

SCD 2341 My Benefits CalWIN Pamphlet

10.2.2 Informational MC RD Forms

The informational MC forms are sent to all MC clients at least 60 days prior to their MC RD due date.

The following are the MC RD informational forms:


GEN 1365 Notice of Language Services

MC 003 Early and Periodic Screening, Diagnosis and Treatment Services Flyer

MC 019 Medi-Cal Information for Beneficiaries

MC 219 Important Information for Persons Requesting Medi-Cal

NOTE: A returned, signed copy of the MC 219 is not required; however case comments that the form was sent must still be entered in CalWIN.

MC 372 Breast and Cervical Cancer Treatment Program (BCCTP) information



10.2.3 Foster Care MC RD Forms


MC 250 Application and Statement of Facts for Child Not Living with A Parent or Relative and for Whom aPublic Agency is Assuming Some Financial Responsibility

The MC 250 is used for the annual RD for Foster Care (FC) children.

MC 250A Application and Statement of Facts for an Individual who is over 18 and under 26 and who was in FC Placement on his or her 18th Birthday

The MC 250 A may be used for clients in the FFY program, aid code 4M.

NOTE: The MC 250 A is NOT a mandatory form.

10.2.4 Additional MC RD Forms

The following additional forms must be completed at the annual RD, if applicable:

• “Student Educational Expenses” (MC 210 S-E)

• “Income In-Kind/Housing Verification” (MC 210 S-I)

• “SSA Referral Notice” (MC 194), if there is no SSN on file.

• Medical Support Forms: (if an absent parent exists and the form was not previously completed or the custodial parent has new information to report.):

• “Notice and Agreement for Child, Spousal and Medical Support” (CW 2.1)

Pub 13 Your Rights Under California Welfare Programs

Pub 183 CHDP Informational Flyer

SCD 115 Consent to Exchange/ Release Information - Children’s Health Initiative (CHI)

SCD 508 National Voter Registration Interest Form

SCD 1264 Language Survey- Interpreter/ Translation Request

SCD 2341 My Benefits CalWIN Pamphlet

SCD 2365 Second Harvest Food Bank and CalFresh Outreach Flyer

WIC 2 WIC Outreach Flyer




• “Support Questionnaire” (CW 2.1Q)

• “Paternity Affidavit” (SCD 95)

• “90-Day Status Letter” (MC 179) (if reexamination date is due).

• “Referral To/From Social Security” (SCD 169) [Medicare eligibility referral if client is 64 years and 9 months of age.]

• “Veteran's Benefits Referral” (MC 05) if not previously completed.

• “Insurance Affordability Program - Request for Tax Household Information” (RFTHI/SCD 2350)

• “Request for Tax Household Information Supplemental Form” (SCD 2350 Supplemental)

10.2.5 SAWS 2 PLUS

EWs may use the “Application for Cash Aid, CalFresh, and/or Medi-Cal” (SAWS 2 PLUS) for both the CW and MC only RD when all the following conditions are met:

• The case contains CW and MC only family members,

• CW and MC eligibility information/verifications are kept in the same case number and assigned to the same caseload number, and

• Both the CW and MC RDs are scheduled and completed in the same month.

Example:A family consists of both CW and MC only family members. The EW schedules the CW/MC annual RD for January 2017 and both are completed with the client on January 10, 2017. The SAWS 2 PLUS is sufficient for both the CW and MC RD.

10.3 Mailing and Receiving Process

MC RD packets are auto-generated, printed (in Batch print mode) and sent by CalWIN and the print vendor for MC cases WITHOUT an AR listed in the Collect Authorized Representative Detail window in CalWIN.



MC RD packets are auto-generated but will NOT be mailed for MC cases WITH an AR in the CalWIN window. These MC RD packets will be placed in Online print mode in CalWIN to ensure the RD packets are mailed to the client and AR.

10.3.1 Sending MC RDs without an AR

The process for sending and receiving the MC RDs without an AR are as follows:

Step Who Action

1. CalWIN Provides a file to the print vendor of all the auto-generated required MC RD forms for the future-future month’s MC RDs.

Example: On April 22nd CalWIN will provide a file of all MC RDs without an AR due in June.

2. Print Vendor

• Prints the barcoded MC RD forms out of CalWIN.

• Creates the entire MC RD packets (required and informational forms).

• Mails the MC RD packets to the clients at least 60 days prior to the due month.

Example: The Print Vendor will mail, at the end of April, the MC RDs without an AR due in June.

10.3.2 Sending MC RDs with an AR

The process for sending and receiving the MC RDs with an AR are as follows:

Step Who Action

1. DSR Data matches and sends listing to Program to validate the MC RDs with an AR for the future-future month.

Example: In April, data matches and sends list for June MC RDs with an AR.

2. Program Validates the listing and distributes the listing to the appropriate District Office (D.O.) or Central Support Services (CSS).



3. D.O.

If the D.O. is... Then...

BSC, BSC Clerical staff:

• Generates and prints the MC RD forms (i.e. MC 216, MC 210RV, MC 262, etc.) from CalWIN (in order for the barcode to be printed on the forms).

• Assembles the MC RD packets with both CalWIN printed forms and additional informational forms.

• Stuffs the MC RD packets along with BSC Business Reply Mail (BRM) envelope into large envelopes.

• Sends the MC RD envelopes to CSS.

Not BSC, CSS:

• Generates and prints the required MC RD forms from CalWIN (in order for the barcode to be printed on the forms).

• Assembles the MC RD packets with both CalWIN printed forms and additional informational forms.

• Stuffs the MC RD packets along with CSS Business Reply Mail (BRM) envelope into large envelopes.

4. CSS Mails out the MC RD packets to the clients.

Step Who Action



10.3.3 Receiving MC RD forms

Step Who Action

1. CSS • Opens the MC RD packets mailed-in by clients.

• Scans the barcode on the MC RD forms (MC 216, MC 210 RV, MC 604 IPS or MC 262) or manually enters the MC RD forms through the Maintain Periodic Reports Detail window.

If the RD forms are logged in...

Then CalWIN...

As Received before NOA cut-off (NCO),

• Automatically changes the MC RRR Status to Received Not Processed (on the View RRR Detail Listing window) at NCO. Note: CalWIN will not auto-start the RRR queue.

• Records the date received.

• Prevents the case from auto-discontinuance.

As Received in the RD due month but after NCO,

• Auto-rescinds the MC discontinuance.

• Updates the MC RRR Status from Overdue to Received Not Processed on the View RRR Detail Listing window.

After the RD due month,

• Will NOT auto-rescind the MC program.

• Will keep the MC RRR Status as Overdue.

• The EW will need to rescind, run RRR queue and run EDBC and determine if the client is still eligible for MC before authorizing benefits.

2. CSS Scans all forms and verifications returned into IDM.

3. I.S. / D.O. Assigns the TMTs to the Unit’s EWs.

10.3.4 Receiving MC RD Information Verbally

The general process on how to handle situations in which the client provides the MC RD information verbally (i.e. via phone or in person) is as follows:



Note:Each District Office has the discretion to modify this process based on their individual operational needs, as long as it does not go against MC policy, the process can be modified accordingly.

Step Who Action

1. Client Receives the RD packet forms to complete and return to the county.

NOTE: The client does not have to return the paper MC RD forms.

If the client... Then...

Walks in to the office with the information being requested,

The EW will:

• Collect the forms and verification (if applicable) provided by the client.

• Proceed to Step 2.

Calls with the information being requested,

The EW who takes the call will:

• Update CalWIN with the information provided by the client.


For BSC TMT process, the EW who takes the call will:

• Obtain the information from the client. Note: If the case is an LTC case, transfer the call to the LTC unit (408) 758-4040.

• Update the Received Status column to Received for the MC RD form(s) in the Search for Periodic Reports window.

• If there is no record of an MC RD form in the Search for Periodic Reports window, then the EW must proceed to Step 3.

• Enter case comments in the Search Case Comments window.



2. EW Update the Received Status column to Received for the MC RD form(s) in the Search for Periodic Reports window in order to prevent auto-discontinuance of MC for failure to complete the MC RD.

NOTE: If an EW is the officer of the day (O.D.), then he/she must update this window because if the Search for Periodic Reports window is not updated the case will auto-discontinue.

• On the Search for Periodic Reports window:

• Enter the Case #.

• Select Not Received on the Status field.

• Enter the Month/Year From and Month/Year To fields. Note: This date is not necessarily the RRR due month, it is the month the forms are printed.

• Click on the [Search] button.

In the “Search Results” group box, if there is...

Then...

A Report # of one or more of the following MC RD forms:

• MC 216, • MC 210 RV,• MC 604 IPS, or • MC 262,

• Change the Received Status column to Received for at least one of the MC RD forms.

• Enter the current date as the Received Date.

• Save.

• Document on the Search Case Comments window.

No record of an MC RD form, Proceed to Step 3.

Step Who Action



2. (cont)

Note: The fields in the child window, Maintain Periodic Reports Program Details, do not need to be completed. Completion of these fields does not impact the Medi-Cal case.

Step Who Action



3. EW On the Search/View for Client Correspondence in Print Queue window:


• Select Forms from the drop-down list

• Select Medi-Cal from the Program drop-down list

• Enter two months prior to the MC RD due month as the Requested From Date


If there is... Then...

At least one of the following MC RD forms in the “Search Results” group box:

• MC 216,• MC 210 RV,• MC 604 IPS, or• MC 262,

• Select the MC RD form (i.e. MC 216, MC 210 RV, etc.).

• Click on the [Print] button.

• Repeat Step 2 to log MC RD form as Received.

None of the following:

• MC 216,• MC 210 RV,• MC 604 IPS, or• MC 262,

Continue to Step 4.

Step Who Action



10.3.5 Manually logging in the MC RD

Designated staff must take the following steps to manually log in the receipt of MC RD forms submitted without a barcode (e.g., original RD forms were generated and mailed during the batch process, and the client returns another RD form created outside of the CalWIN automated system).

Step Action

1. Open the View RRR Detail Listing window.

2. Enter the case number in the Case # field and click [Search].

3. Verify that the MC RD month shows the current month.

4. Manually log in the RD form on the Maintain Periodic Report Details window.

[Refer to “Receiving MC RD Information Verbally,” page 10-18, Steps 2 through 4, as appropriate, for detailed steps on manually logging the MC RD forms.]

10.4 MC RD Process

4. EW • On the Print a Form/Other Correspondence Manually window, make the appropriate entries to print the MC RD form manually. [Refer to “Manually Printing the MC RD Forms in CalWIN,” page 10-92 for detailed instructions on printing the MC RD form(s) manually from CalWIN.]

• Repeat Step 2 to log MC RD form as Received.

Step Who Action


Revised: 11/3

page 10- Medi-Cal HandbookRedeterm

10.4.1

The AGI MC RDs:

0/16 Update # 15-34

24inations

MAGI MC RD Overview Chart

following chart illustrates a basic overview of the three processes that can occur for M


10.4.2 CalWIN Automated Renewal Process



10.4.3 Income at MC RD

The following chart explains how income is treated during the MC RD:

If there is… Then…

No change in income Do not update the income-related CalWIN windows.

Income information over 90 days old,

Complete the ex parte process. [Refer to “Ex Parte Process,” page 11-1]

A recent change in income and paper verification is on file,

Enter a new line in CalWIN with the updated income and enter Received in the Verification field.

NOTE: The Personal Verification Page in CalHEERS will show SAWS in the Verification Status column.

A recent change in income but verification is not on file,

Example:

The EW speaks with the client who provides a verbal statement of changed income but does not provide verification of that changed income.

Enter a new line in CalWIN with the updated income and enter Not Received in the Verification field.

If the CalHEERS results are...

Then...

E-Verified, • Authorize the case.

• Make sure the MC RD has been approved for another 12 months.

• Send an approval NOA and MC 219.

• Document actions in the Search Case Comments window.

Not E-Verified, Failed, or Verifications are Pending,

(These statuses indicate that results are not compatible through the Federal Hub),

• Request paper verification of the income.

• Mail an MC 355 and document actions in the Search Case Comments window.

• Allow 30 days for the client to provide the required verification.

• If verification is not provided by due date, discontinue for failure to provide.

• If verification is provided, complete the MC RD and approve MC for another 12 months.

[Refer to “MC RD Forms,” page 10-10]




10.4.4 MAGI MC Only RD Process

The electronic health information transfer (eHIT) process is an automated process to CalHEERS that occurs for the MAGI MC RD which does not involve initial EW action. The following table outlines this automated process:

Step Action

1. Two months before the MC RD due month, CalWIN automatically sends an EDR to CalHEERS with the current existing CalWIN data.

2. • CalHEERS makes a MAGI MC eligibility determination based on the information CalWIN sent.

• CalHEERS sends a DER with MAGI MC eligibility results back to CalWIN.


Then...

E-Verified, • CalHEERS will send CalWIN the eligibility results along with a NOA confirming eligibility. The eligibility result will have the client’s MAGI MC aid code for the upcoming benefit year. [Refer to “MAGI MC RD Approval NOA,” page 10-27]

• CalWIN will automatically:



• CalHEERS will inform the county via CalWIN which data elements could not be electronically verified.

• CalWIN will auto-generate and send the client the pre-populated MC 216 to request verification of information not e-verified.

• Allow the client at least 60 days to provide the information requested.

MAGI MC RD Approval NOA

If MAGI MC eligibility is approved, CalHEERS will generate and send a NOA confirming eligibility to CalWIN. Then, CalWIN will auto-send the NOA to the client. The NOA informs the client that his/her eligibility has been continued for another year, and that no additional information is needed. The NOA will also include the

• Approve another 12-month MC RD period,

• Authorize the case, and

• Send an approval NOA.



MAGI MC household size and income amount that was used to redetermine eligibility for each client in the household. If a client believes the income and household size reported on the NOA are incorrect, the client must contact the county within 90 days to provide the most current information.

MAGI MC Renewal Form (MC 216)

If CalHEERS cannot successfully e-verify current CalWIN case information, CalWIN will auto-generate and send a pre-populated MC 216 form. CalWIN will pre-populate case information from CalWIN for the client to update any changes and/or provide verification of the information.

Per MC regulation, MC clients must be given at least 60 days to provide the information requested on the MC 216.

Example:If the MC RD month is 1/2017, the last day for the client to provide necessary information is 1/31/2017. The MC 216 must be mailed to the client no later than 12/1/2016.

The information requested on the MC 216 may be provided by phone, mail, e-mail or in person. The client is not required to return the MC 216 form; however, the requested verifications must be provided.

When the client has provided the information from the MC 216, the EW must verify in the Search for Periodic Reports window that the form was marked as Received. The EW does not need to complete the Program Status field (i.e. Incomplete- Not OK or Complete -OK) in the Maintain Periodic Reports Program Details window.

The following outlines the MC 216 process:

Step Action

1. • The pre-populated MC 216 is generated and sent by CalWIN.

• The client is allowed at least 60 days to provide the information and verification requested on the MC 216.



2. Steps after the client’s action:

If the client... Then...

States that the information on the MC 216 is correct,

After the client provides paper verification of the information:

• Go to the Search for Periodic Reports window and update the Received Status column to Received.

• Initiate the RRR workflow.

• Update the information in CalWIN.

• Run EDBC.

• Verify the EDR was sent and received successfully in the Search for CalHEERS Results window.

• Run EDBC again to accept the results from CalHEERS into CalWIN.


Provides updated information,



• Run EDBC.

• Verify the EDR was sent and received successfully in the Search for CalHEERS Results window.

• Run EDBC again to accept the results from CalHEERS into CalWIN.


Does not respond, • Discontinue MC benefits for failure to comply with MC RD process.

• Issue a timely and adequate discontinuance NOA.


Reminder: Since the MC RD form is sent 60 days before the MC RD due month, two required contacts must be made before discontinuance. [Refer to “MC RD is Not Returned,” page 10-68]

Step Action



3. If the CalHEERS results show...

Then...

The client is MAGI MC eligible,

• Authorize the case.


• Send an approval NOA.


[Refer to “MAGI MC RD Approval NOA,” page 10-27]

The client is NOT MAGI MC eligible,

• Determine if the client(s) is potentially eligible for Non-MAGI MC.

• Complete an ex-parte review (all income and property verifications must be within 90 days) and/or send a Non-MAGI MC Screening Packet.

NOTE: Allow 30 days for the client to provide the necessary information and verifications for a Non-MAGI MC determination. The Non-MAGI MC Screening Packet does not have to be returned.

• Evaluate for other health coverage programs (APTC, MCAP, CCHIP).

[Refer to “MAGI MC Ineligibility,” page 19-27]



• Complete the ex parte review process.

• Mail an MC 355 to request the needed verification; verify that the due date is set to 30 days. If not, change it to 30 days. Reminder: The Verification field in CalWIN for the information that needs to be verified must remain as Not Received until the client provides paper verification.

• If the client does not make a good faith effort to provide the requested information by the end of the MC RD due month:

• Discontinue the case for failure to provide verification.

• Issue a timely and adequate discontinuance NOA.


Step Action



10.4.5 Non-MAGI MC Only RD Process

CalWIN will auto-generate and send the Non-MAGI MC RD packet at least 60 days before the end of the MC RD due month.

Example:For cases with the MC RD due in 11/2016, CalWIN will auto-generate and send the Non-MAGI MC RD packet in 9/2016.

Reminder:At least one of the RD form needs to be marked as Received in the Search for Periodic Reports window to prevent the case from being discontinued.

EWs must review Non-MAGI MC cases for potential MAGI MC eligibility. For example, the case has a 70-year-old individual who becomes a caretaker relative. When there is potential MAGI MC eligibility, the EW must first obtain tax filing household information, complete all essential and very important fields, and run EDBC to call the BRE for a MAGI MC evaluation without requesting property information. If the client is not eligible for MAGI MC,then request property information to complete the Non-MAGI MC RD. [Refer to “Essential and Very Important Fields,” page 19-11]

For the Non-MAGI MC RD process, the client must provide paper verifications of income and property, as applicable. However, the MC RD forms DO NOT need to be returned. The MC RD information may be provided over the phone, in writing, or in person.

Example:The MC RD is due 11/2016. The Non-MAGI MC RD packet is sent requesting income and property information and verification on 9/2016. The client calls and reports no change to his/her RSDI income and has no countable property. The client DOES NOT need to return the MC RD forms (i.e. MC 210 RV, MC 210 PS, MC 262). The client’s RSDI income can be verified via the Medi-Cal Eligibility Data System (MEDS) and the client reported no property; therefore, no paper verification is required for his/her income or property NOTE: If the client previously had property information in CalWIN and he/she no longer has it, then he/she must provide verification (i.e. bank statement showing checking account is closed).



Example:The MC RD is due 2/2017. The Non-MAGI MC RD packet is sent requesting income and property information/verification on 12/2016. The client calls and reports a change in property. The client DOES NOT need to return the MC RD forms; however, the client DOES need to provide verification of property.

Example:The MC RD is due 2/2017. The Non-MAGI MC RD packet is sent requesting income and property information/verification on 12/2016. The client has an open bank account listed in CalWIN. The client calls and reports that the bank account is closed. The client DOES NOT need to return the MC RD forms (i.e. the MC 210 RV or the MC 210 PS); however, the client DOES need to provide verification of the closed bank account. (Verbal verification is not sufficient.)

Eligibility determination requests to the CalHEERS Business Rules Engine (BRE) for Non-MAGI only cases are not to be made when no potential MAGI eligibility exists. Once all MC RD information has been obtained, EWs must process the Non-MAGI MC RD and determine benefits through CalWIN.

Example:A 75-year-old couple (both on Non-MAGI MC aid code 17) without dependents are non-potential MAGI individuals. This case would not have an e-HIT sent to the CalHEERS BRE.

ACA Non-MAGI MC Process

The following is an outline of the ACA Non-MAGI MC process:

Step Action

1. Two months before the MC RD due date, CalWIN will automatically send the Non-MAGI MC RD packet for the Non-MAGI MC individuals in the case. [Refer to “Non-MAGI MC RD Packet,” page 10-11.]



2. The client must be provided at least 60 calendar days to provide the information and verifications requested on the MC RD forms.

If the client does... Then...

Not respond, • A required client contact must be made before discontinuance. [Refer to “Automated Reminder Calls,” page 10-68.]

• CalWIN will auto-discontinue the case for failure to comply with the MC RD process at the end of the MC RD due month.

[Refer to “Non-MAGI MC verification requirements,” page 10-62.]

Provides information but not all required verifications,

• Mail an MC 355 requesting missing paper verifications and allowing 30 days for the client to respond.

• If verification is not provided within 30 days, then discontinue MC for failure to provide.

• If verification is provided within 30 days, then complete MC RD process and approve MC for another 12 months.


Provide the requested information and all required verifications,

• Process the MC RD.


• Make sure MC has been approved for another 12 months.

• Send appropriate NOA(s).


Step Action



Pre-ACA Non-MAGI MC Process

The following is an outline of the Pre-ACA Non-MAGI MC process:

Step Action

1. • Three months prior to the MC RD due date, EWs must review and update essential, very important, and Schema 4.0 fields. [Refer to “Essential and Very Important Fields,” page 19-11]

NOTE: These are assigned via TMTs or Listings.

• Transition Pre-ACA case to determine MC eligibility. [Refer to CA 311.3 - Transitioning Pre-ACA MC to ACA (MAGI and/or APTC)]

2. Determine if the case is MAGI MC, Non-MAGI MC, Mixed MC (MAGI MC & Non-MAGI MC), or another health coverage program (i.e. APTC, MCAP, etc.).

If... Then...

All of the individuals in the case are MAGI MC eligible,

[Refer to “MAGI MC Only RD Process,” page 10-27]

Some of the individuals are MAGI MC and some are Non-MAGI MC eligible,

[Refer to “Mixed (MAGI MC and Non-MAGI MC) Medi-Cal RD,” page 10-34]

None of the individuals in the case are MAGI MC eligible,

• [Refer to “ACA Non-MAGI MC Process,” page 10-32]

• Evaluate for other health coverage programs (APTC, MCAP, CCHIP).


10.4.6 Mixed (MAGI MC and Non-MAGI MC) Medi-Cal RD

For Mixed MC household cases, a combination of the instructions from “MAGI MC Only RD Process,” page 10-27 and “Non-MAGI MC Only RD Process,” page 10-31 will be applied.

The process for Mixed MC cases begins with:

1. CalWIN automatically sending an eHIT to CalHEERS with the most current CalWIN data.

2. CalWIN auto-generates and sends the pre-populated MC 216 for the MAGI MC household members whose information was not e-verified.


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/calwin_searchable/calwin_announcements/ca_311.pdf


3. CalWIN auto-generates and sends the MC 604 IPS for the Non-MAGI MC household members.

[Refer to “Mixed MC RD Packet,” page 10-11 for additional information about forms]

Example:A 67-year-old individual on ABD-MN (Non-MAGI MC aid code 14) and his spouse, a 62-year-old individual eligible for MAGI MC (MAGI MC aid code M1) are on the same case. This case is considered a Mixed MAGI MC and Non-MAGI MC household.

When processing an RD for a Mixed MC household, paper verification is required for all Non-MAGI MC clients (as applicable). Information that is e-verified only applies to the MAGI MC clients. If all information has been e-verified for the MAGI MC clients but there is no paper verification for the Non-MAGI MC clients, then MC eligibility can be determined for the MAGI MC clients but not for the Non-MAGI MC clients.

If no paper verification is received for the Non-MAGI MC clients after an MC 355 (allowing 30 days to provide missing paper verification) has been sent to the Non-MAGI MC client, then only the Non-MAGI MC clients must be discontinued.

When processing an RD for a Mixed MC household, if a Non-MAGI MC client provides all paper verification of income and property but the MAGI MC client’s income is not e-verified, then the MAGI MC client must provide paper verification of income. If no paper verification is received for the MAGI MC client after an MC 355 (allowing 30 days to provide missing paper verification) has been sent to the MAGI MC client, then only the MAGI MC client must be discontinued with 10-day NOA.

Example:Macia Rossi is eligible for ABD-MN and her spouse, Alekos Rossi is eligible for MAGI MC on the same case. They both work but do not have any countable property. Alekos’ income is not e-verified and Macia only provided her paystubs. An MC 355 is mailed but Alekos does not provide paper verification; therefore, Alekos is discontinued from MC with a timely 10-day NOA.



Mixed MC Household RD Process

The following is an outline of the Mixed MAGI MC and Non-MAGI MC RD process:

Step Action

1. Two months before the MC RD due date CalWIN will automatically:

• Send an e-HIT to CalHEERS with the most current CalWIN data.

• Send the MC 604 IPS for the Non-MAGI MC individuals in the case.


And... Then...

E-Verified, The MC 604 IPS information and all required paper verifications ARE provided,

Reminder: The form is NOT required, the information and verifications ARE required.

• Update the Search for Periodic Reports window as Received.



• Run EDBC.







2. E-Verified, The MC 604 IPS information is provided but the paper verifications are NOT provided,

• Mail an MC355 allowing 30 days for the client to provide the paper verifications for income and property.

• If the client provides the paper verification within 30 days, then:




• Run EDBC.





• If the client does NOT provide the verifications within 30 days, then:

• Discontinue the Non-MAGI MC client(s) for failure to provide.

• Send a timely and adequate discontinuance NOA.


The MC 604 IPS information is NOT provided but the paper verifications ARE provided,




• Run EDBC.





Step Action



E-Verified, The MC 604 IPS information and verifications are NOT provided,






• Run EDBC.









Step Action



Not E-Verified, Verifications are Pending, or Failed


The MC 604 IPS information and paper verifications ARE provided,

Reminder: The form is not required, the information and verifications are required.

• CalWIN automatically sends the MC 216.

NOTE: If the paper verifications are only for the Non-MAGI MC client(s), then process the MC RD for the Non-MAGI MC client only.




• Run EDBC.





Step Action



Not E-Verified, Verifications are Pending, or Failed,


The MC 604 IPS information is provided but the paper verifications are NOT provided,






• Run EDBC.









Step Action



Not E-Verified, Verifications are Pending, or Failed


The MC 604 IPS information is NOT provided but the paper verifications ARE provided,

• CalWIN automatically sends the MC 216.

NOTE: If the paper verifications are only for the Non-MAGI MC client(s), then process the MC RD for the Non-MAGI MC client only.




• Run EDBC.





Step Action



10.4.7 MAGI MC and APTC RD

Any changes reported during the annual renewal for APTC will be sent via eHIT to the CalWIN External Change Data subsystem.

• For MAGI MC RD process, refer to “MAGI MC Only RD Process,” page 10-27.

• For APTC renewal process, refer to “APTC/CSR/QHP Renewal,” page 2-17.

• For ECD process, refer to “ECD at RD,” page 21-42.



The MC 604 IPS information and paper verifications are NOT provided,






• Run EDBC.









Step Action



Example:Parents are receiving APTC and the children are on OTLIC MC. During the October APTC renewal, the parents complete their APTC renewal online at www.coveredca.com with changes. A referral is sent from CalHEERS to the External Change Data subsystem in CalWIN and a TMT is assigned to an EW.

10.4.8 SSI QMB Cases

The EW must review MEDS to ensure that the individual is still receiving SSI. Once SSI eligibility is confirmed, only two requirements must be completed by the EW:

1. Re-verify the SSI/SSP client's net non-exempt income via the [INQX] screen on MEDS.

2. Check the [INQ1] and [INQB] screens on MEDS to make sure that QMB eligibility is being correctly reported to MEDS and that verification of Medicare Part A entitlement is on file.

Deny or discontinue QMB if the individual is ineligible for Part A.

Copies of MEDS screens used to verify income and Medicare eligibility must be kept in IDM. No other forms or verifications are necessary for SSI QMB RDs.

[Refer to “Qualified Medicare Beneficiary (QMB) Program,” page 30-25]

10.4.9 Mega-Mandatory Coverage Groups

The following programs are referred to as the Mega-Mandatory coverage groups.

Program Name Aid Code

CalWORKs 30, 31, 32, 33, 35, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3L, 3M, 3P, 3U, 3W, and K1

SSI/SSP 10, 20, and 60

Title IV-E Foster Care 42, 46, and 49

State-Only Foster Care 40, 43, 45, 4C, 4H, 4L, 4K, 4N, 4P, 4R, and 5K

Title IV-E Adoption Assistance 03, 06, 07, and 4A

State-Only Adoption Assistance 04



MC RDs for individuals in the Mega-Mandatory coverage groups are completed following the rules that existed for those coverage groups before the Affordable Care Act (ACA). Eligibility in these categories must remain as long as the individual continues to be eligible for them. Eligibility for these groups is higher on the MC hierarchy than MAGI MC coverage groups.

The Mega-Mandatory individuals must be excluded from the tax household for any MAGI-linked individual in CalWIN. Per Pre-ACA rules for Non-MAGI MC MFBUs, Mega-Mandatory individuals are considered Public Assistance or Other Public Assistance individuals for Non-MAGI MC eligibility determination. Therefore, they are excluded from the MFBU for the Non-MAGI MC RDs. EWs should verify that RDs on other family members in other aid codes do not create a negative action for individuals in the Mega-Mandatory coverage group.

10.4.10 MAGI MC Evaluation for LTC MC

Individuals in the MAGI MC full-scope aid codes are eligible to receive long-term care (LTC) services without a SOC and without regard to property; therefore, MAGI MC eligibility must first be explored before determining Non-MAGI LTC MC eligibility for individuals (including parents, children, or pregnant women) who are 19 years old up to 65 years old without Medicare.

The EW should use the tax household information obtained at RD, to determine whether the individual or family is MAGI MC eligible. If determined ineligible for MAGI MC, then complete the Non-MAGI MC eligibility determination using the information from the submitted MC 262.

Title IV-E Kinship Guardian Assistance Payment Program (KinGAP)

4S and 4T

State-Only KinGAP 4F, 4G, and 4W

Pickle 16, 26, and 66

Disabled Adult Child 6A and 6C

Disabled Widow/Widower 36

Former Foster Youth 4M

Program Name Aid Code



10.4.11 MC RD for San Andreas Regional Center

An annual MC RD must be completed for individuals under the Department of Developmental Services - Home and Community-Based (DDS-HCBS) waiver for the San Andreas Regional Center (SARC). SARC is also required to complete an annual medical recertification for the DDS-HCBS waiver program. Whenever possible, the two reviews should be aligned and completed in the same month.

As documentation of continued medical certification for the DDS-HCBS waiver, SARC will forward a copy of the annual medical recertification to the EW. This document must be filed in IDM for the case. If the EW has not received verification of recertification from SARC by the time the annual MC RD is due, the EW must request the SARC liaison to contact SARC for confirmation of medical eligibility for the waiver program.

If an individual loses his/her medical certification for the DDS-HCBS Waiver, then the EW must evaluate the individual for all MC programs before discontinuing the case with a timely 10-day NOA.

The MC 210 RV can be completed for the SARC MC RD. When processing the MC RD for SARC, the EW must review the income reported to determine if the income remains above the MC income limits for zero SOC MC. OTLIC MC with premiums is considered zero SOC MC (i.e. T1, T3, etc.). If a client remains ineligible for zero SOC MC and the SARC certificate has been received, then he/she will remain on a SARC aid code. The EW must process the MC RD, approve another 12 months of SARC eligibility, and document all actions in the Search Case Comments window in CalWIN.

However, if the income reported is below the MC income limits for zero SOC MC, then the EW must evaluate the client for MC and make sure the appropriate aid code is in MEDS. The client will no longer have a SARC aid code. The EW must process the MC RD, approve another 12 months of MC eligibility, and document all actions in the Search Case Comments window in CalWIN.

When processing the MC RD for SARC, if income is not reported, then the EW must contact the client by telephone and ask for income information over the phone. If the client provides income information over the phone and the income is above the MC income limits for zero SOC MC, then the EW must process the MC RD, approve another 12 months of SARC eligibility, and document all actions in the Search Case Comments window in CalWIN. If the income is below the MC income limits, then the EW must evaluate for MC eligibility.

If the EW is unable to reach the client by telephone to request income information, then the EW will pend the case for missing income information and mail an MC 355 requesting income information. The client must be given 30 days to respond. For



SARC cases, the client can provide the income information over the phone or the information can be mailed. If the client does not respond within 30 days, then the case can be discontinued with a timely 10-day NOA for failure to respond.

10.5 MC RD for Intake

There may be instances in which the applicant’s MC eligibility is not determined until after their MC RD is due or in the month before the MC RD is due. In these instances, the EW approving the MC case must also process the MC RD to prevent the client’s case from being discontinued in the month of approval or in the month after approval.

Example:MC application submitted in 1/2015. The MC application is approved in 11/2015 with an effective begin date of 1/2015. The MC RD is due 12/2015. Since the EW approved the case one month before the MC RD is due, the EW must also process the MC RD for this case.

MC application submitted Original MC RD due date

EW processes and approves MC application and MC RD

New MC RD due date

1/2/2015 12/31/2015 11/09/2015 12/31/2016

Example:MC application submitted in 12/2015. The MC application is approved on 12/2016 with an effective begin date of 12/2015. The MC RD is due 11/2016. Since the EW approved the case after the MC RD due date, the EW must also process the MC RD for the case.

MC application submitted Original MC RD due date

EW processes and approves MC application and MC RD

New MC RD due date

12/15/2015 11/30/2016 12/11/2016 11/30/2017

Note:If the MC case is approved more than one year after the application date and the client has medical bills during that timeframe, the LOA process must be followed. [Refer to “Letter of Authorization,” page 49-13]



Intake Process

The following is an overview of the process the EW will need to do when approving a MC case and processing the MC RD during the same time period.

Step Action

1. Approves the MC case using the information provided in the application (i.e. information from the previous year).

2. Determine the type of case.

If the case is... Then...

MAGI MC Only, Initiate and run the MC RRR queue using the same information received with the MC application.

Reminder: The income Verification field must be Not Received.

If CalHEERS Results are...

Then...

E-Verified, • Authorize the case.

• Make sure MC RD has been approved for another 12 months.


Send the MC 216 to obtain current information and verification.

[Refer to CalWIN Announcement 316, “”Manual Medi-Cal Redetermination Process.”]

Non- MAGI MC Only,

Send the Non-MAGI MC RD packet to the client.

[Refer to “Non-MAGI MC RD Packet,” page 10-11]

Mixed (MAGI MC and Non-MAGI MC),

Send the Mixed MC RD packet to the client.

[Refer to “Mixed MC RD Packet,” page 10-11]

10.6 Change in Circumstance

A CIC occurs whenever the client reports a change in a data element that requires a redetermination of eligibility; this allows the MC RD due date to be reset for a new 12-month period. The CIC and the new 12-month period begins the month after the change was reported.


http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_searchable/calwin_announcements/ca_316.pdf


These types of changes include, but are not limited to:

• Income (Earned, unearned, employment, rental, etc.)

• Expenses (Child care, self-employment, etc.)

• Household (Add-a-person, removing a person, MFBU, Tax Filing Household, etc.)

• Tax Filing Status (Single, Married Filing Jointly, etc.)

• Immigration Status

• Property (Cases with Non-MAGI MC)

EWs need to determine MC eligibility for the future month and provide an adequate and timely 10-day NOA. When resetting the RD due date, the EW must mail an MC 219 and document in Search Case Comments window.

There are some data elements that would NOT require the EW to reset the RD due date based on the CIC. These types of changes include, but are not limited to:

• Address

• Phone number

• Rent

MAGI MC Household CIC

For MAGI only, if all information is E-Verified no additional verification is required, the MC RD due date can be reset for another 12-month period.

If the Federal Hub returns results of Not E-Verified, Pending, or Failed, the EW must mail the MC 355 requesting paper verifications, allowing 30 days for the client to respond. The MC RD date must not be reset at that time.

• If the client provides the paper verification within 30 days, the EW must update the case and reset the MC RD due date to another 12-month period.

• If the client does not provide the required paper verification within 30 days, the EW must discontinue the case for failure to provide verification.



Non-MAGI MC Household CIC

When a Non-MAGI MC household reports a change, regardless of the change reported, the income and property both need to be verified BEFORE a CIC can be completed to reset the MC RD due date for another 12 months. Non-MAGI MC clients must submit paper verifications for both income and property before resetting the MC RD date.

• If a Non-MAGI MC client reports a change, the EW updates CalWIN appropriately but does not reset the MC RD due date.

• If the Non-MAGI MC client reports a change and also provides ALL verifications of ALL income and property in the case, then the EW updates CalWIN and the MC RD due date must be reset for a new 12-month period.

If the client does not provide verifications for the change that was reported, then the EW must mail an MC 355 requesting paper verifications, allowing 30 days for the client to respond. The MC RD date must not be reset at that time.

• If the client only provides verification of the reported change, then the EW will update the case in CalWIN but the MC RD due date should not be reset.

• If the client provides ALL paper verification of BOTH income and property within 30 days, the EW must update the case and reset the MC RD due date for another 12 months.

• If the client does NOT provide the required paper verification of the reported change within 30 days, the EW must discontinue the case for failure to provide verification with a timely 10-day NOA.

Note:The case should not be discontinued if the client only provides the verification of the reported change; the MC RD due date should not be reset.

If the client provides the verification of the information that changed (i.e. pay stubs provided for an income change) but does not provide paper verifications for something that they DID NOT report changed, the verified change is updated and the MC RD due date is not reset.



Example:Lana Jonssen is a Non-MAGI MC client with income and property. Lana Jonssen mails in a pay stub indicating that her income has increased by $150. The EW calls the client and asks if Lana would like to reset her MC RD due date by sending in paper verification of her property. Lana does not send any current property verification. The MC RD due date should not be reset.

The following table describes an EW’s actions when verification of reported change is provided or is not provided.

If the client... And... Then the EW...

Provides verification of the reported change,

Verification of ALL other income and property,

Updates the case information and resets the MC RD due date for a new 12-month period.

Provides verification of the reported change,

Does NOT provide any other verifications,

Updates the case information but does NOT reset the MC RD due date

Does not provide verification of the reported change,

Provides or does not provide any other verifications,

Follows the Ex Parte process.

[Refer to “Ex Parte Process,” page 11-1]

Mixed MC Household CIC

[Refer to “MAGI MC Household CIC,” page 10-48]

[Refer to “Non-MAGI MC Household CIC,” page 10-49]

The following table describes actions when a change is reported for Mixed MC Households (MAGI MC and Non-MAGI MC):

If... And... Then the EW...

MAGI MC individual’s reported change is E-Verified,

Non-MAGI MC individual(s) provide ALL income and property verification,

Updates the case information and resets the MC RD due date for a new 12-month period.

MAGI MC individual’s reported change is E-Verified,

Non-MAGI MC individual(s) does NOT provide all income and property verification,

Updates the case information but does NOT reset the MC RD due date.

NOTE: This case would not be discontinued.



10.6.1 Changes Reported for Other Programs

CalFresh and/or General Assistance

If the MC client is also receiving other public assistance programs (CalFresh (CF) and/or General Assistance (GA)), and the client reports a change in a data element for those programs that requires a MC redetermination of eligibility, the client must have his/her MC eligibility redetermined and the MC RD due date reset for a new 12-month period.

CalWORKs, Foster Care, Adoption Assistance Program, and Kinship Guardian Assistance Payment Program

If the case has MC and a cash-linked program (CW, FC, AAP, or KinGAP), the MC and cash-linked annual redetermination dates will NOT be impacted by this change. Do not reset the MC RD due date.

Example:A CF/MC combo case with a 3/2017 MC RD. On 7/6/2016, the client reports a decrease in income on their 6/2016 SAR 7. When EDBC and the BRE are run, if the client remains MC eligible, then the MC RD is reset to 7/2017.

June SAR 7 processed

New 12 month RD period begins (based on CIC reported in July)

original MC RD due month

Reset MC RD due month (based on CIC reported in July)

7/6/2016 8/2016 03/2017 7/2017

Example:An applicant is approved for both CF and MC in 1/2016.

MAGI MC individual’s reported change is NOT E-Verified,

Non-MAGI MC individual(s) provide ALL income and property verification,

• Updates the case information but does NOT reset the MC RD due date.

• Follows the Ex Parte process.


MAGI MC individual’s reported change is NOT E-Verified,

Non-MAGI MC individual(s) does NOT provide all income and property verification,

• Does NOT reset the MC RD due date.

• Follows the Ex Parte process.


If... And... Then the EW...



set RD e

nth ed n rted me nge n 016 CF C

017

• In 6/2016, the client reports income changes on his/her SAR 7. This change is also considered a CIC for MC; therefore, it resets the MC RD due date to 6/2017.

• In 10/2016, the client reports the return of the absent parent into the home. This change is also considered a CIC for MC; therefore, it resets the MC RD due date to 10/2017.

• In 12/2016, the client reports income changes at his/her CF recertification (RC). This change is also considered a CIC for MC; therefore, resets the MC RD due date to 12/2017.

CF/MC App.

SAR 7 w/ income change reported

processed

New 12 mo. RD period begins (due to change reported in SAR 7)

Client reports return

of Absent Parent to the home

New 12 mo. RD period begins (based on HH change report in 10/2016)

original MC RD

due month

CF RC due &

process with

income changes

New 12 mo. RD period begins (due to income change report at CF RC)

Reset MC RD

due month (based

on reported income change on SAR

7)

Reset MC RD

due month (based on HH change reported

in 10/2016

)

ReMC

dumobas

orepoincocha

o12/2

at R

1/2016 6/2016 7/2016 10/2016 11/2016 12/2016 1/2017 6/2017 10/2017 12/2

10.6.2 CalWIN Entries for Change in Circumstance

The Collect Case Summary Detail window contains the Reset RRR [Y/N] field on the [Case Information] tab, which allows the MC RD due date to be updated when there is a CIC reported.

[Refer to “Income at MC RD,” page 10-26 for additional policy information.]



When the EW is processing a CIC that will reset the MC RD due date, the EW must update the Effective Begin Date and select Yes from the dropdown menu of the Reset RRR [Y/N] field.

Once the case is authorized the Reset RRR [Y/N] field will clear out (i.e. the Yes will be blanked out).

EWs also need to mail the MC 219 to the client and document that it was mailed in the Search Case Comments window.

Note:If a mistake is made, the MC RRR field on the Edit RRR Details window may be edited to the correct due month.



10.6.3 Change in Circumstance Examples

This section provides various examples of what may or may not be considered a CIC.

Example:Figaro is a MAGI MC client and he reports a new job (Pasta My Heart) on September 3rd. The EW updates the income in CalWIN and runs EDBC to call the BRE to determine eligibility. The new income is E-Verified. The EW updates the Effective Begin Date on the Collect Case Summary Detail window, and selects Yes from the dropdown menu of the Reset RRR [Y/N] field and reruns EDBC. Figaro continues to be MC eligible and his new 12-month period begins in October. This type of change (income) is considered a CIC and all information has been E-Verified, the MC RD due date must be reset to September 2017.

Client reports CIC

EW enters changes in CalWIN and

issues NOA to client

New 12 mo. RD period begins (based on CIC reported in

Sept.)

Reset MC RD due month (based on CIC reported in

Sept.)

9/6/2016 9/7/2016 10/2016 9/2017

Example:Clarabelle reports a change in her home address within Santa Clara County. This is not a change to a MC eligibility data element that would trigger a CIC. This type of change (address within CA) would not be considered a CIC; therefore, an eligibility redetermination would not occur and the MC RD due date should not be reset.

Note:As long as the client is still a California resident, the EW has no reason to make a new eligibility determination because a home address change would not change MC eligibility (unless out of state).

Example:Sylvester reports that his rent increased from $500 to $1750. This type of change (rent) would not be considered a CIC and the MC RD due date should not be reset.



Example:Alice Bluebonnet has been working at The Hat Shack and receiving $300 weekly for the last 2 years. She submits her SAR 7 for CalFresh and reports $300 weekly from her current employment at The Hat Shack. Since there is no change to her income or employer, this is not considered a CIC. The MC RD due date should not be reset for her case.

Example:Babbs McBunny has been working at the Elmer's Petting Zoo and receiving $520 bi-weekly for the last 4 years. She submits her SAR 7 for CF and reports $520 bi-weekly from her new employment at Sweet Carrots Restaurant and that her employment at Elmer’s Patting Zoo has ended. Babbs provides verification that her previous employment ended but does no provide verification for Sweet Carrots Restaurant. Following a successful BRE hit the income at Sweet Carrots is E-Verified. Although there is no actual change in income amount, there is a change in employer which requires multiple MC eligibility data element changes and entries in CalWIN. This is a CIC and all information has been verified/e-verified; the MC RD due date must be reset for another 12 months. NOTE: Refer to the CalFresh Handbook for more information on CF income verification requirements.

Example:Daisy Hobbin calls on August 19, 2016 to report that she is 7 months pregnant. Since there is a change in household size, this type of change (pregnancy) would be considered a CIC and self-attestation for pregnancy is a sufficient form of verification; therefore, the MC RD due date must be reset to August 2017.

Example:Daisy Hobbin calls on November 4, 2016 to report her newborn child, Laurie Hobbin. Although there is no change in household size because she previously reported her pregnancy, end dating the pregnancy and the addition of Laurie requires MC eligibility data element entries which make this type of change a CIC. Therefore, the MC RD due date must be reset to November 2017. NOTE: The Collect Pregnancy Detail window must be updated as appropriate.


https://ssaconnect.sccgov.org/ssa_departments/debs_program/Documents/handbooks/foods/fschap06.pdf


Example:Massimo Pesto has been working at Le Pizzeria for 1 year and earns $798 monthly. He drives over to Social Services Agency on September 10, 2016 to report an income change from $798 monthly to $799 monthly and hand delivers the income verification. This type of change (income) would be considered a CIC and paper verification was submitted satisfying the verification requirement; therefore, the MC RD due date must be reset to September 2017. NOTE: Even if Massimo had reported a change of one (1) cent to Social Services Agency, it would be considered a CIC and the MC RD would be reset to a new 12-month period as long as the amount was verified.

Example:Tao Zhang has not filed taxes for the last 3 years. His Display Tax Filer Detail window in CalWIN has a No in each of the fields. However, he called on July 29, 2016 to report that he will be filing taxes as Single in tax year 2016. There are no other changes to his case. This type of change (tax filing status) would be considered a CIC and self attestation is sufficient because tax filing information is prospective; therefore, the MC RD due date must be reset to July 2017.

Example:Dmitry Pavlov is a non-citizen who has been in the United States for 8 years and works as a biomedical consultant. On May 5, 2016, he mails a letter stating that his immigration status has changed from non-citizen to Legal Permanent Resident (LPR). There are no other changes reported by Dmitry. This type of change (immigration status) would be considered a CIC; therefore, the MC RD due date must be reset to May 2017.

Example:On February 18, 2016, Annelise calls to report that she is now disabled and there are no other changes. This type of change (disability) would be considered a CIC; therefore, the MC RD due date must be reset to February 2017. EWs must also send a DDSD referral.

Example:Vesna currently has a MC only case. She walks into our Intake office on October 20th, 2016 and completes the CF 285 to add CF to her existing case. After reviewing the CF application, the Intake EW discovers that the information on the application is exactly the same as the information that already exists in her current case in CalWIN. Since there is no new information, this is not considered a CIC. The MC RD due date should not be reset for her case.



Example:Zuzka currently has a MC only case. She walks into our Intake office on October 20th, 2016 and completes the CF 285 to add CF to her existing case. After reviewing the CF application, the Intake EW discovers that the only change is the social security number reported for Zuzka's one year old (Anbessa) on the application. This type of change (SSN) would be considered a CIC. The MC RD due date must be reset to October 2017.

Example:Yohannes currently has a CF/MC case. He walks into our GA Intake office on June 12th, 2016 and completes a GA application. After reviewing the GA application, the Intake EW discovers that the only change is his home address This type of change (address) would not be considered a CIC. The MC RD due date should not be reset.

Example:Jacques Le’Orange is receiving Non-MAGI MC, his wife receives MAGI MC, and he reports a new bank account. The EW sends an MC 355 requesting verification of the new bank account and income because he is receiving Non-MAGI MC. If the clients would like to reset their RD due date, then they must provide these verifications. Jacques does not provide the verification of either property or income. This type of change (property) would be considered a CIC; however, property does not affect the MAGI MC client. Jacques is discontinued but his wife continues to receive MAGI MC. NOTE: If Jacques provided property verification but not income verification, then he would continue to receive Non-MAGI MC but the MC RD due date would not be reset.

Example:Waleed is receiving Non-MAGI MC, he reports a new savings account with Sunshine Bank. However, he does not submit verification of the new account. The EW completes the ex parte review and contacts the client by phone but there is no response. The EW then sends the MC 355 requesting verification allowing 30 days for Waleed to respond. Waleed still does not respond. The EW discontinues MC for failure to provide verification.

Example:Amihan Santos is receiving Non-MAGI MC, she is a tattoo artist at the Once Upon A Tattoo shop. She has been earning $250 per week consistently for 3 years. She calls to report a new IRA account with Liwayway Bank in February 2016. The EW requests verification of the new bank account and her income because she is receiving Non-MAGI MC. Amihan provides the verification of both the IRA and her income. This type of change (property) would be



considered a CIC and Amihan provided income verification; therefore, the MC RD due date must be reset to February 2017. NOTE: If Amihan did not provide income verification, she would not be discontinued because it was not a reported change. However, her MC RD should not be reset without income verification.

Example:Aayush Chaudhary is receiving MAGI MC. He is a licensed Sky Diving instructor at The Sky is Falling Academy earning $300/bi-weekly. He called to report that his immigration status changed from T-Visa to Legal Permanent Resident. The EW makes the changes in CalWIN and then runs EDBC to call the BRE. The Federal Hub verifies immigration status but comes back incompatible for the income. The EW completes the ex parte review and contacts the client by phone but there is no response. The EW sends the MC 355 requesting verification allowing 30 days for Aayush to respond. Aayush sends in verification of income. This type of change (immigration status) would be considered a CIC; therefore, the MC RD due date must be reset.

Example:Anastasia Watson is receiving Non-MAGI MC and her child Alastair Watson is receiving MAGI MC. Anastasia calls to report child support in the amount of $455 per month. The EW completes the ex parte review and contacts the client by phone but there is no response. The EW sends the MC 355 requesting verification allowing 30 days for Anastasia to respond. Anastasia does not respond. Due to Anastasia’s failure to provide verifications this CIC will not reset the RD due date. Furthermore, the Non-MAGI client (Anastasia) must be discontinued while the MAGI MC individual (Alastair) continues to receive MAGI MC.

Example:Sadiki Azikiwe updates his income in CalHEERS. The Change DER is sent to the CalWIN External Change Data subsystem. The EW opens the Search for Case Updates window, initiates the queue and imports the changes into CalWIN. The information is not E-Verified. The EW completes the ex parte review and contacts the client by phone but there is no response. The EW sends the MC 355 requesting verification allowing 30 days for Sadiki to respond. Sadiki sends in verification of income. This type of change (income) would be considered a CIC and paper verification was submitted satisfying the verification requirement; therefore, the MC RD due date must be reset.



Example:Rupkatha Majumdar is a United Nations interpreter currently receiving APTC; her children Deepak and Farhana are receiving OTLIC. Rupkatha completes her APTC renewal in October 2016 in CalHEERS (although the MC RD is May 2017 for the children’s MAGI MC) indicating that her income increased; however, the income is not E-Verified. A Change DER is sent to the CalWIN External Change Data subsystem. The EW opens the Search for Case Updates window, initiates the queue and imports the changes into CalWIN. The information is not E-Verified. The EW completes an ex parte review and contacts the client by phone but there is no response. The EW sends the MC 355 requesting verification allowing 30 days for Rupkatha to respond. Rupkatha does not send in verification of income. This type of change (income) would be considered a CIC. However, verification was not received, therefore, the MC RD due date must not be reset. The MAGI MC case must be discontinued for the children because the client did not provide verification of income, but the children are eligible for CEC until RD (May 2017).

Example:Henrik Greene is a Non-MAGI MC client currently receiving RSDI and a pension from Global Associate Creators LLC. He did not send any paper verifications.The EW completes the ex parte review and verifies the RSDI through MEDS. The EW contacts the client by phone for verification of the pension but there is no response. The EW sends the MC 355 requesting verification allowing 30 days for Henrik to respond. Henrik sends paper verification. This type of change (income) would be considered a CIC and paper verification was submitted satisfying the verification requirement; therefore, the MC RD due date must be reset.

Example:Gertrude Kovács is 75 years old, receiving Non-MAGI MC.Gertrude works at the Floral Gymnastics Center earning $150 weekly. Her grandchild Edward was recently abandoned by his parents. Gertrude calls to report that she is now in care and control of Edward and needs to add him to her MC case. While on the phone with the client, the EW collects Gertrude's tax filing information, along with all necessary information to add Edward. There are no changes in income. The EW runs the case through the BRE, all information is e-verified. This type of change (tax filing status and household) would be considered a CIC and all information is verified; therefore, the MC RD due date must be reset. Gertrude is now MAGI MC eligible under the parent/caretaker relative group.



Example:Sameen is receiving Non-MAGI MC and she has an existing bank account. She reports a change in income. The EW asks the client if she would like to reset her RD due date by sending her current bank statement. The EW sends an MC 355 requesting the income and property verifications. Sameen sends income verifications but does not provide the property verification. This type of change (income) would be considered a CIC; however, she did not provide property verification so her MC eligibility continues but the MC RD due date is not reset. NOTE: If Sameen provides the property verification after 60 days and the income verification is still within 90 days, a new verification of income is not required. This type of change (property) is considered a CIC. The MC RD due date would be reset.

Example:Imari and Sherri Weisman are both receiving Non-MAGI MC and they have income and a joint bank account. They call to report the birth of their newborn, Clarisse. The EW first evaluates everyone (Imari, Sherri, and Clarisse) for MAGI MC because Imari and Sherri may be eligible for the MAGI MC Parent/Caretaker coverage group. If Imari and Sherri are not eligible for the MAGI MC Parent/Caretaker coverage group, then the EW can inform the Weismans to submit verification of income and property to reset their MC RD due date because they are still Non-MAGI MC clients. If the Weismans decide not to submit any additional paperwork. Even though this type of change (birth of a child) is considered a CIC, all income and property must be verified for Non-MAGI MC to reset the RD due date. Therefore, the MC RD due date must not be reset.

10.6.4 Change in Circumstance for Pre-ACA Cases

When a CIC occurs on a Pre-ACA case, the case must be transitioned before the MC RD due date can be reset for a new 12-month period. [Refer to “Transitioning from Pre-ACA MC to ACA MC,” page 19-2]



Example:Nancy's case is a Pre-ACA case with a MC RD due in November 2016. Nancy calls to report a change in income on September 13, 2016. The EW completes the transition process and updates the case in CalWIN on September 20, 2016; Nancy is eligible for MAGI MC effective October 2016. The EW must reset the MC RD due date to September 2017.

Nancy reports

change in income

EW completes the transition process and updates the case in CalWIN

New 12-month RD period begins (based on CIC processed in 9/2016)

original MC RD due month

Reset MC RD due month (based on CIC processed in 9/2016)

9/13/2016 9/20/2016 10/2016 11/2016 9/2017

10.7 Verification Requirements at MC RD and CIC

Clients are NOT initially required to provide supporting verification of information reported on the MC RD forms when it is returned for MAGI MC only cases.

The EW must use the following available electronic data systems to verify a client’s eligibility before requesting verifications from the client:

• CalHEERS Business Engine Rules (BRE)

• Income Eligibility Verification System (IEVS)

• Payment Verification System (PVS)

• Systematic Alien Verification of Eligibility (SAVE)

• MEDS

These systems can be used to verify information such as:

• Income,

• Unemployment benefits/Disability payments from the Employment Development Department,

• Social Security benefits from the Social Security Administration,


• Social Security Number,

• Earned interest on an account from a financial institution, and

• Immigration status.

10.7.1 Non-MAGI MC verification requirements

The following must be completed/verified at RD for Non-MAGI MC:

• Income

• Legal responsibility for child applying alone. NOTE: The parent must be contacted, but is not required to apply.

• Status and value of nonexempt property.

10.7.2 Income Verification for Individuals without a SSN or Individual Taxpayer Identification Number

Individuals who do not have a valid SSN or Individual Taxpayer Identification Number (ITIN) are required to provide verification of their income only AFTER the Federal Hub has provided results of Not-Verified, Failed or Pending.

10.7.3 Required Verifications

When information cannot be verified through electronic data systems (MEDS, Federal Hub, etc.), the EW must request the required verification from the client allowing 30 days for the client to provide. Required verifications must be provided, if they are not provided within 30 days then the case must be discontinued with a timely 10-day NOA.

There are some CalWIN windows which have two places to show verified information. These verification fields include:

• “SAWS Verification” means the county received paper verification from the client.

• 'State Verification” means a Covered California employee or the Federal Hub verified the information and the CalWIN Verification field was updated automatically.



• “Reasonably Compatible Verification” means a Covered California employee (Service Center Rep) or the Federal Hub verified the information and the CalWIN Verification field was updated automatically.

If something is verified by the Federal Hub or Covered California employee (Service Center Rep), the EW must not update the other Verification field unless there is paper verification listed in IDM. If the MAGI MC eligibility is not functioning properly, create a GADWIN ticket. All Non-MAGI MC cases should have paper verifications in IDM.

10.7.4 Printed Verification for IDM

EWs must print certain screenshots from each system (CalWIN, CalHEERS and MEDS) and send those screen prints to IDM as verification. These print outs include:

• CalHEERS Personal Verification page (i.e. FedHUB verifications) for each eligible individual. Refer to the Finding Information in CalHEERS (FInCH) document.

• Print CalWIN, CalHEERS, and MEDS screens that display the exact same information for each eligible individual. [IDM Fastner - MEDS]

• For CalWIN, print the Inquire on Medi-Cal Aid window from the Search on Case Information window.

• For CalHEERS, print Program Eligiblity Summary by Person page.


http://intranet.ssa.co.santa-clara.ca.us/calwin/calheers/calheers_finch.pdf

http://intranet.ssa.co.santa-clara.ca.us/calwin/calheers/calheers_finch.pdf


• For MEDS, print [INQM] screen and, if applicable, [INQ1], [INQ2], and [INQ3].

CalWIN Screenshot to Print

Print the individual’s Inquire on Medi-Cal Aid CalWIN screenshot for each active household member.

Step Action

1. Go to Inquiry subsystem.

2. Select Case Inquiry.

3. Click on Inquire on Medi-Cal Aid.

4. Enter Case Number.

5. Click [Open].

6. Select each Active Individual in the dropdown menu.

7. Enter the appropriate date range in the Month From and Month to fields.

8. Click [Search].

9. Print the Screen. Repeat for each active member in the household.



MEDS Screenshot to Print

Print the individuals [INQM] MEDS screen for each active household member. Depending on the case/individual the EW may also need to print screens [INQ1], [INQ2] and/or [INQ3] to capture all eligibility.

CalHEERS Screenshots to Print

Each household members’ eligibility appears together on the [Program Eligibility by Person] screen CalHEERS. The following steps will reduce the number of unnecessary pages printed from CalHEERS.

Step Action

1. Select Print Preview

2. Change Custom setting to 60%

3. Select page range to print only the pages with content.



10.8 MC RD is Not Returned

If after the two required contacts the client still has not returned the MC RD forms or provided the requested information, an adequate and timely discontinuance NOA must be sent to the client for failure to complete RRR process. The discontinuance action is effective on the last day of the month the RD is due, provided a timely NOA can be issued to the client. The NOA must explain the reason for termination and have the 90-Day Cure Period information.

If the client provides the requested information before the discontinuance action, the discontinuance must be rescinded.

Note:The MEDS termination code will be auto-generated when the client fails to complete the RRR process.

10.8.1 Automated Reminder Notice

CalWIN will auto trigger the “Your Medi-Cal Annual Redetermination is Due” (CSC 108) reminder notice on the 25th of the month following the renewal packet generation month.

Example:The MC RD is due in September. The MC RD packet is sent to the client on July 22nd. If the MC RD packet is not marked as Received in the Maintain Periodic Report Details window, CalWIN will auto-generate the CSC 108 and sent it on August 25th.

10.8.2 Automated Reminder Calls

Following the automated BRE run, cases that did not successfully auto renew will receive an automated outbound reminder call made to the Home Telephone number listed in the Collect Case Summary Detail window in CalWIN. This call reminds the clients who have not returned their RD packet or provided the information requested of their RD packet due date.

The reminder call(s) will be placed to the Day Telephone for LTC cases.



Message

The first automated outbound reminder call will occur on the 21st of the month before the RD due month and will state:

This is an important reminder for [1] [2]. A redetermination packet was mailed to you a few weeks ago. Please return the completed forms and the required verification or call us with the information in order to continue receiving your benefits. If you have already returned your forms, please disregard this call. Thank you. This message will repeat. This is an important reminder for [1] [2]. A redetermination packet was mailed to you a few weeks ago. Please return the completed forms and the required verification in order to continue receiving your benefits. If you have already returned your forms, please disregard this call. Thank you.

The second automated outbound reminder call will occur on the 5th of the RD due month and will state:

This is a second reminder for [1] [2]. A redetermination packet was mailed to you several weeks ago. Please return the completed forms and the required verification or call us with the information in order to continue receiving your benefits. If you have already returned your forms, please disregard this call. Thank you. This message will repeat. This is an important reminder for [1] [2]. A redetermination packet was mailed to you several weeks ago. Please return the completed forms and the required verification or call us with the information in order to continue receiving your benefits. If you have already returned your forms, please disregard this call. Thank you.

Missing or Invalid Telephone Numbers

An exception report will be produced for cases which the automated outbound reminder call was not made due to missing or invalid telephone numbers. These cases will be mailed a reminder notices. Central Support Services will generate and mail these notices. The mailed notice states the following:

Your Medi-Cal redetermination is due this month. We have not received your redetermination packet. Please send your redetermination forms that were mailed to you last month if want to keep your Medi-Cal.

If you have already provided your Medi-Cal redetermination forms for this month please disregard this notice.

Thank you.

[Refer to “Two Contact Requirement,” page 12-2 for additional information regarding the two contact policy for MC.]



10.9 Discontinuance at MC RD or CIC

10.9.1 MC RD Discontinuance due to Non-compliance

When a client fails to comply with the MC RD process, MC will be discontinued for failure to complete the RD or failure to provide information or verifications. The client must be informed of the reason for the discontinuance with a timely 10-day NOA.

For Non-MAGI MC cases, if the client reports a change, regardless of the change reported, the income and property both need to be verified BEFORE a CIC can be completed to reset the MC RD due date for another 12 months. The case should not be discontinued if the client only provides the verification of the reported change; the MC RD due date should not be reset. However, if the client does NOT provide the required paper verification of the reported change within 30 days, the EW must discontinue the case for failure to provide verification with a timely 10-day NOA.

10.9.2 MC RD Discontinuance due to Ineligibility

MAGI MC

At RD, a MAGI MC client may be determined ineligible for MAGI MC. The EW must complete an ex-parte review (all income and property verification must be within 90 days) and/or send out the Non-MAGI MC Screening Packet. An eligibility determination for a Covered CA healthcare program will happen automatically at the same time in CalWIN. In addition, the client may or may not be placed into Soft Pause. [Refer to “MAGI MC Ineligibility,” page 19-27]

Non-MAGI MC

At RD, a Non-MAGI MC client may be:

• Determined ineligible due to loss of linkage, at which point an eligibility determination for any other healthcare program should be evaluated.


https://ssaconnect.sccgov.org/ssaforms/Pages/DEBS-Medi-Cal-Forms.aspx#nonmagimcscreening


• Ineligible for zero SOC MC, the client can choose whether they want MC with SOC only (which is not MEC), MC with SOC and a Covered CA healthcare program, a Covered CA healthcare program only, or any other healthcare coverage programs they qualify for including CCHIP, MCAP, etc.

10.9.3 Mixed MC (MAGI MC & Non-MAGI MC) Discontinuance

All determinations are individually based, the Non-MAGI MC rules cannot be applied to MAGI MC clients and vice versa.

There are some case scenarios where MAGI MC clients or Non-MAGI MC clients may have to be discontinued without discontinuing the other MAGI MC or Non-MAGI MC client. For Mixed MC cases, when the automated renewal BRE occurs and e-verifies all the information for the MAGI MC client, the Non-MAGI MC client must still provide paper verification of income and/or property (as applicable) to complete the MC RD. If paper verification is not received for income and/or property for the Non-MAGI MC client, the EW must mail an MC 355 allowing 30 days for the client to respond. If the client does not respond, then only the Non-MAGI MC client must be discontinued with a timely 10-day NOA.

If the scenario was reversed where the Non-MAGI MC client provided paper verification for income and/or property but the automated renewal BRE did not e-verify the information for the MAGI MC client, the EW must mail an MC 355 allowing 30 days for the client to respond. If the client does not respond, then only the MAGI MC client must be discontinued with a timely 10-day NOA.

10.10 MC RD Rescissions

If the MC RD forms are not logged in or scanned into the Search for Periodic Reports window as Received by NCO, CalWIN will auto-generate the MC discontinuance NOA and set the MC program to discontinue at the end of the month in which the RD is due.



10.10.1 Rescission Between NCO and the End of the Discontinuance Month

When clients provide the MC RD information or forms after NCO to prevent the auto-discontinuance for failure to comply with the MC RD process the following steps must be followed:

Step Action

1. The MC RD forms must be logged in or scanned as Received in CalWIN

If a client provides... Then...

MC RD forms with a barcode,

The MC RD form must be scanned into CalWIN.

MC RD forms without a barcode,

• The MC RD form must be logged into CalWIN as Received in the Search for Periodic Reports window.

• Follow the instructions on “Manually logging in the MC RD,” page 10-23 to manually log in the MC RD forms.

The MC RD information verbally,

Reminder: Clients do NOT need to complete and return the MC RD forms.

• The MC RD form must be logged into CalWIN as Received in the Search for Periodic Reports window.

• Follow the instructions on “Receiving MC RD Information Verbally,” page 10-18, Steps 2-4, to manually log in the MC RD forms.

2. CalWIN will

• Auto-rescind the MC discontinuance.

• Update the MC RRR Status from Overdue to Received Not Processed on the View RRR Detail Listing window.

3. The EW must:

• Process the MC RD.


If clients return incomplete MC RD forms and/or verifications after the requested due date, but before the discontinuance date, EWs must rescind MC at the same benefit level, send rescission NOA, and obtain any missing information through the ex parte review and/or by sending an MC 355 to request missing information and allow 30 days.



Example:MAGI MC is discontinued on 10/31/2016 for failure to return the MC 216 and missing income verification for the 10/2016 MC RD. The client returns the MC 216 on 10/29/2016 before the MC discontinuance date (10/31/2016). MAGI MC must be rescinded effective 11/1/2016. The EW must send an MC 355 to request the income verification and allow 30 days for the client to respond.

If clients return the MC RD forms and/or verifications before the discontinuance date and they are not eligible for MAGI MC, but eligible for APTC/CSR, EWs must first rescind MAGI MC at the same benefit level before the discontinuance date and authorize the case. Then, the EW must determine If the client is potentially eligible for Non-MAGI MC and mail the Non-MAGI MC Screening Packet allowing 30 days for the client to return the forms or provide the necessary information. If the client does not provide any information after 30 days, the EW updates the change, discontinues MAGI MC with a timely 10-day MC discontinuance NOA, and approves APTC/CSR.


[Refer to “MAGI Medi-Cal Discontinuance Notice of Action,” page 13-13]

Example:MAGI MC is discontinued on 10/31/2016 for failure to return the MC 216 and income verification for the 10/2016 MC RD. The client returns the MC 216 and a paystub on 10/29/2016 before the MC discontinuance date (10/31/2016). The income is over MAGI MC limits and the client is eligible for APTC/CSR. First, the EW must rescind MAGI MC benefit effective 11/1/2016 and authorize the case. Second, the EW must determine If the client is potentially eligible for Non-MAGI MC and mail the Non-MAGI MC Screening Packet allowing 30 days for the client to return the forms or provide the necessary information. If the client does not provide any information after 30 days, then update the new income, run EBDC, authorize case to fail MAGI MC, send 10-day MC discontinuance NOA, and approve APTC/CSR in CalHEERS.

10.10.2 Rescissions After the End of Discontinuance Month

After the discontinuance month, clients must provide ALL MC RD information and/or verifications (within 90 days from the discontinuance date) to rescind discontinuance for failure to comply with the MC RD, the following steps must be followed:



Note:When applying this workaround do NOT update Data Collection with any new information.

Step Action

1. The client provides ALL required MC RD forms and/or information.

If the information is... Then....

More than 90 days after the discontinuance date,

• The MC Program cannot be rescinded.

• Advise the client to reapply for Medi-Cal.

[Refer to “The 90-day Cure Period,” page 10-52.]

Within 90 days after the discontinuance date,

Proceed to Step 2.

2. • Go to the Intake and Case Maintenance in the Select Function menu.

• Select the Periodic Reporting subsystem.

• Select Search for Periodic Reports.

• Click on the [Open] button.

• On the Search for Periodic Reports window:

NOTE: If there is no MC RD form then manually generate and print one. Refer to the “Manually logging in the MC RD,” page 10-23 process.

If the Received Status column for the MC RD form is...

Then Click on the [Report Details] button...

Not Received, • On the Maintain Periodic Report Details window, change the Status to Received.

• Save and close.

Received, Make sure that the Status is also Received on the Maintain Periodic Report Details window.



2. (cont)

.

Step Action



3. • Go to the Intake and Case Maintenance in the Select Function menu.

• Select the Authorization subsystem.

• Select Rescind.



• On the Rescind window:

• Select the Medi-Cal program record.

• Click on the Select check box.

• Select Erroneous Discontinuance from the dropdown menu of the Rescission Reason field.

• Click on the [Rescind] button.

• Save and close.

NOTE: Do not run EDBC.

Step Action



4. On the Collect Case Individual Detail window, make sure all Non-MAGI MC individuals who are to be rescinded have a Yes on the Evaluate for Non-MAGI [Y/N] field on the [Program Requested] tab.

5. On the Collect Case Special Indicators window, if there is an active Batch AU Exception-MC Special Indicator, then enter an Effective End Date.

6. • Go to RRR in the Select Function menu.

• Select the Redetermination subsystem.

• Select View RRR Detail Listing.


• On the View RRR Detail Listing window:

• The Medi-Cal RRR Status column is either Overdue, Discontinued or Received Not Processed.

• Select the Medi-Cal program record.

• Click on the [Start RRR Queue] button.

Step Action



7. On the Initiate Window Workflow window:

• Select the Redetermination radio button in the “Case Mode” action box.

• Select the check box for Medi-Cal in the Initiate Interview for column.

• Click the [Initiate Workflow] button.

• Update appropriate CalWIN windows with client’s information.

• Run EDBC.

8. • On the Capture Discrepancy Information window, re-evaluate the MC months that had previously failed by making sure the Evaluate Benefit Discrepancy field has a Yes.

• Click save and close.

Step Action



9. • Once EDBC is complete, review the Display Eligibility Summary window to make sure MC is passing for all applicable months.

• Click on the [Individual Details] button.

• Review the Display Individual Eligibility Summary window on the [Medi-Cal] tab.

• Click the [Health Care] button.

• On the Display Health Care Programs window make sure all eligible individuals have a Pass in the Eligibility Status column with the correct aid code.

10. • Click the [Initiate Wrap Up] button.

• Select all applicable windows and click the [Start Workflow] button.

• Once all selected windows have been reviewed for accuracy, then authorize the case.

Step Action



10a. • If the Rescission is taking place during the Y or Z-Period, the Capture Timely Notice Waiver Information window will appear.

• Select Yes for the Waiver Requested [Y/N] field.

• Select Printed and Unsigned for the Waiver Status field.

• Click save and close.

11. On the View RRR Detail Listing window, the MC RRR Month column should be a new 12-month period from the date of the original MC RD due month and show Pending in the RRR Status column.

Step Action



If clients partially return the MC RD forms and/or verifications after the discontinuance date but within the 90-Day Cure Period, their MC benefits will remain discontinued. EWs will send an MC 355 to request missing information. If the verification is received by the due date, EWs will restore the same level of benefits back to the date of discontinuance.

Example:MAGI MC is discontinued 8/31/2016 for failure to return the MC 216 and income verification for the 8/2016 MC RD. The client returns only the MC 216 on 11/5/2016 (90-Day Cure Period ends on 11/30/2016). The case is NOT rescinded and the EW sends an MC 355 to request the income verification. The client returns a paystub on 11/15/2016. Therefore, MAGI MC is restored effective 9/1/2016.

If clients return ALL the requested forms and/or verifications after the discontinuance date but within the 90-Day Cure Period, and the EW determines the client will not be eligible for MAGI MC with changes reported, then the EW will rescind to the same level of benefits before the discontinuance date and authorize the case. Then, the EW must determine If the client is potentially eligible for Non-MAGI MC and mail the Non-MAGI MC Screening Packet allowing 30 days for the client to return the forms or provide the necessary information. If the client does not provide any information after 30 days, the EW updates the change, discontinues MAGI MC with a timely 10-day MC discontinuance NOA, and approves APTC/CSR.


[Refer to “MAGI Medi-Cal Discontinuance Notice of Action,” page 13-13]

Example:MAGI MC is discontinued 8/31/2016 for failure to return the MC 216 and income verification for the 8/2016 MC RD. The MC 216 and paystub are received on 11/5/2016 (90-Day Cure Period ends on 11/30/2016). The income is over the MAGI MC limits. First, the EW rescinds MAGI MC benefit effective 9/1/2016, runs EBDC, and authorizes MAGI MC benefits. Then, the EW determines if the client is potentially eligible for Non-MAGI MC. If the client is potentially eligible for Non-MAGI MC, then the EW mails the Non-MAGI MC Screening Packet allowing 30 days for the client to return the forms or provide the necessary information. If the client does not provide any information after 30 days, the EW updates the income in CalWIN, discontinues MAGI MC with a timely 10-day MC discontinuance NOA, and approves APTC/CSR. If the client is not potentially eligible for Non-MAGI MC, then the EW does not



mail the Non-MAGI MC Screening Packet. The EW updates the income in CalWIN, discontinues MAGI MC with a timely 10-day MC discontinuance NOA, and approves APTC/CSR.

10.11 The 90-Day Cure Period

MC clients have up to 90 days from the discontinuance date for failure to complete an MC RD to provide appropriate information for the county to review eligibility for possible restoration of benefits back to the discontinuance date (no break in aid).

Note:A full MC application is not required to rescind the case. The client only needs to provide the information required for the MC RD.

A client who is discontinued must be notified in writing that he/she has a 90-Day Cure Period to provide any missing information.

If a client returns the MC RD packet or provides the requested information within the 90-Day Cure Period, the information must be treated as if it were received timely and entered into CalWIN to be evaluated for MC eligibility.

If the client does not return the MC RD packet or provide the requested information within the 90-Day Cure Period, then he/she must reapply for MC.

If the MC RD or all necessary information is returned within the 90-Day Cure Period and the client is found... Then...

Eligible for MAGI MC, • MC benefits must be restored back to the discontinuance date.

• A NOA mailed to the client informing them of restoration and no break in aid.


NOTE: The original application and renewal dates must be kept in the case once benefits are restored.

Ineligible for MAGI MC, • Xref. Ch. 19.4.1



10.12 CalWORKS Discontinuance for Failure to Complete the Annual RD

Individuals receiving CW benefits cannot be terminated from MC for failure to meet CW only requirements. When CW is being discontinued for failure to complete the CW RD, all family members must be determined for ongoing MC only benefits.

The CW discontinuance action on these cases will place the household members in aid code 38 pending a determination for MC only benefits.

Note:If the CW application was taken before 1/1/2014, then the case must be transitioned. EWs must contact the client to request tax filing household information (which can be provided over the phone).

Refer to the chart below for applicable procedures:

If... Then...

The parent(s) fail to keep their scheduled appointment for a CW face-to-face interview,

The family can continue to receive MC if the parent(s) cooperate with other requirements such as providing necessary information to complete the MC RD.

The CW case contains current information (within the last 90 days), such as a signed but incomplete SAWS 2 PLUS,

Continue to process the MC RD using the SAWS 2 PLUS.

NOTE: If the client did not complete the tax filing household information on the SAWS 2 PLUS, then contact the client to request the information (which can be provided over the phone).

Additional information is needed to determine MC eligibility,

Follow the ex parte process to complete the MC RD.

The CW case does NOT contain a current SAWS 2 PLUS (within the last 90 days),

Send the MC RD form(s) to the client with an MC 355 explaining that MC will also be terminated if the MC RD is not returned or the information is not provided within 30 days.



10.13 Deemed Eligibility for Infants

Infants receiving benefits under Deemed Eligibility (DE) or Continuous Eligibility will have their eligibility redetermined along with the other household members at the MC RD. If other family members are discontinued from MC due to reported changes or failure to complete the MC RD, the infant remains eligible until he/she turns one year old as long as DE requirements are met. The MC RD due date for the DE child is not until the month of the infant’s first birthday. A redetermination of eligibility for MC must be completed when the infant turns one year old.

The 90-Day Cure Period applies when a DE infant is discontinued for no response to the MC RD at the first birthday. If there is contact within 90 days of the infant’s discontinuance, only the RD information is needed to rescind the infant’s MC eligibility.

If the entire household was discontinued on or before the DE infant’s first birthday the 90-Day Cure Period rules apply to the household’s MC eligibility.

Note:The DE infant’s evaluation may not align with the household’s MC RD due date; as a result, there may be two different 90-Day Cure Periods.

If the infant is determined eligible for a zero SOC program at the annual MC RD, he/she would also be concurrently eligible under CEC until the household’s next RD.

In addition, if the RD shows a decrease in income and the infant has been in a SOC program, reduce the SOC or transfer the infant to a zero SOC program as applicable.

Example:The Periwinkle household has an MC RD due in 5/2016. The Periwinkles failed to respond and were discontinued from MC on 5/31/2016. However, Christoph Periwinkle remained active on MC because he is a DE infant who turns one year old on 10/12/2016. In this scenario: The 90-Day Cure Period for the household is from 6/2016 through 8/2016. Christoph’s 90-Day Cure Period is from 11/2016 through 1/2017.



The Periwinkle’s provide the RD information in 12/2016, requesting MC for the entire household. The EW rescinds MC eligibility for Christoph, but mails an SSApp for the rest of the household members because the MC RD information was received after the household’s 90-Day Cure Period. NOTE: The household members will receive eligibility as of the date they complete the intake application requirements. They are also eligible for retroactive MC, if requested.

10.14 Loss of Contact

When mail is returned as undeliverable, EWs must document in case comments, complete an ex parte review, mail an MC 355 (if applicable), and mail a discontinuance NOA if the MC 355 is undeliverable or not returned by the client.

Loss of contact, including mail returned as undeliverable, is not a basis for discontinuing benefits for the following programs:

• Former Foster Youth (FFY)

• Continuous Eligibility for Children (CEC)

• Supplemental Security Income/State Supplementary Payment (SSI/SSP)

• KinGAP

• Adoption Assistance

If a client provides updated address information and all other information that was requested within 90 days of the discontinuance date, EWs must immediately redetermine eligibility. If the client is found MC eligible, the discontinuance must be rescinded as if the information was submitted in a timely manner.

10.14.1 Ex Parte Review

An EW must complete an ex parte review before contacting the client when there is undeliverable mail. This includes the client’s case, electronic databases or verification services (i.e. MEDS), and CalWORKs (CW) and CalFresh (CF) cases of the client’s immediate family members which are open or were closed within the last 90 days.



If the EW locates a more recent address, the EW must update the Medi-Cal (MC) case with the new address, document in Search Case Comments, and attempt to send the previously undeliverable mail to the client at the new address.

Immediate Family Members

For purposes of obtaining a new address, DHCS defines “immediate family members” as any of the individuals who make up the MC household of the applicant/client for purposes of an MC eligibility determination. The address must be more recent than the address on the MC case if provided for an immediate family member. The most recent information available to the EW must indicate that the immediate family member lives with the applicant/client.

Confidentiality

Due to confidentially of client information, EWs must make sure that an address that is identified in a CW or CF case is more recent than the address on the client’s MC case. EWs must not use a forwarding address provided by the Post Office or hand written on the envelope unless the address has been confirmed by the client.

EWs must refer to Common-Place Update 14-24: “Safe at Home Confidential Post Office (P.O.) Box Process,” page -1 for instructions on the Safe at Home program, which helps victims or survivors of domestic violence or stalking to remain safe from an abusive situation.

10.14.2 MC 355

When an EW is unable to locate a more recent address through an ex parte review, the EW must send the MC 355 requesting only the current address and any other information that is necessary to redetermine eligibility and allowing 30 days for the client to respond. The MC 355 must be sent to the client’s last known address.

During the 30-day period after the MC 355 was sent, the EW must attempt to contact the client by telephone, in writing, or by other commonly available electronic means, to request the necessary information if the client has not responded to the request for additional information or has provided incomplete information.

Reminder:If there is a child-only CEC case, the EW must not send the child an MC 355 because of undeliverable mail. If the CEC child has other family members on his/her case that are not CEC eligible, then the EW should send the MC 355 to request the current address.



10.14.3 Notice of Action

If an MC 355 is returned as undeliverable, the EW must discontinue with a NOA that includes the 90-day cure period language. The discontinuance NOA must list the missing information that is needed to determine eligibility, including that the address is not current. The NOA is not required to be mailed at least 10 days before the date of discontinuance. The EW must also document actions in Search Case Comments in CalWIN.

If an MC 355 is not returned and the missing information is not provided within 30 days, the EW must discontinue with a timely 10-day NOA that lists the missing information that is needed to determine eligibility and includes 90-day cure period language. The EW must also document actions in Search Case Comments in CalWIN.

10.14.4 Case Documentation

Document the following information in Search Case Comments:

• Mail was returned as undeliverable,

• The date the mail was sent,

• The date it was returned as undeliverable,

• The form, letter, or notice mailed to the client that was returned, and

• What address was used.

Note:The mail that was returned as undeliverable, including both the envelope and its contents, must be sent to IDM.

10.15 Face-to-Face Interview

A face-to-face interview is NOT REQUIRED at an annual RD for any MC client. All MC RDs can be completed using the mail-in or phone-in process. However, MC clients may request a face-to-face interview with an EW and receive assistance in completing the forms. If the client requests a face-to-face interview DO NOT schedule the appointment in CalWIN, the appointment can be tracked in the EWs



Outlook calendar. If there is a suspicion of fraud, the EW may request a face-to-face appointment.

NOTE: If a case is discontinued for a no show face-to-face appointment, when fraud is not suspected, the case should be rescinded.

10.15.1 When a Face-to-Face is Required by the EW

When a face-to-face interview is required by the EW, the EW must:

Step Action

1 Thoroughly document the reason the EW is requiring the face-to-face interview in the Search Case Comments window in CalWIN.

2 Thoroughly review the case information to determine which verifications and/or forms will be required from the client to complete the redetermination.

3 Send the appointment notice and appropriate forms at least 10 working days in advance of the appointment to the client.

Reminder: The appointment should be scheduled early enough in the month so there will be enough time to reschedule before NCO, if necessary.

4 If the client fails to keep the appointment in the RD due month:

• Send a timely discontinuance notice.

• Reschedule the redetermination if contact from the client is made by the last working day of the RD month.

• If contacted within 90 days of discontinuance, rescind the discontinuance if all requirements are met.

• If contacted after 90 days of discontinuance, instruct the client to reapply for MC unless a reason for good cause is established.

Note:When a face-to-face interview is conducted, the EW must document the reason in the Search Case Comments window for program review and audit purposes.



10.16 Transitional Medi-Cal

TMC clients are NOT required to complete an MC RD while receiving TMC benefits until the end of the TMC period. Household members who are not on TMC are required to complete the MC RD when it is due. If non-TMC members fail to complete the MC RD process, they must be discontinued from MC. TMC eligible household members will remain on TMC for the entire TMC period providing all program requirements are met.

All Household Members are receiving TMC

When all household members are receiving TMC and the original MC RD is due before the TMC period expires, the MC RD is NOT due until the end of the TMC period. The MC RD for all household members must be completed in the last month of the TMC period to determine eligibility for other MC programs.

Household Members with Different TMC Expiration Dates

If the household has members receiving TMC with different expiration dates, the MC RD completed for the first household member at the end of his/her TMC period will establish the next RD for the entire household. At the end of the other household members’ TMC period, use existing case information to redetermine that individual’s MC eligibility.

Some Household Members are Receiving TMC

If some household members are receiving TMC and others are not when the RD is due for the household, the non-TMC members are required to complete the RD. Once the RD is completed, the RD date is established for the entire household. At the end of the TMC period for other household members, use existing case information to redetermine eligibility.



10.17 CalWIN RRR

10.17.1 CalWIN RRR Status Definitions

The following are definitions for the various CalWIN RRR Statuses:

Status Definition

Pending This is the default status for RRRs due in the future. When an RRR is Completed, CalWIN assigns a new RRR date and changes the status to Pending. If the status is Pending on the day before 10-day NCO in the month the RRR is due, batch EDBC/Authorization will discontinue the program for RRR non-compliance. The status will change to Overdue and the “W” NOA will be generated.

Initiated CalWIN changes the RRR status to Initiated when the RRR Packet/Appointment letter is generated. If the status is Initiated on the day before 10-day NCO in the month the RRR is due, batch EDBC/Authorization will discontinue the program for RRR non-compliance. The status will change to Overdue and the “W” NOA will be generated.

Started An EW has started the RRR interview/process.

Received Not Processed

CalWIN changes the RRR status to Received Not Processed on NCO when the MC RD form is scanned or manually logged in as Received in the RRR due month. The case will remain active.

Completed RRR has been Started and EDBC has been run and results have been Authorized.

NOTE: Completed status is never displayed in CalWIN. Once the RRR is completed, the status immediately changes to Pending for the next RRR.

Overdue MC is discontinued for RRR non-compliance. This happens automatically to RRRs in Pending or Initiated status on the day before 10-day NCO in the month the RRR is due.

Discontinued When MC is discontinued prior to the RRR due date, the RRR will also be set to Discontinued status.

10.17.2 Reprinting MC RD forms

CalWIN functionality includes the reprinting of previously printed MC RD forms. Replacement forms must be generated through the Maintain Periodic Report Details window. The form selected for reprinting will print out exactly as it did the first time it was printed, including all client specific information and barcode.



If the client requests a replacement RD packet, staff must re-print the forms that were originally auto-generated and must NOT manually generate new forms.

Note:DO NOT reprint these forms from the Print a Form/Other Correspondence Manually window; this will create a duplicate record on the Search for Periodic Reports window.

Step Action

1. Go to the Intake and Case Maintenance in the Select Function menu:

• Select Periodic Reporting subsystem.

• Select Search for Periodic Reports.


2. On the Search for Periodic Reports window:

• Enter Case #.

• Select the Status (i.e. Received, Not Received, Returned).

• Ensure the Month/Year From and Month/Year To dates are the dates the original MC RD form was printed.

• Click the [Search] button.

• Click on the MC RD form(s) in the “Search Results” action box.

• Click on the [Report Details] button.



10.17.3 Manually Printing the MC RD Forms in CalWIN

The MC RD forms with barcode functionality must be printed from the Print a Form/Other Correspondence Manually window. EWs must always check the Search for Periodic Reports window first to verify if the MC RD forms were generated. If the MC RD forms were already generated, then refer to “Reprinting MC RD forms,” page 10-90. If the forms were NOT generated, then follow the

3. On the Maintain Periodic Reports Details window, click on the [Reprint] button.

Step Action



instructions in the table below.

Step Action

1. Go to the Intake and Case Maintenance in the Select Function menu:

• Select Client Correspondence subsystem.

• Select Print a Form/ Other Correspondence manually.


2. On the Print a Form/Other Correspondence window:

• Select Forms from the Correspondence Type dropdown field.


• Select the appropriate Individual Name.

• Select Medi-Cal from the Program drop-down field.

• Select the appropriate Print Mode from dropdown field.

• Click on the [Find] button.



3. On the Select Correspondence window:

• Enter MC RD form (MC 0216, MC 604 IPS, MC 210 RV, or MC 262) in the Correspondence # field.


• Highlight the form in the “Search Results” action box.

• Click on the [Select] button.

Step Action



10.18 MC RD for Pre-ACA Clients

MC clients must have their annual MC RD completed via an ex parte review of available information to the greatest extent possible. The ex parte review means a review of current client data and information by the EW before asking the client for additional information/verification.

For Pre-ACA MC clients, the tax filing household information must be collected and entered into CalWIN before calling the BRE. EWs must complete all essential and very important fields in CalWIN. [Refer to “Essential and Very Important Fields,” page 19-11]

Clients are NOT required to return the paper MC RD packet. Clients can provide the information requested in the packet by mail, by fax, in person, or over the phone.

MC clients who are not required to file taxes because their income is below the tax filing threshold must still provide the additional information to determine current income and the MAGI MC household. [Refer to “Tax Filing Threshold,” page 2-11]

4. On the Print a Form/Other Correspondence manually window, click on the [Print] button.

Step Action



10.19 Aligning CF RC with the MC RD

The client may choose to align the CF RC date by shortening the CF due date to align with the MC RD date. The MC RD due date must never be shortened or extended. However, changes reported may allow the EW to reset the MC RD due date based on the CIC. [Refer to “Change in Circumstance,” page 10-47]

The sole purpose of giving the client the option of completing the MC RD as a CIC during the CF RC is to promote retention of MC benefits. MC must NOT be discontinued if the client fails to complete the CF RC. The CF RC and MC RD dates may become misaligned throughout the year because the client may have a CIC that affects the MC RD due date.
