Table of Contents · Medi-Cal Page -5 Update #15-34 Medi-Cal 3.2.25 Copayment.....3-10 3.2.26 Deductible .....3-10

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Table of Contents

1. Medi-Cal Hierarchy ...........................................................................................1-1

1.1 Mega Mandatory ............................................................................................1-4

1.2 Cash Grant Programs ....................................................................................1-5

1.3 MAGI MC........................................................................................................1-61.3.1 Children ...........................................................................................1-61.3.2 Parent/Caretaker relative ................................................................1-61.3.3 Pregnant woman/Infant Groups ......................................................1-61.3.4 Expanded MC (New Adult Group)...................................................1-71.3.5 MAGI Optional Targeted Low Income Child....................................1-71.3.6 MCAP Pregnant Women and Linked Infant and Child ....................1-71.3.7 CCHIP .............................................................................................1-7

1.4 Non-MAGI MC................................................................................................1-71.4.1 Non-MAGI MC Optional Categorical ...............................................1-71.4.2 Non-MAGI MC Medically Needy .....................................................1-8

Aged, Blind or Disabled .............................................................1-8Aid to Families with Dependent Children (AFDC) MN ...............1-8

1.4.3 Non-MAGI MC Medically Indigent (MI)............................................1-81.4.4 Long Term Care ..............................................................................1-81.4.5 BCCTP ............................................................................................1-9

1.5 Special Treatment Programs..........................................................................1-9

1.6 State/County Administered Programs ............................................................1-9

1.7 Consumer Protection Programs ...................................................................1-101.7.1 Transitional Medi-Cal ....................................................................1-10

1.8 Medi-Cal Benefits for Refugees ...................................................................1-10

1.9 TCVAP .........................................................................................................1-10

1.10 Minor Consent Services ...............................................................................1-11

2. Covered California Overview...........................................................................2-2

2.1 Affordable Care Act ........................................................................................2-22.1.1 ....................Patient Protection and Affordable Care Act Overview2-22.1.2 Health Care changes since 2014 ....................................................2-2

Increased Access to Health Insurance ......................................2-2Affordable Coverage and Financial Support ..............................2-2Guaranteed Availability of Coverage .........................................2-3Young Adult Coverage ...............................................................2-3

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Preventive Care .........................................................................2-3Essential Health Benefits ...........................................................2-3Health Benefit Standard .............................................................2-3No Lifetime or Annual Limits ......................................................2-3Consumer Assistance Program .................................................2-4Penalties for No Coverage .........................................................2-4Business Healthcare Requirements ...........................................2-4Rate Increase Rules ..................................................................2-4Small Business Premium Assistance .........................................2-4

2.1.3 Health Insurance Exchange ............................................................2-4

2.2 Minimum Coverage Provision ........................................................................2-52.2.1 Minimum Essential Coverage (MEC) ..............................................2-6

2.3 Health Insurance Fundamentals ....................................................................2-7

2.4 Types of Insurance.........................................................................................2-7Private Health Insurance ............................................................2-7Public Health Insurance .............................................................2-8

2.4.1 Managed Care.................................................................................2-82.4.2 Non-Managed Care.........................................................................2-82.4.3 Health Maintenance Organization ...................................................2-82.4.4 Preferred Provider Organization......................................................2-82.4.5 Exclusive Provider Organization .....................................................2-9

2.5 Insurance Options through Covered CA .......................................................2-92.5.1 Provider Network Directories...........................................................2-9

HMO, PPO, and EPO Networks ................................................2-9Customized Networks ..............................................................2-10CalHEERS Network Directory ..................................................2-10

2.6 Tax Filing Threshold.....................................................................................2-10

2.7 Acceptable Applications ...............................................................................2-11

2.8 Quick Sort Transfer ......................................................................................2-112.8.1 Call Process ..................................................................................2-112.8.2 Quick Sort Transfer Work Flow .....................................................2-12

Quick Sort Transfer Home County Scenario ............................2-13

2.9 Coverage Enrollment Period ........................................................................2-132.9.1 Open Enrollment ...........................................................................2-142.9.2 Special Enrollment ........................................................................2-142.9.3 APTC/CSR/QHP Renewal ............................................................2-15

2.10 Coverage Available ......................................................................................2-16

2.11 Metal Tiers....................................................................................................2-16Bronze Plan .............................................................................2-17Silver Plan ................................................................................2-17


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Gold Plan .................................................................................2-17Platinum Plan ...........................................................................2-17Catastrophic Coverage ............................................................2-17

2.12 APTC/CSR/QHP Eligibility ...........................................................................2-19

2.13 Tax Filing Household....................................................................................2-202.13.1 Single ............................................................................................2-202.13.2 Head of Household........................................................................2-21

Married Exception ....................................................................2-212.13.3 Married Filing Jointly .....................................................................2-222.13.4 Married Filing Separately ..............................................................2-222.13.5 Covered CA Tax Filing Household Examples ...............................2-22

2.14 Income..........................................................................................................2-242.14.1 American Indian/Alaskan Native Income.......................................2-26

2.15 Deductions ...................................................................................................2-26

2.16 Budgeting .....................................................................................................2-272.16.1 Qualified Health Plan (QHP) .........................................................2-272.16.2 Advanced Premium Tax Credit .....................................................2-272.16.3 Cost Sharing Reduction/Enhanced Silver Plan .............................2-28

2.17 APTC Budget in CalWIN ..............................................................................2-29

2.18 Employer Sponsored Coverage ...................................................................2-30

2.19 CalHEERS....................................................................................................2-30

2.20 Access to Health Coverage Work Flow........................................................2-31

2.21 Covered CA Notices of Action......................................................................2-322.21.1 CalNOD62A...................................................................................2-322.21.2 NOD01 ..........................................................................................2-322.21.3 NOD11 ..........................................................................................2-322.21.4 NOD12 ..........................................................................................2-322.21.5 NOD17 ..........................................................................................2-332.21.6 NOD60 ..........................................................................................2-33

2.22 Plan Selection ..............................................................................................2-342.22.1 Health Plan Basics ........................................................................2-342.22.2 Covered Services ..........................................................................2-342.22.3 Premiums ......................................................................................2-342.22.4 Out-of-Pocket Costs/Cost Sharing ................................................2-35

2.23 Comparing Plan Choices..............................................................................2-362.23.1 Premiums vs. Out-of-Pocket Costs ...............................................2-362.23.2 Plan Structure................................................................................2-372.23.3 Doctor Selection ............................................................................2-37


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HMO .........................................................................................2-37PPO, EPO, and other plans .....................................................2-37

2.24 Plan Enrollment ............................................................................................2-37Summary of Benefits ................................................................2-37ID Card .....................................................................................2-37Evidence of Coverage ..............................................................2-38Explanation of Benefits ............................................................2-38

2.25 Changes .......................................................................................................2-38

2.26 Disenrollment ...............................................................................................2-392.26.1 Voluntary Disenrollment ................................................................2-392.26.2 Involuntary Disenrollment..............................................................2-39

2.27 Tax Penalties................................................................................................2-402.27.1 Tax Penalty Formula ....................................................................2-41

2.28 Covered CA Appeals Process......................................................................2-43

3. Acronyms & Definitions ..................................................................................3-1

3.1 Acronyms .......................................................................................................3-1

3.2 Definitions.......................................................................................................3-53.2.1 Adequate Consideration..................................................................3-53.2.2 Adult ................................................................................................3-53.2.3 Adverse Action ................................................................................3-53.2.4 Aid Category....................................................................................3-63.2.5 Aid Code..........................................................................................3-63.2.6 Average Private Pay Rate ...............................................................3-63.2.7 Beginning Date of Aid......................................................................3-63.2.8 Benefits Identification Card .............................................................3-63.2.9 Board and Care ...............................................................................3-73.2.10 Burial Insurance ..............................................................................3-73.2.11 CalWORKs .....................................................................................3-73.2.12 Cash Grant ......................................................................................3-73.2.13 Cash-Linked Medi-Cal.....................................................................3-73.2.14 Share of Cost Certification—Effective Date ....................................3-83.2.15 Certification for Medi-Cal.................................................................3-83.2.16 Change in Circumstance .................................................................3-83.2.17 Child ................................................................................................3-83.2.18 Child Health and Disability Prevention Program (CHDP) ...............3-83.2.19 Coinsurance ....................................................................................3-83.2.20 Community Spouse .........................................................................3-93.2.21 Community Spouse Resource Allowance .......................................3-93.2.22 Competent/Competency .................................................................3-93.2.23 Continuous Period of Institutionalization .........................................3-93.2.24 Conversion of Property..................................................................3-10


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3.2.25 Copayment ....................................................................................3-103.2.26 Deductible .....................................................................................3-103.2.27 Derivative Relatives.......................................................................3-103.2.28 Determination Eligibility Response................................................3-103.2.29 Diligent Search ..............................................................................3-113.2.30 Eligibility Quality Control ...............................................................3-113.2.31 Eligibility Determination Request...................................................3-113.2.32 Encumbrance ................................................................................3-113.2.33 Family Member..............................................................................3-113.2.34 Heirloom........................................................................................3-123.2.35 Home.............................................................................................3-123.2.36 Horizontal Integration ....................................................................3-123.2.37 In-Home Supportive Services........................................................3-123.2.38 In-Kind Support and Maintenance.................................................3-123.2.39 Inmate ...........................................................................................3-123.2.40 Institution .......................................................................................3-123.2.41 Institution — Medical ....................................................................3-133.2.42 Institution — Mental Diseases.......................................................3-133.2.43 Institution — Non-medical .............................................................3-133.2.44 Institution — Private ......................................................................3-133.2.45 Institution — Public........................................................................3-133.2.46 Institution — Tuberculosis .............................................................3-133.2.47 Institutionalized Individual .............................................................3-133.2.48 Institutionalized Spouse ................................................................3-143.2.49 Life Insurance................................................................................3-143.2.50 Limited Service Status...................................................................3-143.2.51 Linked............................................................................................3-143.2.52 Long-Term Care Facility................................................................3-153.2.53 Long-Term Care Status.................................................................3-153.2.54 Marriage ........................................................................................3-153.2.55 Medi-Cal ........................................................................................3-153.2.56 Medi-Cal Family Budget Unit.........................................................3-153.2.57 Medi-Cal Only Eligibility.................................................................3-153.2.58 Medically Indigent Person or Family .............................................3-153.2.59 Medically Needy Person or Family................................................3-153.2.60 Medicare........................................................................................3-163.2.61 Medicare Savings Program...........................................................3-163.2.62 Minimum Basic Standard of Adequate Care .................................3-163.2.63 Minor Consent Services ................................................................3-163.2.64 Multiple Dwelling Unit ....................................................................3-163.2.65 Next Friend of the Alien.................................................................3-163.2.66 Nonrecurring Lump Sum Payment ................................................3-173.2.67 Nursing Facility..............................................................................3-173.2.68 Nursing Facility Level of Care .......................................................3-173.2.69 Obligate .........................................................................................3-173.2.70 Other Public Assistance (Other PA) Recipient ..............................3-173.2.71 Out-of-Pocket Limit........................................................................3-17


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3.2.72 Overpayment.................................................................................3-173.2.73 Parent............................................................................................3-173.2.74 Parents — Unmarried....................................................................3-183.2.75 Parent — Minor .............................................................................3-183.2.76 Patient ...........................................................................................3-183.2.77 Persons Living in the Home ..........................................................3-183.2.78 Premium........................................................................................3-193.2.79 Prepaid Health Plan ......................................................................3-193.2.80 Prepaid Health Plan — Comprehensive........................................3-193.2.81 Presumed Maximum Value ...........................................................3-193.2.82 Property — Community .................................................................3-193.2.83 Property — Personal ....................................................................3-203.2.84 Property — Real............................................................................3-203.2.85 Property — Separate.....................................................................3-203.2.86 Property — Share of Community ..................................................3-203.2.87 Provider .........................................................................................3-203.2.88 Public Assistance Recipient ..........................................................3-203.2.89 Public Funds..................................................................................3-203.2.90 Publicly Operated Community Residence.....................................3-213.2.91 Reapplication.................................................................................3-213.2.92 Redetermination ............................................................................3-213.2.93 Relative .........................................................................................3-213.2.94 Caretaker Relative.........................................................................3-213.2.95 Repayment ....................................................................................3-223.2.96 Rescind/Rescission .......................................................................3-223.2.97 Residence .....................................................................................3-223.2.98 Responsible Relative.....................................................................3-223.2.99 Severe form of trafficking in persons.............................................3-223.2.100 Share-of-Cost ................................................................................3-233.2.101 Share of Encumbrances................................................................3-233.2.102 Skilled Nursing Care/Facility .........................................................3-233.2.103 Soft Pause....................................................................................3-233.2.104 Spousal/Parental Deeming............................................................3-233.2.105 State Data Exchange ....................................................................3-233.2.106 Stepparent.....................................................................................3-233.2.107 Substantial Gainful Activity............................................................3-233.2.108 Supplemental Security Income/State Supplemental Program ......3-243.2.109 Tax Filing Household.....................................................................3-243.2.110 Tax Filer ........................................................................................3-243.2.111 Dependent.....................................................................................3-24

Tax Dependent .......................................................................3-24Coverage Dependent ...............................................................3-24

3.2.112 Therapeutic Wages ......................................................................3-243.2.113 Third Party Liability.......................................................................3-253.2.114 Title II Disregard Person...............................................................3-253.2.115 Title II (Social Security Act) ..........................................................3-253.2.116 Title XVI (Social Security Act) ......................................................3-25


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3.2.117 Title XVIII (Social Security Act) ....................................................3-253.2.118 Title XIX (Social Security Act) ......................................................3-253.2.119 Transfer of Property .....................................................................3-253.2.120 Unconditionally Available Income..................................................3-263.2.121 U.S. Citizenship and Immigration Services ...................................3-263.2.122 Value of the One-Third Reduction.................................................3-263.2.123 Verification....................................................................................3-263.2.124 Definitions......................................................................................3-263.2.125 Actual Value (AV) ..........................................................................3-263.2.126 Couple ...........................................................................................3-263.2.127 Current Market Value (CMV) or Current Market Rental

Value (CMRV) ..............................................................................3-263.2.128 Dependent Relative ......................................................................3-273.2.129 Discounted Amount .......................................................................3-273.2.130 Equity Value (EV) .........................................................................3-273.2.131 Excludable Equity Value................................................................3-273.2.132 Home ............................................................................................3-273.2.133 Household Expenses ...................................................................3-273.2.134 Immediate Family .........................................................................3-283.2.135 Independent Living Arrangement ..................................................3-283.2.136 Ineligible Spouse ...........................................................................3-283.2.137 In-Kind Support and Maintenance (ISM) ......................................3-293.2.138 Institutionalization .........................................................................3-293.2.139 Items of Unusual Value .................................................................3-293.2.140 Life Estate and Remainder Interest ..............................................3-293.2.141 Liquid Resources ..........................................................................3-303.2.142 Nonliquid Resources .....................................................................3-303.2.143 Non-Medical Out of Home Care (NMOHC) ...................................3-303.2.144 Parent ...........................................................................................3-303.2.145 Presumed Maximum Value (PMV) ...............................................3-303.2.146 Principal Place of Residence.........................................................3-303.2.147 Property (Real or Personal), Essential to Self-Support .................3-313.2.148 Rebutting the PMV ........................................................................3-323.2.149 Recreational Vehicle (RV) .............................................................3-323.2.150 Rent-Free Shelter .........................................................................3-323.2.151 Resources ....................................................................................3-323.2.152 Sharing .........................................................................................3-333.2.153 Successful Rebuttal.......................................................................3-333.2.154 Value of the One-Third Reduction (VTR) .....................................3-33

4. Inquiries and Resources ..................................................................................4-2

4.1 General Public Inquiries for Clients ................................................................4-24.1.1 Ability to Pay Program Determination (APD)...................................4-24.1.2 Medi-Cal Access Program (MCAP).................................................4-24.1.3 “Acquired Immune Deficiency Syndrome" (AIDS) Hotline...............4-34.1.4 Breast & Cervical Cancer Treatment Program (BCCTP) ................4-3


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4.1.5 Buy-In Problems for Medicare Parts A & B and Technical Problems for Medicare Part D4-4

4.1.6 Child Health & Disability Prevention Program (CHDP) ...................4-44.1.7 Children's Health Initiative (CHI) .....................................................4-44.1.8 COBRA............................................................................................4-44.1.9 Complaints Against Health Care Providers .....................................4-44.1.10 Consumer Information Center .........................................................4-54.1.11 Dental Services ...............................................................................4-54.1.12 Dental Treatment Options ...............................................................4-64.1.13 Doctor Services ...............................................................................4-64.1.14 Electronic Data Systems (EDS) Help Desk.....................................4-74.1.15 Every Woman Counts (EWC) Program...........................................4-74.1.16 Family Planning, Access, Care and Treatment Program ................4-74.1.17 Health Access Program Card (HAP) ...............................................4-84.1.18 Health Care Options (HCO) ............................................................4-84.1.19 Health Insurance Billing and Coding ...............................................4-84.1.20 Health Insurance Premium Payment (HIPP) Program....................4-94.1.21 Healthy Kids ....................................................................................4-9

Coverage ...................................................................................4-94.1.22 Ombudsman....................................................................................4-9

Cal MediConnect Ombudsman ..................................................4-9LTC Ombudsman Program ......................................................4-10Managed Care Ombudsman ....................................................4-10Santa Clara County Social Services Agency Ombudsman .....4-11

4.1.23 Medical Board of California Central Complaint Unit ......................4-114.1.24 MC Cards with Utilization Restrictions ..........................................4-114.1.25 MC Fraud and Patient Abuse ........................................................4-114.1.26 MC General Information for All Aid Programs ...............................4-124.1.27 MC Managed Care Plans ..............................................................4-124.1.28 Medicare........................................................................................4-134.1.29 Medicare Part D ............................................................................4-134.1.30 Probate/Estate Recovery ..............................................................4-144.1.31 Railroad Retirement Information ...................................................4-144.1.32 Safely Surrendered Baby Hotline ..................................................4-144.1.33 San Andreas Regional Center.......................................................4-154.1.34 Santa Clara County Mental Health Plan (MHP) ............................4-154.1.35 Senior Outreach ............................................................................4-154.1.36 State Hearings and Appeals..........................................................4-154.1.37 Disability Determination Service Division (DDSD) ........................4-164.1.38 Supplemental Security Income (SSI) and Social Security Administration (SSA)4-164.1.39 Third-Party Liability........................................................................4-174.1.40 Medi-Cal Vision Benefits ...............................................................4-184.1.41 Valley Kids.....................................................................................4-19

Provider ....................................................................................4-19Coverage .................................................................................4-19

4.1.42 Voluntary Repayment of Benefits by Clients .................................4-20


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4.2 Provider Inquiries .........................................................................................4-204.2.1 Automated Eligibility Verification System (AEVS) .........................4-204.2.2 Dental Contract Questions ............................................................4-214.2.3 Drug Benefits.................................................................................4-214.2.4 Electronic Data Systems (EDS) ....................................................4-214.2.5 General Information.......................................................................4-214.2.6 Health Access Programs (HAP) Hotline........................................4-224.2.7 Non-Emergency Medical Transportation.......................................4-224.2.8 Out-of-State Authorization for Treatment ......................................4-224.2.9 Out-of-State Provider Billing..........................................................4-224.2.10 Provider Enrollment.......................................................................4-224.2.11 Treatment Authorization Requests................................................4-234.2.12 Contract Hospitals .........................................................................4-23

5. Applications ......................................................................................................5-1

5.1 HIPAA/PII .......................................................................................................5-1

5.2 Mandatory Reporting......................................................................................5-15.2.1 Reporting Child Abuse ....................................................................5-15.2.2 Reporting Numbers .........................................................................5-25.2.3 Reporting Adult Abuse ....................................................................5-2

5.3 Application......................................................................................................5-35.3.1 Medi-Cal Application .......................................................................5-3

Medi-Cal Intake Informational Packet ........................................5-4Medi-Cal Intake Packet ..............................................................5-5Minor Consent ............................................................................5-5Applications from the Single Point of Entry ................................5-6CalWORKs .................................................................................5-6CalFresh ....................................................................................5-6

5.3.2 Paper Applications ..........................................................................5-65.3.3 Additional Information/Verifications Needed ...................................5-65.3.4 Outdated but Acceptable Forms......................................................5-65.3.5 Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP (SAWS 2 PLUS)

5-7

5.4 Who Can Complete a Medi-Cal Application ...................................................5-75.4.1 Applications from Non-Custodial Parents........................................5-85.4.2 Family Members..............................................................................5-9

5.5 Persons Who May Represent a Client ...........................................................5-95.5.1 Authorized Representatives ............................................................5-9

Who can be Appointed ...............................................................5-9Client Responsibilities ..............................................................5-10Authorized Representative's Role ............................................5-11Authorized Representative Limitations ....................................5-11

5.5.2 Representative Payees .................................................................5-12


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5.5.3 Durable Powers of Attorney ..........................................................5-12Definition ..................................................................................5-12Types of Durable Powers of Attorney ......................................5-12State Policy ..............................................................................5-13Expiration of Authority ..............................................................5-14

5.5.4 Public Guardian.............................................................................5-145.5.5 MC 306 and Other Written Authorization ......................................5-14

Written Authorization ................................................................5-14Signature and Date ..................................................................5-15Notices of Action ......................................................................5-17Multiple Authorized Representatives .......................................5-17Expiration of Authority ..............................................................5-17

5.5.6 Authorized Representation Documentation...................................5-175.5.7 Mental Health Sub Payee Cases ..................................................5-18

5.6 How to File an Application............................................................................5-185.6.1 My Benefits CalWIN (Online) ........................................................5-195.6.2 Mail-In and Phone-In Medi-Cal Application Procedures................5-195.6.3 In-Person/Walk-In Medi-Cal Application Procedures ....................5-215.6.4 Forms Not Returned......................................................................5-24

5.7 Face-to-Face Interview.................................................................................5-245.7.1 When a Face-to-Face Interview is Required .................................5-24

Failure to Keep an Appointment ..............................................5-25

5.8 Single Point of Entry Applications ................................................................5-255.8.1 One-e-App.....................................................................................5-26

Application Process .................................................................5-26SPE Actions .............................................................................5-26Application Date .......................................................................5-26Clerical Role .............................................................................5-27

5.8.2 Application Tracking System.........................................................5-275.8.3 SPE Screening Process ................................................................5-275.8.4 CIN Assignment ............................................................................5-285.8.5 Accelerated Enrollment Process ...................................................5-285.8.6 SPE Transmittal Forms .................................................................5-295.8.7 Processing SPE Applications ........................................................5-29

Missing Information ..................................................................5-29Required Forms .......................................................................5-30Additional Forms: .....................................................................5-30Adding Adults ...........................................................................5-31SPE File Clearance Procedures ..............................................5-32

5.9 Applications from Medi-Cal Benefits Assistance ..........................................5-32

5.10 Homeless Applicants....................................................................................5-33

5.11 .............................................................................. Informing Requirements5-34


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5.12 Date of Application .......................................................................................5-35

5.13 Verifications..................................................................................................5-36Non-MAGI MC Verification .......................................................5-36MAGI MC Verification ..............................................................5-36

5.13.1 Identity Proofing and Identity Verification ......................................5-37Identity Proofing .......................................................................5-38Identity Verification ...................................................................5-38

5.13.2 Self-Attestation for Plan to File Taxes ...........................................5-41

5.14 Timeframes for Processing Applications ......................................................5-425.14.1 Application Processing ..................................................................5-425.14.2 Immediate Need Criteria ...............................................................5-425.14.3 Beginning Date of Eligibility...........................................................5-42

Medi-Cal Only ..........................................................................5-42Cash-linked Medi-Cal ...............................................................5-43CalWORKs Denials ..................................................................5-43SSI/SSP Denials ......................................................................5-43

5.15 Courtesy Applications...................................................................................5-44Courtesy Application ................................................................5-44

5.15.1 Courtesy Applications....................................................................5-455.15.2 Person Maintains a Home.............................................................5-455.15.3 Homeless Persons ........................................................................5-465.15.4 Person with a Guardian.................................................................5-475.15.5 Persons Under 21 Years of Age Not living at Home .....................5-475.15.6 Deceased Individual ......................................................................5-495.15.7 Out of Home Placement ................................................................5-495.15.8 Pending SP-DDSD Disability Determination .................................5-505.15.9 Withdrawals/Requests for Discontinuance....................................5-50

5.16 Intake Documents to IDM.............................................................................5-515.16.1 System Screenshots to Print .........................................................5-515.16.2 CalWIN Screenshot to Print ..........................................................5-515.16.3 MEDS Screenshot to Print ............................................................5-525.16.4 CalHEERS Screenshots to Print ...................................................5-53

Program Eligibility by Person ...................................................5-53Manual Verifications .................................................................5-55

5.16.5 Printing External Referral Data Report..........................................5-56

5.17 Retroactive Medi-Cal ....................................................................................5-575.17.1 Retroactive Medi-Cal Request Time Limit.....................................5-585.17.2 Eligibility Conditions ......................................................................5-585.17.3 Retroactive Medi-Cal Applications ................................................5-595.17.4 Retroactive Medi-Cal for Mail-In Applications ...............................5-595.17.5 Retroactive Medi-Cal Based on Disability .....................................5-59

5.18 Supplemental Forms ....................................................................................5-605.18.1 Other Required Forms/Intake Packets ..........................................5-60


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5.19 CalFresh Application for Medi-Cal................................................................5-625.19.1 Overview .......................................................................................5-625.19.2 “Good News for California Families!” Requirements .....................5-625.19.3 Application Process.......................................................................5-63

Initial Intake Applications .........................................................5-63Continuing (Recertification) ......................................................5-63

5.19.4 Processing the SCD 90 .................................................................5-635.19.5 CalFresh Forms used for Medi-Cal ...............................................5-645.19.6 Misaligned Redetermination Dates ...............................................5-645.19.7 Medi-Cal Eligibility Determination..................................................5-65

Citizenship/Immigration Status ................................................5-65Property for Non-MAGI Medi-Cal .............................................5-65Tax Filing Information ..............................................................5-65

5.19.8 Informing Notices and Other Required Forms...............................5-655.19.9 CalFresh Ineligibility/Discontinuance.............................................5-665.19.10 Required Documentation...............................................................5-66

5.20 Express Lane Enrollment Program ..............................................................5-665.20.1 Aid Codes......................................................................................5-675.20.2 DHCS Process ..............................................................................5-675.20.3 County Process .............................................................................5-685.20.4 CalFresh Discontinuance ..............................................................5-695.20.5 CalFresh Forms.............................................................................5-70

CF 285 .....................................................................................5-70SAWS 2 PLUS .........................................................................5-70

5.20.6 Pending Applications.....................................................................5-705.20.7 Retroactive Coverage....................................................................5-715.20.8 Redeterminations ..........................................................................5-715.20.9 Undocumented Individuals ............................................................5-715.20.10 Inter County Transfers...................................................................5-715.20.11 Notices of Action ...........................................................................5-725.20.12 Frequently Asked Questions .........................................................5-72

5.21 Medi-Cal Access Program............................................................................5-735.21.1 Processing MCAP Applications.....................................................5-73

5.22 Additional Children's Programs ....................................................................5-74Healthy Kids .............................................................................5-74Valley Kids ...............................................................................5-74County Children’s Health Initiative Program ............................5-74

5.23 Children's Health Initiative ............................................................................5-755.23.1 CHI Objectives ..............................................................................5-75

Fast-Track Enrollment of Kids ..................................................5-75Single-Point-of-Service ............................................................5-75

5.23.2 Role of the Intake EW ...................................................................5-765.23.3 Application Forms and Verifications ..............................................5-76

CHI Release of Information Form ............................................5-76


Medi-CalMedi-Cal

Other Forms and Verifications .................................................5-765.23.4 Adding Other Family Members......................................................5-775.23.5 Healthy Kids ..................................................................................5-77

Eligibility Criteria ......................................................................5-77Benefits ....................................................................................5-78EW Requirements ....................................................................5-78

5.23.6 Healthy Kids Process ....................................................................5-79

5.24 Express Enrollment for Children in the National School Lunch Program .....5-795.24.1 Overview .......................................................................................5-795.24.2 Express Enrollment Definition .......................................................5-805.24.3 NSLP Application Process ............................................................5-805.24.4 Modified NSLP Application Form ..................................................5-805.24.5 ..................................Income Verification for Express Enrollment5-815.24.6 Express Enrollment Process .........................................................5-81

Activation on MEDS .................................................................5-81Date of Application/Enrollment .................................................5-82Ineligible Children ....................................................................5-82Required Supplemental Forms/Notices ...................................5-82Information NOT Required .......................................................5-83Fair Hearing Rights ..................................................................5-83

5.24.7 Medi-Cal Eligibility Determination..................................................5-83Other Family Members Requesting Medi-Cal ..........................5-84Request for Retroactive Benefits .............................................5-84Required Actions ......................................................................5-84

5.25 Public Guardian Cases.................................................................................5-855.25.1 General Information.......................................................................5-855.25.2 EW Procedures .............................................................................5-855.25.3 Referrals to Public Guardian .........................................................5-865.25.4 Guardian and Conservator Fees ...................................................5-86

5.26 Presumptive SSI and Extended Medi-Cal ....................................................5-875.26.1 Identification of Presumptive SSI Individuals ................................5-875.26.2 Referrals to the DHCS...................................................................5-875.26.3 DHCS Responsibility .....................................................................5-89

5.27 Foster Care Program, Former Foster Youth and Adoption Assistance Program5-89

5.28 Medically Indigent Adult in Long Term Care ................................................5-895.28.1 MIA LTC - Intake ...........................................................................5-895.28.2 MIA LTC - Continuing....................................................................5-90

5.29 San Andreas Regional Center......................................................................5-915.29.1 SARC Special Treatment ..............................................................5-915.29.2 SARC Aid Codes...........................................................................5-925.29.3 Medi-Cal Benefits Assistance Application Process .......................5-92

5.30 Tuberculosis Clinic Applications...................................................................5-93


page -14Medi-Cal

5.31 Therapeutic Abortions ..................................................................................5-94

5.32 .........................................................Partners in AIDS Care and Education5-95

5.33 ..............................................................................................Renal Dialysis5-95

5.34 Organ Transplant Anti-Rejection Medication Program.................................5-955.34.1 Eligibility Requirements .................................................................5-96

Identifying Eligible Beneficiaries ..............................................5-96Eligibility Determination ............................................................5-97

5.34.2 Notices of Action ...........................................................................5-975.34.3 MEDS Transactions ......................................................................5-97

MEDS Alerts ............................................................................5-98

6. Citizenship/Immigration Status .......................................................................6-1

6.0.1 Scope of Coverage..........................................................................6-1Full-scope MC Benefits ..............................................................6-1Restricted-scope MC Benefits ...................................................6-1

6.1 Status/Medi-Cal Entitlement Chart .................................................................6-2

6.2 U.S. Citizens...................................................................................................6-4No Documentation .....................................................................6-5Citizenship Verification for Aged Persons ..................................6-5

6.3 Verification Requirements for U.S. Citizens ...................................................6-66.3.1 Verification of U.S. Citizenship and Identity ....................................6-6

Proof Already Provided ..............................................................6-66.3.2 Electronic Verification......................................................................6-6

Verified by Federal Hub .............................................................6-7Not Verified by Federal Hub .......................................................6-7

6.3.3 Electronic Birth Record Match.........................................................6-76.3.4 Social Security Number Data Match ...............................................6-86.3.5 Frequency of Verification.................................................................6-86.3.6 Acceptable Citizenship/Identity Documents ....................................6-86.3.7 Original Documents.......................................................................6-11

Use of Affidavits for Citizenship ...............................................6-11Use of Affidavits for Identity .....................................................6-12

6.3.8 Original Document Certification Forms .........................................6-12Document Certification by CAAs ..............................................6-13

6.3.9 Reasonable Opportunity Period ....................................................6-136.3.10 Clients with Mismatching SSN Results .........................................6-14

Resolving Mismatches .............................................................6-146.3.11 Documents Received After Restricted-scope Benefits are Granted6-156.3.12 Adding a Person to an Existing Case............................................6-156.3.13 Good Faith Effort ...........................................................................6-156.3.14 Providing Client Assistance...........................................................6-16

Requesting Birth Certificates ...................................................6-16


Medi-CalMedi-Cal

Requesting Identity Documents ...............................................6-166.3.15 Exempt Individuals ........................................................................6-18

Presumptive Eligibility (PE) Programs .....................................6-196.3.16 Citizenship Verification Process ....................................................6-206.3.17 Single Point of Entry Applications .................................................6-216.3.18 CalWORKs Cases.........................................................................6-226.3.19 Medi-Cal Performance Standards .................................................6-226.3.20 Processing Intake Applications .....................................................6-22

Face-to-face Interview .............................................................6-23Mail-In Applications ..................................................................6-24

6.3.21 Processing Annual Redeterminations ...........................................6-26Face-to-Face Annual RD; CalWORKs/CalFresh/MC ...............6-26Mail in Redeterminations - Non-BSC .......................................6-27Mail In Originals .......................................................................6-27Adding a Person ......................................................................6-28Client at Outstation Office ........................................................6-29Documents Received by Mail ..................................................6-30

6.3.22 Follow Up Process for Pending Verifications ................................6-31

6.4 Non-citizens Eligible for Full-Scope MC Benefits .........................................6-316.4.1 Persons Eligible ............................................................................6-316.4.2 Canadian Born American Indians..................................................6-32

6.5 Inconsistent Birthdates & SAVE Process .....................................................6-326.5.1 Primary SAVE ...............................................................................6-326.5.2 Secondary SAVE...........................................................................6-326.5.3 Acceptable Documentation ...........................................................6-33

I-551 Alien Registration Receipt Card ......................................6-33I-151 Alien Receipt Card ..........................................................6-33AR-3/AR-3a Resident Cards ....................................................6-33I-137 Re-Entry Permit ..............................................................6-33I-94-Arrival/Departure Record ..................................................6-34Foreign Passport Stamped ......................................................6-34I-181 B .....................................................................................6-34G-711 Individual Fee Receipt ..................................................6-35Canadian Indian Affairs Letter .................................................6-35Registry Alien Status ................................................................6-35

6.5.4 Reasonable Opportunity Period ....................................................6-35ROP Process ...........................................................................6-35

6.6 MC13............................................................................................................6-36Automatic MC 13 Generation ...................................................6-37Immigration Questions .............................................................6-37

6.7 PRUCOL ......................................................................................................6-38Benefit Level for PRUCOL Clients ...........................................6-39PRUCOL Definition ..................................................................6-39

6.7.1 Categories of PRUCOL.................................................................6-39


page -16Medi-Cal

Category 1-15 ..........................................................................6-40Category 16 .............................................................................6-41Examples of PRUCOL individuals ...........................................6-41

6.7.2 Change in PRUCOL Status...........................................................6-426.7.3 USCIS Responses on the G 845...................................................6-43

PRUCOL Approved ..................................................................6-43PRUCOL Denied Aid Code ......................................................6-44

6.7.4 PRUCOL CalWIN Entries..............................................................6-44

6.8 Expiration of Documents ..............................................................................6-45

6.9 DACA ...........................................................................................................6-45

6.10 SB75.............................................................................................................6-466.10.1 SB75 Age Policy............................................................................6-47

19 Year Old Household Income ...............................................6-4719 Year Old NOA .....................................................................6-47

6.10.2 Income changes (Under 19 Years Old).........................................6-486.10.3 Managed Care/Fee-For-Service....................................................6-48

6.11 Restricted-scope Benefits ............................................................................6-486.11.1 Eligibility ........................................................................................6-496.11.2 SSN Requirement .........................................................................6-496.11.3 Emergency Care ...........................................................................6-496.11.4 Pregnancy Services ......................................................................6-506.11.5 Undocumented Non-citizens and Visas ........................................6-506.11.6 Undeclared Status.........................................................................6-50

6.12 Questions and Answers ...............................................................................6-51Automated Birth Record Matches ............................................6-51Exempt Persons .......................................................................6-51Presumptive Eligibility: Accelerated Enrollment .......................6-53Acceptable Documents ............................................................6-53Reasonable Opportunity Period (ROP) ....................................6-55Use of Affidavits .......................................................................6-55CalWORKs Cases ...................................................................6-55

6.13 Citizen/Alien Indicator...................................................................................6-56

7. Residency..........................................................................................................7-1

7.1 Overview ........................................................................................................7-17.1.1 General [50320, 50320.1]................................................................7-17.1.2 Additional Ways to Establish Residence [50325,50327, 50329] .....7-17.1.3 Who Must Provide Verification? ......................................................7-37.1.4 Exception to Providing Proof of Residency .....................................7-37.1.5 When Required ...............................................................................7-37.1.6 CalWORKs to Medi-Cal Only ..........................................................7-37.1.7 Ineligibility........................................................................................7-4


Medi-CalMedi-Cal

7.2 Establishing California Residency Requirements...........................................7-4

7.3 Verification of Residency................................................................................7-57.3.1 “Specified Documents” ....................................................................7-57.3.2 Other Evidence of Residency..........................................................7-67.3.3 Rent Receipt From a Relative .........................................................7-87.3.4 Free Housing...................................................................................7-87.3.5 Unmarried Parents ..........................................................................7-87.3.6 Migrant Workers ..............................................................................7-97.3.7 Homeless Persons ........................................................................7-107.3.8 Foreign Students and Others With Non-Immigrant Visas .............7-107.3.9 Holders of Border Crossing Cards and Temporary Visas .............7-117.3.10 Entry to Seek Medical Care...........................................................7-127.3.11 Case Documentation.....................................................................7-127.3.12 Unacceptable Evidence.................................................................7-13

7.4 Principal Residence......................................................................................7-13

7.5 Public Assistance/Government Benefits ......................................................7-14

7.6 Discrepancies/Evidence to the Contrary ......................................................7-15

7.7 Temporary Absence .....................................................................................7-167.7.1 Definition [50321] ..........................................................................7-167.7.2 Temporary Absence, More Than 60 Days [50323] .......................7-177.7.3 EW Actions....................................................................................7-17

7.8 Out-of-State Students...................................................................................7-177.8.1 Individuals Who Come to California to Attend School...................7-187.8.2 California Residents Attending School in Another State ...............7-197.8.3 Parents of Out-of-State Students ..................................................7-197.8.4 CalWIN Entries for Out-Of-State Students ....................................7-20

Collect Individual Residency Detail Window ............................7-20Collect Case Individual Detail Window ....................................7-20Collect Individual Address Detail Window ................................7-21

7.9 Out-of-County Students................................................................................7-227.9.1 CalWIN Entries for Out-of-County Students..................................7-22

Collect Case Individual Detail Window: ...................................7-22Collect Case Individual Residency Detail Window ...................7-23Collect Individual Address Detail Window ................................7-23

8. Transitions (MAGI/Non-MAGI/APTC) ..............................................................8-2

8.1 Transitioning from Pre-ACA MC to ACA MC..................................................8-28.1.1 Pre-Transition Review.....................................................................8-38.1.2 Identifying If the Case Needs to be Merged ....................................8-38.1.3 Identifying If the Case Needs to be Linked......................................8-58.1.4 Transitioning....................................................................................8-8


page -18Medi-Cal

8.2 Essential and Very Important Fields.............................................................8-11

8.3 Consumer Protection Programs ...................................................................8-25

8.4 Transitioning from MAGI MC to Non-MAGI MC or APTC.............................8-258.4.1 MAGI MC Ineligibility .....................................................................8-26

Non-MAGI MC Screening Packet ............................................8-28Mixed MC Cases (MAGI MC/Non-MAGI MC) ..........................8-29Children turning 19 years old ...................................................8-29Individuals turning 65 years old ...............................................8-29Medicare ..................................................................................8-32

8.4.2 MAGI MC to APTC........................................................................8-32

8.5 Soft Pause....................................................................................................8-328.5.1 Soft Pause Functionality................................................................8-338.5.2 Soft Pause CalWIN Display Reasons ...........................................8-36

Soft Pause Display Reason .....................................................8-36Soft Pause Lift Display Reason ...............................................8-36

8.5.3 Soft Pause Lifting Process ............................................................8-37

8.6 Transitioning from Medi-Cal to Covered CA during Special Enrollment Periods8-398.6.1 Qualifying Life Events....................................................................8-39

Lose of Minimum Essential Coverage .....................................8-40Marriage or Entry into Domestic Partnership ...........................8-40Birth or Adoption or Foster Care ..............................................8-40

8.6.2 Avoiding a Gap in Coverage .........................................................8-408.6.3 Loss of Medically Needy Share of Cost Coverage........................8-41

8.7 Transitioning from Covered CA to Medi-Cal.................................................8-42

8.8 Carry Forward (APTC/QHP to MAGI) ..........................................................8-428.8.1 Covered CA to Medi-Cal Referral Process....................................8-43

Notification ...............................................................................8-44Premium Reimbursement ........................................................8-44Dual Coverage .........................................................................8-44

8.8.2 District Office Process ...................................................................8-44EW Instructions ........................................................................8-45

8.8.3 Potential Medi-Cal Eligibility ..........................................................8-46Eligible .....................................................................................8-47Conditionally Eligible ................................................................8-47Pending Eligible .......................................................................8-48Missing Information Provided ...................................................8-48Not Enough Information ...........................................................8-49

8.9 Transitioning from CalWORKs to Medi-Cal ..................................................8-49

8.10 Ex Parte Process..........................................................................................8-498.10.1 No Ex Parte Process Required .....................................................8-50


Medi-CalMedi-Cal

8.11 Eligibility Determination Procedures.............................................................8-51

8.12 CalWORKs Denials ......................................................................................8-51

9. Budgeting ..........................................................................................................9-1

9.1 Accessing MAGI MC Budget..........................................................................9-19.1.1 Accessing MAGI MC Budget in CalWIN..........................................9-19.1.2 Accessing MAGI Budget Worksheet in CalHEERS.........................9-39.1.3 MAGI Budget Worksheet.................................................................9-5

9.2 Treatment of Income for MAGI and Non-MAGI..............................................9-89.2.1 Actual Income..................................................................................9-89.2.2 Treatment of Apportioned Income...................................................9-8

Income Received other than Monthly or Semi-Monthly .............9-9Self-Employment Income ...........................................................9-9Loans .......................................................................................9-10Interest Income ........................................................................9-10

9.2.3 Apportionment of Income Exemptions and Deductions ................9-109.2.4 Fluctuating Income........................................................................9-119.2.5 CalWIN..........................................................................................9-129.2.6 Ending Income ..............................................................................9-13

Collect Income Received Detail ...............................................9-13Collect Earned Income Detail ..................................................9-13Collect Employment History Detail ...........................................9-14

9.2.7 Documentation Requirements.......................................................9-14

9.3 Bounce Back Rule........................................................................................9-14INTAKE Bounce Back Rule Examples .....................................9-16CONTINUING Bounce Back Rule Examples ...........................9-19

9.4 Use of Medi-Cal Budget Worksheets For Non-MAGI MC ............................9-24

9.5 Completion of Medi-Cal Budget Worksheets for Non-MAGI MC..................9-259.5.1 Column I of MC 176M ...................................................................9-259.5.2 Column II of MC 176M ..................................................................9-259.5.3 Column III of MC 176M .................................................................9-25

9.6 Use of MC 176W, Allocation/Special Deduction Worksheet-A.....................9-269.6.1 MC 176W-Allocation/Special Deduction Worksheet-A..................9-26

Part I. Children with Separate Income or Property Excluded from the MFBU 9-26Part II. SSI/SSP or IHSS Recipient(s) in Family - Income Available/Allocated 9-27Part III. Allocation from Board and Care Person to Spouse and/or Children at Home, or from LTC Person with No Community Spouse to Children at Home 9-27Part IV: AFDC-MN/MI Earned Income Deductions ..................9-27Part V. ......................................................................................9-27Part VI. Aged, Blind, and Disabled (ABD) Income Deductions 9-27

10. Redeterminations ...........................................................................................10-1


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10.1 Frequency & Timeliness...............................................................................10-110.1.1 MC RD Due Date ..........................................................................10-2

Initial 12-Month Period with Retroactive Months ......................10-310.1.2 MC RD Due Date for DDSD..........................................................10-5

DDSD Evaluation is received after the 11th month ..................10-610.1.3 MC RD and CalWORKs ................................................................10-7

MC RD Date when the CalWORKs Case is Discontinued .......10-810.1.4 MC RD and Former Foster Youth .................................................10-8

10.2 MC RD Forms ..............................................................................................10-910.2.1 MC RD Packets.............................................................................10-9

MAGI MC RD Packet .............................................................10-10Non-MAGI MC RD Packet .....................................................10-10Mixed MC RD Packet .............................................................10-10Long Term Care MC RD Packet ............................................10-11

10.2.2 Informational MC RD Forms........................................................10-1210.2.3 Foster Care MC RD Forms .........................................................10-1310.2.4 Additional MC RD Forms.............................................................10-1310.2.5 SAWS 2 PLUS ............................................................................10-13

10.3 Mailing and Receiving Process ..................................................................10-1410.3.1 Sending MC RDs without an AR .................................................10-1410.3.2 Sending MC RDs with an AR ......................................................10-1510.3.3 Receiving MC RD forms..............................................................10-1610.3.4 Receiving MC RD Information Verbally.......................................10-1610.3.5 Manually logging in the MC RD...................................................10-21

10.4 MC RD Process..........................................................................................10-2110.4.1 MAGI MC RD Overview Chart.....................................................10-2210.4.2 CalWIN Automated Renewal Process.........................................10-2310.4.3 Income at MC RD........................................................................10-2410.4.4 MAGI MC Only RD Process ........................................................10-25

MAGI MC RD Approval NOA .................................................10-25MAGI MC Renewal Form (MC 216) .......................................10-26

10.4.5 Non-MAGI MC Only RD Process ................................................10-28ACA Non-MAGI MC Process .................................................10-30Pre-ACA Non-MAGI MC Process ..........................................10-31

10.4.6 Mixed (MAGI MC and Non-MAGI MC) Medi-Cal RD ..................10-31Mixed MC Household RD Process ........................................10-33

10.4.7 MAGI MC and APTC RD.............................................................10-3710.4.8 SSI QMB Cases ..........................................................................10-3810.4.9 Mega-Mandatory Coverage Groups............................................10-3810.4.10 MAGI MC Evaluation for LTC MC ...............................................10-3910.4.11 MC RD for San Andreas Regional Center...................................10-39

10.5 MC RD for Intake........................................................................................10-40Intake Process .......................................................................10-41


Medi-CalMedi-Cal

10.6 Change in Circumstance ............................................................................10-42MAGI MC Household CIC ......................................................10-43Non-MAGI MC Household CIC ..............................................10-43Mixed MC Household CIC .....................................................10-44

10.6.1 Changes Reported for Other Programs ......................................10-45CalFresh and/or General Assistance .....................................10-45CalWORKs, Foster Care, Adoption Assistance Program, and Kinship Guardian Assistance Payment Program ................................................10-45

10.6.2 CalWIN Entries for Change in Circumstance ..............................10-4610.6.3 Change in Circumstance Examples ............................................10-4810.6.4 Change in Circumstance for Pre-ACA Cases .............................10-55

10.7 Verification Requirements at MC RD and CIC ...........................................10-5510.7.1 Non-MAGI MC Verification Requirements...................................10-5610.7.2 Income Verification for Individuals without a SSN or Individual Taxpayer Identification

Number........................................................................................10-5610.7.3 Required Verifications .................................................................10-5710.7.4 Printed Verification for IDM .........................................................10-58

CalWIN Screenshot to Print ...................................................10-58MEDS Screenshot to Print .....................................................10-59CalHEERS Screenshots to Print ............................................10-60

10.8 MC RD is Not Returned..............................................................................10-6210.8.1 Automated Reminder Notice .......................................................10-6210.8.2 Automated Reminder Calls .........................................................10-62

Message ................................................................................10-63Missing or Invalid Telephone Numbers ..................................10-63

10.8.3 Automated Reminder Text Messages and Emails ......................10-64Text Messages .......................................................................10-64Emails ....................................................................................10-64

10.9 Discontinuance at MC RD or CIC...............................................................10-6510.9.1 MC RD Discontinuance due to Non-compliance .........................10-6510.9.2 MC RD Discontinuance due to Ineligibility ..................................10-65

MAGI MC ...............................................................................10-65Non-MAGI MC .......................................................................10-65

10.9.3 Mixed MC (MAGI MC & Non-MAGI MC) Discontinuance ...........10-65

10.10 MC RD Rescissions ...................................................................................10-6610.10.1 Rescission Between NCO and the End of the Discontinuance Month10-6610.10.2 Rescissions After the End of Discontinuance Month...................10-68

10.11 The 90-Day Cure Period ............................................................................10-76

10.12 CalWORKS Discontinuance for Failure to Complete the Annual RD.........10-77

10.13 Deemed Eligibility for Infants......................................................................10-77

10.14 Loss of Contact ..........................................................................................10-79


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10.14.1 Ex Parte Review..........................................................................10-79Immediate Family Members ...................................................10-79Confidentiality ........................................................................10-80

10.14.2 MC 355........................................................................................10-8010.14.3 Notice of Action ...........................................................................10-8010.14.4 Case Documentation...................................................................10-81

10.15 Face-to-Face Interview...............................................................................10-8110.15.1 When a Face-to-Face is Required by the EW.............................10-81

10.16 Transitional Medi-Cal .................................................................................10-82All Household Members are receiving TMC ..........................10-83Household Members with Different TMC Expiration Dates ....10-83Some Household Members are Receiving TMC ....................10-83

10.17 ............................................................................................ CalWIN RRR10-8310.17.1 CalWIN RRR Status Definitions ..................................................10-8310.17.2 Reprinting MC RD forms .............................................................10-8410.17.3 Manually Printing the MC RD Forms in CalWIN..........................10-86

10.18 MC RD for Pre-ACA Clients .......................................................................10-89

10.19 Aligning CF RC with the MC RD ................................................................10-90

11. Reserved for Future Use ................................................................................11-1

12. Denials/Discontinuances/Suspensions........................................................12-1

12.1 Denial or Discontinuance Due to Lack of Information, Non-cooperation, or Loss of Contact12-112.1.1 Balderas v. Woods ........................................................................12-112.1.2 Reasons for Denial or Discontinuance ..........................................12-112.1.3 Two Contact Requirement.............................................................12-2

First Contact .............................................................................12-2Second Contact .......................................................................12-2

12.1.4 Contact ..........................................................................................12-312.1.5 Documentation Requirements.......................................................12-3

Reasonable Effort ....................................................................12-3Two Contacts ...........................................................................12-3

12.1.6 Relative Responsibility ..................................................................12-412.1.7 Subsequent Action ........................................................................12-512.1.8 Good Cause ..................................................................................12-5

12.2 Discontinuance Due to Death.......................................................................12-512.2.1 Effective Date ................................................................................12-5

12.3 Notice of Action ............................................................................................12-612.3.1 When Required .............................................................................12-6

12.4 Rescission of Denial and Discontinuance ....................................................12-6


Medi-CalMedi-Cal

12.4.1 Rescissions ...................................................................................12-612.4.2 Approval/Rescission Date .............................................................12-6

12.5 Reconsideration of Denials ..........................................................................12-712.5.1 Requirement..................................................................................12-712.5.2 Decision Chart...............................................................................12-7

12.6 Transfer Between Programs ........................................................................12-812.6.1 Requirements ................................................................................12-8

12.7 Suspension of Medi-Cal Benefits for Incarcerated Juveniles .......................12-812.7.1 Overview .......................................................................................12-812.7.2 Program Requirements .................................................................12-912.7.3 Process for Suspending Medi-Cal Benefits...................................12-912.7.4 Suspension of Medi-Cal for Incarcerated Juveniles in a Medi-Cal Case That Includes

Other Family Members................................................................12-1012.7.5 Suspension of Medi-Cal for Incarcerated Juveniles in Child Only Medi-Cal Cases

12-1112.7.6 Impact on Eligibility for Child Only cases ....................................12-1212.7.7 Impact on Eligibility of Other Family Members ............................12-1212.7.8 Notice of Action Requirements....................................................12-1312.7.9 Impact of SB 1147 on SB 1469 Procedures................................12-1312.7.10 MEDS Screens............................................................................12-13

12.8 Medi-Cal Eligibility for Juveniles Placed Temporarily in Juvenile Detention Centers12-14

12.9 SSI/SSP Discontinuances and Denials due to Excess Income..................12-1412.9.1 Craig v Bontá...............................................................................12-1412.9.2 SSI Denials..................................................................................12-15

Date of Application .................................................................12-1512.9.3 Eligibility Requirements ...............................................................12-1512.9.4 Redeterminations ........................................................................12-1512.9.5 Retroactive Benefits ....................................................................12-1612.9.6 Continuing ...................................................................................12-1612.9.7 Documentation ............................................................................12-1612.9.8 Forms ..........................................................................................12-17

13. Reporting a Change and Notices of Action..................................................13-1

13.1 Ten Day Reporting Requirement..................................................................13-113.1.1 Requirements ................................................................................13-113.1.2 Medi-Cal Contact Update (MC 354) Form.....................................13-2

13.2 Notices of Action ..........................................................................................13-313.2.1 When to Send a Notice of Action ..................................................13-313.2.2 Informing Requirements ................................................................13-313.2.3 Timely Notice of Action..................................................................13-413.2.4 Adequate Notice of Action.............................................................13-4

Timeframe ................................................................................13-4


page -24Medi-Cal

13.2.5 Other Notice of Action Requirements............................................13-5Long Term Care Medi-Cal Notices of Action ...........................13-6APTC and MAGI MC NOA (NOD01) .......................................13-6

13.2.6 Elimination of Multiple or Conflicting Notices of Action .................13-713.2.7 When Multiple Notices of Action May Be Necessary ....................13-713.2.8 “Conditional” Notices .....................................................................13-713.2.9 Notices of Action and Authorized Representatives .......................13-813.2.10 Discontinuance Notice of Action for Non-Receipt of MC 216........13-8

Manual Printing ........................................................................13-9

13.3 Manual NOAs .............................................................................................13-1013.3.1 Manual Generation of the NOD02...............................................13-1013.3.2 MAGI Medi-Cal Discontinuance Notice of Action ........................13-1413.3.3 Notice of Action Reason Codes ..................................................13-16

13.4 IRS Form 1095-B .......................................................................................13-1613.4.1 Correcting Form 1095-B..............................................................13-1713.4.2 Social Security Administration (SSA) ..........................................13-1713.4.3 Client Questions ..........................................................................13-17

DHCS 1095-B Website and Help Desk ..................................13-17IRS .........................................................................................13-17Volunteer Income Tax Assistance (VITA) ..............................13-17Tax Counseling for the Elderly (TCE) ....................................13-18The Federal Healthcare Exchange ........................................13-18

13.4.4 Request Reprint ..........................................................................13-18

14. Health Care Options (HCO)/Managed Care ..................................................14-1

14.1 Fee-For-Service ...........................................................................................14-1

14.2 Medi-Cal Managed Care Health Plans.........................................................14-114.2.1 Comprehensive Managed Care Goals ..........................................14-114.2.2 Membership Services....................................................................14-2

14.3 Overview of the Managed Care Two-Plan Model.........................................14-214.3.1 Mandatory Enrollment ...................................................................14-314.3.2 Voluntary Aid Codes......................................................................14-314.3.3 Exemptions from Mandatory Enrollment/Voluntary Enrollment.....14-414.3.4 Health Care Options Enrollment Contractor-Maximus ..................14-5

Enrollment/Disenrollment Function ..........................................14-5Health Care Options Flyer .......................................................14-5Health Care Option Presentations ...........................................14-5

14.3.5 EW Role in the Managed Care Enrollment Process .....................14-6HCO Referrals .........................................................................14-6

14.3.6 HCO Referral Process...................................................................14-7HCO Referral Form ..................................................................14-7

14.3.7 Enrollment Information Packet ......................................................14-8Choosing a Primary Care Provider (PCP) ...............................14-8


Medi-CalMedi-Cal

14.3.8 Automatic Default Into a Managed Care Plan ...............................14-814.3.9 Disenrollment ................................................................................14-914.3.10 Two-Plan Model Identification Cards.............................................14-914.3.11 Coding Other Health Coverage with a Mandatory

Managed Care Plan and No Other Coverage .............................14-10HCP Information on MEDS ....................................................14-10

14.3.12 Cost of Care in Managed Care Plans..........................................14-1014.3.13 Managed Care Plans and Health Care Options Contact Information and Verbal Client

Contact Information Update [W&I 14005.36]...............................14-11Consent ..................................................................................14-11No Consent ............................................................................14-11

14.4 Managed Care for Mental Health Services ................................................14-1214.4.1 Overview .....................................................................................14-1214.4.2 Santa Clara County’s Mental Health Plan (MHP)........................14-1214.4.3 Automatic Enrollment in the Plan ................................................14-1214.4.4 Mental Health Services ...............................................................14-13

14.5 Exemption Process for Pregnant Women That Move From Aid Code 44 to 3N During the Last Trimester ....................................................................................................14-1414.5.1 Informing Requirements ..............................................................14-1414.5.2 Ad Hoc Listing .............................................................................14-15

15. Intercounty Transfer (ICT)..............................................................................15-1

15.1 General Requirements [50136-50138, 50185] .............................................15-115.1.1 Definitions......................................................................................15-115.1.2 ICT Application Requirements.......................................................15-115.1.3 Three (3) Main Components of eICT.............................................15-215.1.4 Continuation of Medi-Cal Benefits.................................................15-215.1.5 Redetermination of Medi-Cal Eligibility..........................................15-215.1.6 Temporary vs. Permanent Change of County Residence.............15-315.1.7 Address Change and Cancellations ..............................................15-315.1.8 ICT Time Frames ..........................................................................15-415.1.9 Discontinuance Date .....................................................................15-515.1.10 Completion of an ICT ....................................................................15-515.1.11 Only Part of Family Moved ............................................................15-615.1.12 eICT Processing During a System Outage ...................................15-615.1.13 Request for Retroactive Medi-Cal .................................................15-715.1.14 Craig v. Bonta................................................................................15-715.1.15 In-Home Supportive Services (IHSS)............................................15-715.1.16 Exceptions.....................................................................................15-815.1.17 CalWORKs ICT Discontinued Cases ............................................15-9

15.2 ICT Problems/Issues ....................................................................................15-9

15.3 Medi-Cal Managed Care Health Plans (MMCHPs) ....................................15-1015.3.1 Managed Care Transition During ICT .........................................15-11


page -26Medi-Cal

15.3.2 Managed Care and Temporary County Change .........................15-12

15.4 Recipient Responsibility .............................................................................15-1315.4.1 Client Contacts the Sending County and/or Requests Discontinuance of Medi-Cal

Benefits .......................................................................................15-1315.4.2 Client Applies in the Receiving County While the Case is Active in the Sending County

15-1315.4.3 Client Requests Medi-Cal After Case Has Been Discontinued Due to Loss of Contact

15-14

15.5 Client Reports Other Changes ...................................................................15-15

15.6 Annual Redetermination (RD) ....................................................................15-17

15.7 Processing Outgoing ICT ...........................................................................15-1915.7.1 Waiver Programs.........................................................................15-21

15.8 Processing an Incoming ICT ......................................................................15-2115.8.1 Incoming ICT...............................................................................15-2115.8.2 Client Applies at District Office ....................................................15-2115.8.3 Processing an Incoming ICT .......................................................15-22

15.9 Multiple Transfers.......................................................................................15-23

15.10 County of Responsibility [50135]................................................................15-2415.10.1 Courtesy Applications..................................................................15-2515.10.2 Person Maintains a Home...........................................................15-2615.10.3 Homeless Persons ......................................................................15-2615.10.4 Person with a Guardian...............................................................15-2715.10.5 Persons Under 21 Years of Age Not living at Home ...................15-2715.10.6 Deceased Individual ....................................................................15-2915.10.7 Out of Home Placement ..............................................................15-2915.10.8 Pending SP-DDSD Disability Determination ...............................15-30

15.11 County of Responsibility in CalHEERS ......................................................15-3115.11.1 Establishing COR........................................................................15-31

16. MAGI MC Tax Household ...............................................................................16-2

16.1 Overview ......................................................................................................16-2Collecting Tax Filing Information ..............................................16-2

16.2 IRS Tax Filing Statuses................................................................................16-3

16.3 Tax Filer Rules .............................................................................................16-3

16.4 Tax Dependent Rules...................................................................................16-4Three (3) Tax Dependent Exceptions ......................................16-4

16.4.1 Dependents for Health Insurance Coverage Purposes.................16-5Who Qualifies as a Coverage Dependent? ..............................16-5


Medi-CalMedi-Cal

16.4.2 Dependents for IRS Tax Filing Purposes ......................................16-616.4.3 Dependents for MAGI MC Household Purposes...........................16-6

Married Parents Filing Jointly ...................................................16-6Married Parents Filing Separately ............................................16-7Unmarried Couple ....................................................................16-7

16.4.4 Types of Tax Dependents .............................................................16-8Qualifying Child ........................................................................16-8Qualifying Relative .................................................................16-10

16.4.5 Dependent Child Attending School Out-of-State.........................16-10

16.5 Non-Tax Filer Rules ...................................................................................16-11

16.6 Parent-Child Rules .....................................................................................16-11

16.7 Stepparent Rules........................................................................................16-12

16.8 Married Couples .........................................................................................16-12Married Filing Jointly ..............................................................16-12Married Filing Separately .......................................................16-13

16.9 Unmarried Couples ....................................................................................16-13

16.10 Pregnant Women ......................................................................................16-14

16.11 Determining Household Size......................................................................16-1516.11.1 Household Size Flow Chart.........................................................16-16

16.12 Household Examples .................................................................................16-1716.12.1 Single Adult with no Dependents ................................................16-1716.12.2 Single Adult with a Dependent ....................................................16-1716.12.3 Married Couple Filing Jointly with Common Children..................16-1816.12.4 Married Couple (Pregnant Wife) Filing Separately (Living Together) with Common

Children .......................................................................................16-1816.12.5 Married Couple Filing Separately (Living Apart) with Common Children and a Separate

Child ............................................................................................16-1916.12.6 Unmarried Couple with a Common Child ....................................16-2016.12.7 Unmarried Couple Filing Separately with Common Children and a Separate Child

16-2116.12.8 Non-custodial Parent claims Child as a Tax Dependent .............16-2216.12.9 Three Generation Household ......................................................16-2316.12.10 Three Generation Household ......................................................16-2316.12.11 Single Adults Living Together......................................................16-24

17. MAGI MC Income ............................................................................................17-2

17.1 Reported Income..........................................................................................17-2Single Streamline Application ..................................................17-2Floating View and Summary View ...........................................17-3


page -28Medi-Cal

17.2 Income Verification.......................................................................................17-3MAGI MC Cases ......................................................................17-3Mixed MC Cases (MAGI MC and Non-MAGI MC) ...................17-3Mixed Cases (APTC/CSR/QHP and MAGI MC) ......................17-3Unsuccessful eHIT ...................................................................17-4

17.3 Current Monthly Income ...............................................................................17-4

17.4 Projected Annual Income .............................................................................17-417.4.1 How CalHEERS E-Verifies PAI and CMI ......................................17-517.4.2 When to Enter PAI in CalWIN .......................................................17-5

Examples of when PAI is used: ...............................................17-517.4.3 When to Request Verification........................................................17-617.4.4 Display Projected Annual Income Detail window ..........................17-6

Guidelines for Entering PAI in CalWIN ....................................17-7End Dating PAI ........................................................................17-7

17.4.5 Individuals With No PAI Who Are Pending Eligibility for PAI Verification17-8

17.5 Income Flowchart .......................................................................................17-10Example 1 ..............................................................................17-11Flowchart for Example 1 ........................................................17-11Example 2 ..............................................................................17-12Flowchart for Example 2 ........................................................17-12Example 3 ..............................................................................17-13Flowchart for Example 3 ........................................................17-13

17.6 Income of a Tax Dependent .......................................................................17-14

17.7 Self-Employment Income ...........................................................................17-15

17.8 Unconditionally Available Income...............................................................17-15

17.9 CalWIN Income and Deduction Types .......................................................17-16

17.10 Income Types.............................................................................................17-1717.10.1 Deductions and Expenses...........................................................17-38

17.11 CalWIN Income and Expenses NOT Mapped to CalHEERS .....................17-4017.11.1 Income.........................................................................................17-4017.11.2 Expenses.....................................................................................17-45

Not found in IRS Form 1040 or in CALWIN income windows 17-49

18. Electronic Health Information Transfer ........................................................18-2

18.1 Overview ......................................................................................................18-2

18.2 SAWS...........................................................................................................18-2

18.3 MEDS ...........................................................................................................18-3


Update #15-34

Medi-

18.4 C

18.5 F

18.6 e11

18.7 In

18.8 S111

18.9 V

18.10 E

18.11 D

18.12 e

18.13 e

18.14 E

18.15 E

18.16 A

18.17 R

19. Res

20. Ext

Page -29

Cal

alHEERS ................................................................................................... 18-3Application Started in CalHEERS ............................................ 18-3Application Started in CalWIN ................................................. 18-4

ederal Data Services Hub.......................................................................... 18-4

HIT Illustration............................................................................................ 18-48.6.1 CalHEERS/CalWIN/MEDS Interface: ........................................... 18-58.6.2 MAGI/Non-MAGI Processing Paths.............................................. 18-5

terface Mapping ........................................................................................ 18-6

ystem Screenshots to Print........................................................................ 18-88.8.1 CalWIN Screenshot to Print .......................................................... 18-88.8.2 MEDS Screenshot to Print ............................................................ 18-98.8.3 CalHEERS Screenshots to Print................................................. 18-10

erify Lawful Presence .............................................................................. 18-13

ligibility Determination Request ............................................................... 18-14

etermination of Eligibility.......................................................................... 18-15

HIT Response .......................................................................................... 18-17

HIT Errors ................................................................................................ 18-17

xternal Referral Data Subsystem............................................................. 18-18

xternal Change Data Subsystem............................................................. 18-18

utomated eHIT......................................................................................... 18-18

IDP .......................................................................................................... 18-19

erved for Future Use................................................................................ 19-1

ernal Referral ............................................................................................ 20-1

Update #15-34

Medi-

20.1 O

20.2 C

20.3 Id2222

20.4 P 20-38

21. Ext

21.1 E

21.2 E

21.3 E

21.4 C

21.5 S22

2

Page -30

Cal

pen Enrollment Results ............................................................................. 20-1

arry Forward .............................................................................................. 20-3

entifying and Application Registration....................................................... 20-40.3.1 CalHEERS application with closed case in CalWIN ................... 20-120.3.2 CalHEERS application with pending Medi-Cal CalWIN application20-290.3.3 CalHEERS application with active CalWIN case (not Medi-Cal) - Add a Program20-320.3.4 CalHEERS application with active Medi-Cal in CalWIN.............. 20-35

rocessing a CalHEERS application received through the External Referral Subsystem in CalWIN

ernal Change Data .................................................................................... 21-2

xternal Change Data Interface................................................................... 21-2Unsolicited (started in CalHEERS) .......................................... 21-2Solicited (started in CalWIN) ................................................... 21-2

CD Illustration ............................................................................................ 21-3

CD Effect on BRE...................................................................................... 21-4

ompare Functionality ................................................................................. 21-5Comparing Changes within One Benefit Month ...................... 21-5Comparing Changes across Benefit Months ........................... 21-5

earch for Case Updates Window............................................................... 21-61.5.1 Search Criteria.............................................................................. 21-61.5.2 Search Results ............................................................................. 21-7

Data Submitted ........................................................................ 21-7Status ...................................................................................... 21-7Status Date .............................................................................. 21-8Originated By ........................................................................... 21-8Comparison Date ..................................................................... 21-8Benefit Month .......................................................................... 21-8

1.5.3 Action Buttons............................................................................... 21-9Compare Button .................................................................... 21-10

Update #15-34

Medi-

21.6 R2

222

21.7 H 202

21.8 E

21.9 C

21.10 P22

21.11 E

21.12 E

22. Res

23. Res

24. Non

24.1 D

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Change Types Button ............................................................ 21-10Initiate Queue Button ............................................................. 21-11 Summary View Button .......................................................... 21-12

esources for Processing Change DERs.................................................. 21-121.6.1 Floating View .............................................................................. 21-12

How to Open Floating View ................................................... 21-13Reference Box in Parent Windows ........................................ 21-13Example of “Reference” Box in Display Individual Demographics Summary 21-14Example of “Reference” Box in Collect Individual Address Detail .............................................................................................. 21-15

1.6.2 Summary View............................................................................ 21-151.6.3 How to Open the Summary View................................................ 21-151.6.4 Print Report................................................................................. 21-18

ow to Process Changes Received Through the External Change Data Subsystem in CalWIN21-1.7.1 Common ECD Workflow Windows ............................................. 21-23

rror Message 215 .................................................................................... 21-32

EW Through Portal Change DERs......................................................... 21-33

ending Batch Change DERs.................................................................... 21-341.10.1 Unprocessed Received DERS and Pending Batch DERs.......... 21-341.10.2 APTC Discontinuance in CalWIN ............................................... 21-35

CD at RD ................................................................................................. 21-35

CD at CIC ................................................................................................ 21-36



-MAGI MC MFBU...................................................................................... 24-1

efinitions .................................................................................................... 24-1

page -32Medi-Cal

24.1.1 Definition of an Adult [50014] ........................................................24-124.1.2 Definition of a Child [50030, 50351] ..............................................24-124.1.3 Definition of Responsible Relatives [50351]..................................24-2

24.2 Tax Dependency Requirements ..................................................................24-324.2.1 Tax Dependency Requirements [50351, 50373]...........................24-324.2.2 Persons 18-21 Years of Age [50351, 50373, 50379] ....................24-4

Persons 18-21 Years of Age Living at Home ...........................24-4Persons 18-21 Years of Age Living Away from Home .............24-5Parent Lives in California .........................................................24-5Parent Lives Out of California ..................................................24-6

24.2.3 Persons Under 18 Years of Age [50373].......................................24-6Persons Under 18 Years of Age Living at Home .....................24-6Persons Under 18 Years of Age Living Away from Home .......24-6

24.3 Charts...........................................................................................................24-724.3.1 Parental Responsibility Chart ........................................................24-7

Unmarried Persons Under 21 Living at Home/ Away From Home ....................................................................24-7

24.3.2 Parental Responsibility Chart ........................................................24-9Married, Divorced or Separated Persons Under 21 Living at Home/Away from Home 24-9

24.4 MFBU Determinations ................................................................................24-1024.4.1 MFBU [50060] .............................................................................24-1024.4.2 Family Member [50041]...............................................................24-1024.4.3 Child [50030] ...............................................................................24-1024.4.4 Caretaker Relative [50085, 50351]..............................................24-1124.4.5 Responsible Relative [50351, 50377]..........................................24-11

24.5 MFBU Determinations: General Policy.......................................................24-1224.5.1 Sneede Requirements for MFBU Determinations .......................24-1224.5.2 Additional Rules for MFBU Determinations.................................24-1324.5.3 Common-Law Marriage...............................................................24-14

Basic Requirements For A Common-Law Marriage ..............24-1424.5.4 Same Sex Spouses and Registered Domestic Partners.............24-14

Registered Domestic Partners (RDPs) ..................................24-15Definition ................................................................................24-15Eligibility for Medi-Cal ............................................................24-15

24.6 Caretaker Relative Rules and Requirements [50084] ................................24-1824.6.1 Rules ...........................................................................................24-1824.6.2 Relationship to Child [50084] ......................................................24-1924.6.3 Biological Relatives .....................................................................24-1924.6.4 Step Relatives .............................................................................24-1924.6.5 Spouses of Relatives...................................................................24-1924.6.6 Adoptive Relatives.......................................................................24-2024.6.7 Relinquishment............................................................................24-20


Medi-CalMedi-Cal

24.7 Joint Custody Rules ..................................................................................24-2024.7.1 Alternating Arrangements (Joint Custody) [50374, 50213] .........24-2124.7.2 Equal Amount of Time with Each Parent.....................................24-2124.7.3 Equal Responsibility ....................................................................24-2124.7.4 Alternating Periods of One Month or More..................................24-22

24.8 How to Establish an MFBU [50373- 50379] ...............................................24-22

24.9 No Family Member in LTC or Board and Care [50371] ..............................24-2324.9.1 Determine Family Composition [50373] ......................................24-2324.9.2 MFBU Composition [50373] ........................................................24-2324.9.3 Ineligible Members [50379, 50657] .............................................24-25

Ineligible members of an MFBU include: ...............................24-25The following applies to ineligible members of an MFBU: .....24-27

24.9.4 Excluded Members [50381].........................................................24-28Who are Excluded Members ..................................................24-28Rules Applied to Excluded Members .....................................24-28Adding Excluded Persons to the MFBU .................................24-29

24.9.5 Excluded Child Statement (Medi-Cal), MC 239 SN-3 .................24-2924.9.6 Ineligible vs. Excluded.................................................................24-29

Rules ......................................................................................24-2924.9.7 Unmarried Pregnant Women.......................................................24-30

Requirements .........................................................................24-3024.9.8 MFBU determination when child lives at home ...........................24-3024.9.9 MFBU Determinations when an Unmarried Minor Parent

Lives in the Home of Senior Parent(s) ........................................24-31MFBU Rules for Unmarried Pregnant Minor ..........................24-31Unmarried Minor Parent’s Child(ren) ...................................24-32Unmarried minor parents, their child and minor mother’s parents ..........................................................24-32Minor's Property .....................................................................24-32Minor's Income .......................................................................24-33Income In-Kind to Minor .........................................................24-33MFBU Chart— Married or Unmarried Minor Parent(s) Living at Home 24-33

24.9.10 MFBU Determination When a Married Minor Child (Parent or not) Lives in the Home of Senior Parent(s) ................24-34

MFBU Chart—Married Minor Child Living With Parents ........24-3424.9.11 MFBU Determination When a Minor, Living Away

from Home, Is Claimed as Tax Dependent .................................24-35The following applies when a parent lives in California: ........24-35The following applies when a parent lives out of California. ..24-35Determining Maintenance Need Level ...................................24-35

24.9.12 Minor Consent Services [50147, 50351, 50373] .........................24-3724.9.13 Children in Foster Care or Relinquished for Adoption.................24-37

Definition of a child in foster care: ..........................................24-37Children in foster care: ...........................................................24-37Definition of a child relinquished for adoption: .......................24-37


page -34Medi-Cal

A Child(ren) relinquished for adoption: ..................................24-37MFBU Chart — Foster Care/ Relinquished for Adoption .......24-38

24.9.14 MFBU Limitations When Families are AFDC-MN Linked [50211, 50213] ............................................................................24-38

MFBU Chart — Families with Absent or Deceased Parent Deprivation ..........24-39

24.10 Stepparents ...............................................................................................24-4024.10.1 Definitions [50094, 50375]...........................................................24-4024.10.2 Establishing the Stepparent MFBU [50375] ................................24-4124.10.3 Stepparent Budget Computation and MC 176 W.1 .....................24-42

MC 176 W.1 ...........................................................................24-4224.10.4 Stepparent Case Property Determination ...................................24-4224.10.5 Stepparent Case Income Determination .....................................24-42

Unearned Income In-Kind and stepparent case ....................24-4324.10.6 Stepparent Determination When Parent is PA............................24-43

MFBU Illustration ...................................................................24-44

24.11 Adult/Child Status Chart ............................................................................24-44

25. Non-MAGI MC Income....................................................................................25-1

25.1 General/Ownership ......................................................................................25-125.1.1 General [50501].............................................................................25-125.1.2 Ownership of Income ....................................................................25-1

Rule ..........................................................................................25-1Multiple Owners .......................................................................25-2Community Property Laws .......................................................25-2Representative Payees ............................................................25-2Trusts .......................................................................................25-2

25.1.3 Budgeting ......................................................................................25-2Medicare ..................................................................................25-2Other Health Insurance Premiums ...........................................25-3

25.2 ABD-MN Person in Board and Care With No Community Spouse [50563] .25-325.2.1 Allocations .....................................................................................25-3

25.3 Unconditionally Available Income [50186]....................................................25-325.3.1 Rule ...............................................................................................25-325.3.2 Types.............................................................................................25-325.3.3 PA..................................................................................................25-425.3.4 Non-Cooperation ...........................................................................25-425.3.5 Exception.......................................................................................25-4

25.4 Available Income [50605] .............................................................................25-425.4.1 Rule ...............................................................................................25-425.4.2 Exception.......................................................................................25-525.4.3 Owner............................................................................................25-5


Medi-CalMedi-Cal

25.5 Unavailable Income [50515].........................................................................25-525.5.1 Rule ...............................................................................................25-525.5.2 Types.............................................................................................25-5

Contributions ............................................................................25-5Board & Care ...........................................................................25-6Advance Earnings ....................................................................25-7Overpayment Adjustments .......................................................25-7

25.6 Exempt Income ............................................................................................25-7

25.7 Property Tax Refunds [50523] .....................................................................25-7

25.8 Child/Spousal Support Disregard [50554.5] .................................................25-7

25.9 Public Assistance Grants [50525] ................................................................25-8

25.10 CalWORKs Employment Services (CWES) [50526] ....................................25-9

25.11 Social Services Payments [50527]...............................................................25-9

25.12 Needs-Based Assistance [50529, Proc 10C] ...............................................25-925.12.1 General Criteria .............................................................................25-925.12.2 Exempted by Public Law...............................................................25-925.12.3 Other Exemptions........................................................................25-10

25.13 Federal Housing Assistance [50529]..........................................................25-10

25.14 Training Expenses [50530].........................................................................25-10

25.15 Foster Care Payments [50531] ..................................................................25-11

25.16 Adoptive Assistance Payments ..................................................................25-11

25.17 Loans, Grants, Scholarships, and Fellowships [50533] .............................25-1125.17.1 Title III Loans...............................................................................25-1125.17.2 Title IV Student Assistance [50533] ............................................25-1225.17.3 Other ...........................................................................................25-13

25.18 Victims of Violent Crimes Program[50534].................................................25-13

25.19 Relocation Assistance [50535] ...................................................................25-13

25.20 Indian Claims [50537].................................................................................25-14

25.21 VISTA Payments [50538] ...........................................................................25-15

25.22 WIA Payments [50538]...............................................................................25-1525.22.1 Adults ..........................................................................................25-1525.22.2 Children .......................................................................................25-1525.22.3 Verification/Information................................................................25-16

25.23 Executive Volunteers [50540].....................................................................25-16


page -36Medi-Cal

25.24 Senior Citizen Volunteers [50541]..............................................................25-16

25.25 Senior Citizens Rent Assistance [50523] ...................................................25-17

25.26 EITC [50543.5] ...........................................................................................25-17

25.27 Victims of National Socialist Persecution [50536] ......................................25-17

25.28 Japanese-American and Aleutian Restitution/Reparation/Redress Payments25-18

25.29 Austrian Social Insurance Payments..........................................................25-1825.29.1 Description ..................................................................................25-1825.29.2 Interest ........................................................................................25-1825.29.3 Verification...................................................................................25-18

25.30 Filipino Veterans Equity Compensation Fund ............................................25-19

25.31 Veterans' Aid and Attendance - Not In LTC ...............................................25-20

25.32 Post 9/11 GI Bill Books and Supplies Stipend............................................25-20

25.33 Agent Orange .............................................................................................25-20

25.34 Disaster Assistance....................................................................................25-21

25.35 Susan Walker v. Bayer Corporation Payments ..........................................25-2125.35.1 Description ..................................................................................25-21

25.36 Quilling v. Belshe Payments .......................................................................25-2225.36.1 Description ..................................................................................25-22

25.37 Compensation in Accordance with the National Defense Authorization Act of 199725-22

25.38 Ricky Ray Hemophilia Relief Fund Act Payments....................................25-23

25.39 Gifts to Children With Life-Threatening Conditions ....................................25-23

25.40 Radiation Exposure Compensation Payments.........................................25-24

25.41 Compensation for Participating in Clinical Trials ........................................25-2425.41.1 Verification...................................................................................25-25

25.42 In-Home Care Payments............................................................................25-26

25.43 IHSS Plus Waiver Payments......................................................................25-27

25.44 Interest and Dividend Income.....................................................................25-2725.44.1 Exempt ........................................................................................25-2725.44.2 Nonexempt ..................................................................................25-2825.44.3 Example ......................................................................................25-28

25.45 2009 ARRA Making Work Pay Credit.........................................................25-28


Medi-CalMedi-Cal

25.46 Misc. Income Information ...........................................................................25-29

25.47 Income In-Kind ...........................................................................................25-2925.47.1 Definition [50509] ........................................................................25-2925.47.2 Treatment of Income In-Kind [50511]..........................................25-3025.47.3 Exceptions [50509]......................................................................25-3025.47.4 Value of Income In-Kind ..............................................................25-31

25.48 Income Verification.....................................................................................25-3125.48.1 Unearned Income........................................................................25-3125.48.2 Income In Kind ............................................................................25-3225.48.3 Earned Income............................................................................25-32

The Work Number ..................................................................25-3325.48.4 Income Deductions......................................................................25-33

25.49 Medi-Cal “In Home Supportive Services” Cost As a Deduction from Any Income ....................................................................25-3425.49.1 Who Is Eligible for this Special IHSS Deduction? .......................25-34

25.50 Treatment of Child Support Arrearage Payments ......................................25-3425.50.1 Current Child Support Payments (Not Arrearages).....................25-3525.50.2 Delayed (Past Month) Payments Paid Timely But Received In A Subsequent Month (Not

Arrearages) .................................................................................25-35Child 18 or Older ....................................................................25-36

25.50.3 Treatment of Arrearage Payments for a Child 18 or Older..........25-36

25.51 Earned Income ...........................................................................................25-37

25.52 Nonexempt Earned Income........................................................................25-3725.52.1 Temporary Worker's Compensation............................................25-3925.52.2 State Disability Insurance Benefits..............................................25-39

25.53 Exempt Earned Income..............................................................................25-4025.53.1 Irregular or Infrequent..................................................................25-4025.53.2 Student Exemption ......................................................................25-4025.53.3 Student Exemption Definitions ....................................................25-4125.53.4 Who is Eligible.............................................................................25-4125.53.5 Child Under 14 Years ..................................................................25-4125.53.6 Earned Income Tax Credit ..........................................................25-41

25.54 Deductions from Earned Income................................................................25-4225.54.1 MFBUs Which Include Aged, Blind or Disabled MN

Persons [50549] ..........................................................................25-42Student Deduction [50551] ....................................................25-43“Any Income” Deduction [50551.2] ........................................25-43Court-Ordered Spousal or Child Support [50554] ..................25-44Sixty-Five Plus One-Half [50551.3] ........................................25-44Work Expenses of the Blind [50551.4] ...................................25-44Income Necessary to Achieve Self-Support [50551.5] ..........25-44


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Cost of In-Home Supportive Services— ABD-MN and Substantial Gainful Activity Disabled (SGA) [50551.6] ................................................................................25-45

25.54.2 AFDC-MN, MI, or Ineligible Members of the MFBU [50553] .......25-46Deduction for Work-Related Expenses (WRE) [50553.1] ......25-46Dependent Care .....................................................................25-46Spousal or Child Support .......................................................25-47

25.54.3 All MN or MI Programs [50555] ...................................................25-47

25.55 Stepparent Income .....................................................................................25-4925.55.1 Income Deemed Available from the Stepparent [50559].............25-4925.55.2 Treatment of Income: Stepparent Cases [50561] .......................25-49

25.56 Self-Employment Income ...........................................................................25-5025.56.1 Definition .....................................................................................25-5025.56.2 Indicators of Self-Employment ....................................................25-5025.56.3 Conflicting Indicators ...................................................................25-5125.56.4 Contractual Arrangement ............................................................25-5225.56.5 Determination of Property and Resources [50485] .....................25-5225.56.6 Income Determination [50505] ....................................................25-5225.56.7 Business Expenses Allowed .......................................................25-54

Mandatory Expenses (Paid for Self-Employed Person's Employees) ......................25-54Licenses .................................................................................25-54Advertising .............................................................................25-54Bonds .....................................................................................25-54Expendable Supplies .............................................................25-55Capital Assets—Business Expenses .....................................25-55Maintenance and Repairs ......................................................25-55Taxes .....................................................................................25-55Insurance ...............................................................................25-56Transportation ........................................................................25-56Legal or Professional Services ..............................................25-56Merchandise/Stock/Raw Materials .........................................25-56Rent or Lease Expenses ........................................................25-56Home-Operated Business ......................................................25-57

25.56.8 Non-allowable Business Expense ...............................................25-5725.56.9 Documenting Income Determination ...........................................25-5825.56.10 Net Income From Property [50515, Procedures 10G].................25-59

25.57 Unearned Income.......................................................................................25-62

25.58 Nonexempt Unearned Income [50507] ......................................................25-6225.58.1 Workers’ Compensation ..............................................................25-6325.58.2 Unavailable Workers’ Compensation ..........................................25-6425.58.3 State Disability Insurance............................................................25-6425.58.4 Disability Benefits Other than State.............................................25-6425.58.5 Other Unearned Income..............................................................25-64


Medi-CalMedi-Cal

25.58.6 Personal Property........................................................................25-6525.58.7 Dividends.....................................................................................25-6525.58.8 Interest ........................................................................................25-6625.58.9 Royalties......................................................................................25-6625.58.10 Public Assistance ........................................................................25-6625.58.11 Workforce Incentive Act (WIA) ....................................................25-6625.58.12 Lump Sum...................................................................................25-6625.58.13 Other ...........................................................................................25-66

25.59 Exempt Unearned Income [50542].............................................................25-6725.59.1 Irregular/Infrequent......................................................................25-6725.59.2 Interest ........................................................................................25-67

25.60 Deductions from Unearned Income............................................................25-6825.60.1 Educational Expenses [50547]....................................................25-6825.60.2 MFBUs Which Include Aged, Blind, or Disabled MN

Persons [50549] ..........................................................................25-69Support Payment from an Absent Parent [50549.1] ..............25-69“Any Income” Deduction—Unearned Income [50549.2] ........25-70Court-Ordered Spousal or Child Support [50554] ..................25-70Income Necessary to Achieve Self-Support [50551.5] ..........25-70Cost of In-Home Supportive Services—ABD MN and Activity Disabled (SGA) Substantial Gainful Activity [50551.6] ....................................25-71Guardian and Conservator Fees [50549.3] ............................25-71

25.60.3 AFDC-MN, MI, or Ineligible Members of the MFBU [50554] .......25-7225.60.4 All MN or MI Programs [50555] ...................................................25-73

Income of an MN or MI Person Used to Determine Public Assistance Eligibility of Another Family Member [50555.1] .........................................25-73Health Insurance Premiums [50555.2] ...................................25-73Allocation to Excluded Children [50558] ................................25-74

25.61 Veterans’ Benefits ......................................................................................25-7425.61.1 Background .................................................................................25-7425.61.2 Aid and Attendance.....................................................................25-75

Treatment of A&A Income ......................................................25-7525.61.3 Payments for Unusual Medical Expense.....................................25-75

Treatment ...............................................................................25-75Verification .............................................................................25-75

25.61.4 Definitions....................................................................................25-76Veteran ..................................................................................25-76Veteran’s Dependent .............................................................25-76

25.61.5 Client Responsibility ....................................................................25-7625.61.6 EW Responsibility .......................................................................25-7725.61.7 MC 05 Procedures ......................................................................25-7725.61.8 Follow-Up Procedures When A Claim Has Been Initiated ..........25-7825.61.9 When an MC 05 Referral is Not Necessary ................................25-7825.61.10 Budgeting Information .................................................................25-7925.61.11 Veterans Educational Benefits ....................................................25-79


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GI Bill .....................................................................................25-80Post 9/11 GI Bill .....................................................................25-80Veterans’ Educational Assistance Program (VEAP) ..............25-81

25.62 Unemployment Insurance Benefits/Disability Insurance Benefits ..............25-8125.62.1 Client Responsibility (Unconditionally Available Income)............25-8125.62.2 Eligibility Worker Responsibility...................................................25-8225.62.3 Budgeting Information .................................................................25-83

25.63 Retirement Survivors Disability Insurance (RSDI)......................................25-8525.63.1 Client Responsibility (Unconditionally Available Income)............25-8625.63.2 EW Responsibility .......................................................................25-8625.63.3 General Benefit Information ........................................................25-87

25.64 Supplemental Security Income (SSI) .........................................................25-8825.64.1 Who Is Eligible for SSI.................................................................25-8825.64.2 Who Must Apply for SSI ..............................................................25-8825.64.3 Verification of SSI........................................................................25-8825.64.4 Other Information on SSI.............................................................25-89

25.65 Annual COLAS for Government Pensions .................................................25-9025.65.1 Public Employees Retirement System (PERS) ...........................25-9025.65.2 State Teachers Retirement System (STRS) ...............................25-9025.65.3 Civil Service Annuities (CSA) ......................................................25-90

25.66 Income [50167(a)(7), 50507, 50518, 50186, MEPM Article 10 and 15]............................................................................25-9125.66.1 When Required ...........................................................................25-9125.66.2 Verification Required ...................................................................25-91

Earned Income .......................................................................25-91Self Employment ....................................................................25-92Use of Tax Return to Verify Income .......................................25-92Unconditionally Available Income ..........................................25-93Income-In-Kind .......................................................................25-93Fluctuating Income .................................................................25-94Tip Income .............................................................................25-94Temporary Workers Compensation .......................................25-94Veteran’s Benefits or Aid and Attendance Payments ............25-94Interest and Dividend Income ................................................25-94Child Support Spousal Support ..............................................25-94Educational Grants and Loans ...............................................25-95Net Income from Property ......................................................25-95Income Deductions ................................................................25-95

26. Property ...........................................................................................................26-1

26.1 Property Limits .............................................................................................26-126.1.1 Real Property Limits ......................................................................26-1


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26.2 Availability of Property [50402].....................................................................26-1

26.3 Unavailable Property [50402] .......................................................................26-126.3.1 Intent to Liquidate or Sell the Property ..........................................26-2

Bona Fide Effort and Good Faith .............................................26-226.3.2 No Ownership................................................................................26-2

Period of Unavailability ............................................................26-326.3.3 Property owned by Native American Indians ................................26-3

Verification ...............................................................................26-4

26.4 Property to Be Considered in Determining Eligibility [50401] .......................26-426.4.1 Include...........................................................................................26-4

26.5 MFBU Determination for Property for Persons in Board and Care ..............26-5

26.6 Property Co-Ownership Chart ......................................................................26-7

26.7 Property Worksheet (MC 176P) ...................................................................26-8

26.8 Conversion of Property [50407]....................................................................26-926.8.1 Definition .......................................................................................26-926.8.2 Evaluation......................................................................................26-9

26.9 Property Spenddown [50420, 50710].........................................................26-1026.9.1 Spenddown in Month of Application ...........................................26-1026.9.2 Spenddown for Three-Month Retroactive Medi-Cal ....................26-1126.9.3 Ongoing Medi-Cal Cases ............................................................26-1126.9.4 LTC Insurance Exemption...........................................................26-12

26.10 Excess Property Applied To Medical Bills [50421; MEPM 9L] ...................26-1226.10.1 Rule .............................................................................................26-1226.10.2 When It Applies ...........................................................................26-1326.10.3 Income v Property .......................................................................26-1326.10.4 MC 174........................................................................................26-1426.10.5 Hunt v Kizer.................................................................................26-1526.10.6 Reviewing Property Balance at Intake ........................................26-16

Over Limit ...............................................................................26-16Under Limit .............................................................................26-16Procedure ..............................................................................26-16

26.11 Retroactive Spenddown of Excess Property on Medical Expenses (Principe Exemption)26-1826.11.1 Overview .....................................................................................26-1826.11.2 Impact..........................................................................................26-1826.11.3 Definitions....................................................................................26-19

Qualified Medical Expense ....................................................26-19Principe Property Exemption .................................................26-19Principe Month .......................................................................26-20

26.11.4 Principe v. Belshe........................................................................26-2026.11.5 Verification of Payments..............................................................26-20


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26.11.6 MC 174........................................................................................26-2126.11.7 3-Month Retroactive Medi-Cal.....................................................26-2226.11.8 Informing Requirement................................................................26-2226.11.9 Continuing Beneficiary ................................................................26-23

26.12 Transfer of Property by Persons not in LTC...............................................26-2326.12.1 Transfers by Others (Not Currently in LTC facility) .....................26-2326.12.2 General........................................................................................26-24

26.13 Personal Property......................................................................................26-24

26.14 Motor Vehicles, Boats, Campers, Trailers and Mobile Homes [Procedures 9B, 50461, 50463]..........................................26-2426.14.1 Exempt ........................................................................................26-2426.14.2 Nonexempt ..................................................................................26-2526.14.3 Determination of Value................................................................26-2526.14.4 Determination of Value Using DMV License Fee Rate Table .....26-25

26.15 Cash [50451] ..............................................................................................26-2626.15.1 Exempt ........................................................................................26-2626.15.2 Nonexempt ..................................................................................26-2726.15.3 Verification...................................................................................26-27

26.16 Bank or Credit Union Accounts ..................................................................26-2726.16.1 Exempt ........................................................................................26-2726.16.2 Nonexempt ..................................................................................26-2826.16.3 Verification...................................................................................26-28

26.17 Stocks, Bonds, Mutual Funds [50456]........................................................26-2926.17.1 Exempt ........................................................................................26-2926.17.2 Nonexempt ..................................................................................26-2926.17.3 Verification...................................................................................26-2926.17.4 Determination of Value................................................................26-29

26.18 Oil Leases and Mineral Rights ...................................................................26-3026.18.1 Exempt ........................................................................................26-3026.18.2 Nonexempt ..................................................................................26-3026.18.3 Verification...................................................................................26-3026.18.4 Value ...........................................................................................26-30

26.19 Savings Bonds [50457] ..............................................................................26-30

26.20 Trust Deeds, Mortgages, Notes, RAMs [PROC 9D, 9-G, 50425, 50441]...26-3126.20.1 Exempt ........................................................................................26-3126.20.2 Nonexempt ..................................................................................26-31

26.21 Home Equity Conversion (HEC) Plans.......................................................26-3226.21.1 Verification...................................................................................26-3326.21.2 Value ...........................................................................................26-33


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26.22 Tax Refunds [50454] ..................................................................................26-3426.22.1 State Refunds..............................................................................26-3426.22.2 Federal Refunds..........................................................................26-3426.22.3 Verification...................................................................................26-3426.22.4 Time Limited Changes to Tax Credits and Refunds....................26-35

26.23 2009 ARRA Making Work Pay Credit.........................................................26-35

26.24 Loans [50483].............................................................................................26-3626.24.1 Exempt ........................................................................................26-3626.24.2 Nonexempt ..................................................................................26-3626.24.3 Verification...................................................................................26-36

26.25 Lump Sum Payments [50445, 50455, 50507] ............................................26-3726.25.1 Exempt ........................................................................................26-3726.25.2 Nonexempt ..................................................................................26-3826.25.3 Exception.....................................................................................26-3826.25.4 Verification...................................................................................26-38

26.26 Life Insurance [50475]................................................................................26-3926.26.1 Exempt ........................................................................................26-3926.26.2 Nonexempt ..................................................................................26-3926.26.3 Verification...................................................................................26-4026.26.4 Determination of Value................................................................26-4026.26.5 Availability of CSV.......................................................................26-41

26.27 Burial Insurance [50476] ............................................................................26-41

26.28 Burial Plots, Vaults, Crypts and Related Items [50477]..............................26-4126.28.1 Exempt ........................................................................................26-4126.28.2 Verification...................................................................................26-4226.28.3 Nonexempt ..................................................................................26-42

26.29 Burial Funds [50479] ..................................................................................26-4326.29.1 Irrevocable Burial Funds .............................................................26-43

Exempt ...................................................................................26-43Interest ...................................................................................26-44Changing the Fund ................................................................26-44

26.29.2 Revocable Burial Funds ..............................................................26-44Exempt ...................................................................................26-44Interest ...................................................................................26-45Verification .............................................................................26-45Converting to New Rules .......................................................26-45

26.29.3 Commingled Burial Funds ...........................................................26-46Not Allowed ............................................................................26-46Allowable ................................................................................26-47

26.29.4 Use for Another Purpose.............................................................26-4726.29.5 Designating the CSV of Life Insurance .......................................26-47


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26.30 Life Estate Interest (Personal Property) [50442] ........................................26-4826.30.1 Nonexempt/Exempt.....................................................................26-4826.30.2 Verification...................................................................................26-4826.30.3 Determination of Value................................................................26-49

26.31 Business Property [50485] .........................................................................26-4926.31.1 Exempt ........................................................................................26-49

Property Intended for Self-Employment .................................26-4926.31.2 Nonexempt ..................................................................................26-5026.31.3 Rules for Business Property........................................................26-5026.31.4 Period of Exemption ....................................................................26-5026.31.5 Verifications.................................................................................26-51

26.32 Jewelry [50467] ..........................................................................................26-5226.32.1 Exempt ........................................................................................26-5226.32.2 Nonexempt ..................................................................................26-5226.32.3 Determination of Value................................................................26-52

26.33 Veterans' Educational Assistance Plan (VEAP) .........................................26-5326.33.1 Exempt ........................................................................................26-5326.33.2 Nonexempt ..................................................................................26-5326.33.3 Verification...................................................................................26-53

26.34 Holocaust Restitution Payments ................................................................26-5326.34.1 Exempt ........................................................................................26-5326.34.2 Nonexempt ..................................................................................26-5426.34.3 Verification...................................................................................26-54

26.35 Japanese-American and Aleutian Restitution/Reparation/Redress Payments26-5426.35.1 Exempt ........................................................................................26-5426.35.2 Nonexempt ..................................................................................26-5526.35.3 Verification...................................................................................26-55

26.36 Cash Payments for Medical and Social Services [50455.5] .......................26-5626.36.1 Definitions....................................................................................26-56

Medical Service ......................................................................26-56Social Service ........................................................................26-56

26.36.2 Exempt ........................................................................................26-5626.36.3 Nonexempt ..................................................................................26-5726.36.4 Verification...................................................................................26-57

26.37 Pension Funds (i.e., IRAs, Keogh) [50402, 50458] ....................................26-5826.37.1 Definition .....................................................................................26-58

Pension funds ........................................................................26-58Good Faith/Bona Fide Effort ..................................................26-58

26.37.2 Exempt ........................................................................................26-5926.37.3 Nonexempt ..................................................................................26-6026.37.4 Verification...................................................................................26-60


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26.38 Excess Property Due to SSI Overpayments ..............................................26-61

26.39 Miller v Woods (IHSS Payments) ...............................................................26-62

26.40 Agent Orange Payments ............................................................................26-6226.40.1 History .........................................................................................26-6226.40.2 Exempt ........................................................................................26-6226.40.3 Nonexempt ..................................................................................26-6326.40.4 Verification...................................................................................26-63

26.41 Disaster Assistance....................................................................................26-63

26.42 Replacement of Exempt Property ..............................................................26-6426.42.1 Good Cause ................................................................................26-6426.42.2 Verification...................................................................................26-65

26.43 Payments to Crime Victims ........................................................................26-65

26.44 Prop 103 Refunds ......................................................................................26-65

26.45 Senior Citizens Rent Assistance ................................................................26-65

26.46 Filipino Veterans Equity Compensation Fund ............................................26-66

26.47 Austrian Social Insurance Payments..........................................................26-6626.47.1 Description ..................................................................................26-6626.47.2 Verification...................................................................................26-67

26.48 Relocation Assistance Payments ...............................................................26-6726.48.1 Description ..................................................................................26-6726.48.2 Exempt ........................................................................................26-6726.48.3 Treatment of Interest ...................................................................26-6826.48.4 Effective Date ..............................................................................26-68

26.49 Specialized Adaptive Equipment................................................................26-6826.49.1 Specially Equipped Motor Vehicle...............................................26-68

26.50 Susan Walker v. Bayer Corporation Payments ..........................................26-6926.50.1 Description ..................................................................................26-6926.50.2 Exempt ........................................................................................26-69

26.51 Quilling v. Belshe Payments .......................................................................26-6926.51.1 Description ..................................................................................26-6926.51.2 Exempt ........................................................................................26-7026.51.3 Verification...................................................................................26-70

26.52 Restricted Accounts for CalWORKs or Former CalWORKs Recipients...................................................................26-7026.52.1 Background .................................................................................26-7026.52.2 Description ..................................................................................26-7126.52.3 Example ......................................................................................26-71


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26.52.4 Interest Payments .......................................................................26-71

26.53 California Partnership-approved LTC Insurance Policy or Certificate ........26-72

26.54 National Defense Authorization Act of 1997 Payments............................26-7226.54.1 Exempt ........................................................................................26-7226.54.2 Nonexempt ..................................................................................26-7226.54.3 Verification...................................................................................26-72

26.55 Ricky Ray Hemophilia Relief Fund Act Payments....................................26-7326.55.1 Exempt ........................................................................................26-7326.55.2 Nonexempt ..................................................................................26-7326.55.3 Verification...................................................................................26-73

26.56 Gifts to Children With Life-Threatening Conditions ....................................26-7326.56.1 Exempt ........................................................................................26-7326.56.2 Nonexempt ..................................................................................26-7426.56.3 Verification...................................................................................26-74

26.57 Other Items.................................................................................................26-74

26.58 Radiation Exposure Compensation Payments...........................................26-7526.58.1 Exempt ........................................................................................26-7526.58.2 Nonexempt ..................................................................................26-75

26.59 Compensation for Participating in Clinical Trials ........................................26-7526.59.1 Verification...................................................................................26-76

26.60 IHSS Plus Waiver Payments......................................................................26-78

26.61 Individual Development Accounts (IDA).....................................................26-7826.61.1 Exempt ........................................................................................26-7926.61.2 Nonexempt ..................................................................................26-7926.61.3 Verification...................................................................................26-79

26.62 Trusts: Similar Legal Devices (SLD) ..........................................................26-79

26.63 Endowment Life Insurance Contracts (ELIC) ............................................26-80

26.64 Trusts and Annuities [Article 9J] .................................................................26-81

26.65 Background ................................................................................................26-81

26.66 Overview ....................................................................................................26-81

26.67 Treatment of Trusts ....................................................................................26-82

26.68 General Definitions.....................................................................................26-8326.68.1 Annuitant .....................................................................................26-8326.68.2 Annuitized....................................................................................26-8326.68.3 Annuity ........................................................................................26-84


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26.68.4 Assets..........................................................................................26-8426.68.5 Beneficiary...................................................................................26-8426.68.6 Cash Refund ...............................................................................26-8426.68.7 Cost of Living Increase................................................................26-8526.68.8 Death Benefit...............................................................................26-8526.68.9 Established..................................................................................26-8526.68.10 Irrevocable...................................................................................26-8526.68.11 Payment ......................................................................................26-8526.68.12 Principal/Corpus ..........................................................................26-8626.68.13 Property Right .............................................................................26-8626.68.14 Revocable ...................................................................................26-8626.68.15 Similar Legal Device (SLD) .........................................................26-8626.68.16 Trust ............................................................................................26-8726.68.17 Trustee ........................................................................................26-8726.68.18 Trustor .........................................................................................26-8726.68.19 Trust Income ...............................................................................26-87

26.69 Identifying Characteristic of Trusts .............................................................26-8826.69.1 OBRA ‘93 Trusts .........................................................................26-8826.69.2 Medicaid Qualifying Trusts (MQTs).............................................26-8826.69.3 Other Trusts ................................................................................26-89

26.70 Trust Comparison Chart .............................................................................26-8926.70.1 Example ......................................................................................26-90

26.71 Verification..................................................................................................26-9026.71.1 Written Trusts ..............................................................................26-9026.71.2 Oral Trusts...................................................................................26-91

26.72 Exempt Income or Property Held in Trust ..................................................26-91

26.73 Transferred Asset.......................................................................................26-91

26.74 Treatment of OBRA ‘93 Trusts ...................................................................26-9226.74.1 Revocable OBRA ‘93 Trusts .......................................................26-9226.74.2 Irrevocable OBRA ‘93 Trusts.......................................................26-93

Irrevocable Trust with Disbursements Allowable ...................26-93Irrevocable Trust with NO Disbursements Allowable .............26-94

26.74.3 Undue Hardship ..........................................................................26-95When Undue Hardship Applies ..............................................26-96When Undue Hardship Doesn’t Apply ...................................26-96

26.75 Treatment of MQT Trusts ...........................................................................26-9626.75.1 Revocable MQT ..........................................................................26-9626.75.2 Irrevocable MQT..........................................................................26-97

Trust principal ........................................................................26-97Trust income ..........................................................................26-98

26.75.3 Undue Hardship ..........................................................................26-99


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26.76 Treatment of Other Trusts ..........................................................................26-9926.76.1 Revocable Other Trusts ............................................................26-10026.76.2 Irrevocable Other Trusts............................................................26-10026.76.3 Trusts Established on or after 8/11/93 for Disabled Individuals 26-101

Individual and Pooled Trust Characteristic Table ................26-101Recovery of Costs ................................................................26-102

26.76.4 California Uniform Gift to Minors Act (CUTMA)/Uniform Gift to Minors Act (UTMA) Trusts ..............................................26-102

Treatment .............................................................................26-103

26.77 Special Needs Trust (SNT) ......................................................................26-103

26.78 Living Trusts .............................................................................................26-104

26.79 Identifying Characteristics of Annuities ....................................................26-10526.79.1 OBRA ‘93 Annuities...................................................................26-10626.79.2 Other Annuities..........................................................................26-106

26.80 Annuity Comparison Chart .......................................................................26-107

26.81 Verification................................................................................................26-107

26.82 OBRA ‘93 Annuity (Purchased on or after 8/11/93) .................................26-10826.82.1 Properly Annuitized ...................................................................26-10826.82.2 Determining Life Expectancy.....................................................26-10826.82.3 Treatment of a Properly Annuitized Annuity..............................26-109

Income .................................................................................26-109Property ...............................................................................26-109

26.82.4 Treatment of an Annuity Not Properly Annuitized .....................26-109Deferred Annuity ..................................................................26-110When an annuity cannot be restructured .............................26-110

26.82.5 Undue Hardship ........................................................................26-112

26.83 Other Annuities.........................................................................................26-11226.83.1 Treatment of Other Annuities ....................................................26-11326.83.2 Undue Hardship ........................................................................26-113

26.84 Annuity Distribution/Treatment Chart .......................................................26-113

26.85 Annuity Examples.....................................................................................26-114Example 1: LIFE EXPECTANCY EXCEEDS PERIOD CERTAIN 26-114Example 2: PERIOD CERTAIN EXCEEDS LIFE EXPECTANCY - UNDUE HARDSHIP ..........................................................................26-115Example 3: OTHER BENEFICIARY NAMED PRIOR TO START OF PAYMENTS 26-115Example 4: SPECIFIED DEATH BENEFIT ..........................26-115Example 5: UNSPECIFIED CASH REFUND .......................26-116Example 6: OTHER BENEFICIARY NAMED AFTER PAYMENTS HAVE STARTED 26-116


Medi-CalMedi-Cal

Example 7: PAYMENTS MADE TO ANOTHER PERSON - SOLE SUPPORT 26-116Example 8: LIFE EXPECTANCY EXCEEDS PERIOD CERTAIN 26-117

26.86 Analysis of Sample Annuities ...................................................................26-11726.86.1 Properly Annuitized Payment Schedule ....................................26-11726.86.2 Improperly Structured Payment Schedule.................................26-118

Level Payment Sample ........................................................26-1203% Annual Increase Sample ................................................26-1205% Annual Increase .............................................................26-121

26.87 Life Expectancy (L.E.) Table - Males .......................................................26-123

26.88 Life Expectancy (L.E.) Table - Females ...................................................26-125

26.89 Sneede Considerations ............................................................................26-126

26.90 DHCSPrincipal Residence .......................................................................26-126

26.91 Definitions [50425]....................................................................................26-12626.91.1 Principal Residence...................................................................26-12626.91.2 Appertains .................................................................................26-12726.91.3 Contiguous ................................................................................26-127

26.92 General Rules ..........................................................................................26-127

26.93 Exemption of Principal Residence............................................................26-12926.93.1 Intent to Return..........................................................................26-129

Out of State ..........................................................................26-130Out-of-County Property ........................................................26-131Intent to Return is Questionable ..........................................26-131

26.93.2 Child, Spouse or Dependent Relative in Home.........................26-131Blind Child Age 21 or Older .................................................26-131Disabled Child Age 21 or Older ...........................................26-131Dependency Requirements .................................................26-132

26.93.3 Legal Obstacles to Sell..............................................................26-13226.93.4 Client Not in LTC, Property Listed for Sale ...............................26-133

26.94 Net Nonexempt Income From Principal Residence .................................26-134

26.95 Documentation .........................................................................................26-13426.95.1 “Property Supplement” (MC 210 PS) ........................................26-134

26.96 County Level Review (Bagley v Rank) .....................................................26-13526.96.1 EW Actions................................................................................26-135

26.97 List or Lien Requirements (Non-LTC) ......................................................26-136Lien Requirements ...............................................................26-136List Requirements ................................................................26-136

26.97.1 “List Property for Sale - Persons Not in Long-Term Care” (MC 239 X)26-137


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26.97.2 Applicant's/Beneficiary's Response, Listed at FMV ..................26-13726.97.3 Listing not Provided...................................................................26-13826.97.4 Lien Procedures ........................................................................26-13826.97.5 Effective Date of Lien ................................................................26-13926.97.6 Non-Cooperation .......................................................................26-139

26.98 Reporting Responsibilities........................................................................26-140

26.99 Mandatory Informing Notices ...................................................................26-140

26.100Exemption of Principal Residence Eligibility Flow Chart ..........................26-141

26.101Other Real Property (ORP) ......................................................................26-142

26.102Exemption/Unavailability of ORP [50402] ................................................26-142

26.103Definitions [50413, 50415, 50427] ...........................................................26-14426.103.1 Fair Market Value (FMV) ...........................................................26-14426.103.2 Investment Property ..................................................................26-14426.103.3 Market Value .............................................................................26-145

California property ................................................................26-145Property located outside California ......................................26-145

26.103.4 Encumbrances ..........................................................................26-145Net Market Value (NMV) ......................................................26-146

26.104Determine Ownership Share and Amount to Be Utilized .........................26-146

26.105Utilization [50416].....................................................................................26-147

26.106Time Limits for Utilization .........................................................................26-148

26.107Examples of Other Real Property (ORP) Utilization.................................26-14926.107.1 Value of ORP is Within Property Limits.....................................26-14926.107.2 Value of ORP is Over Property Limits, ORP Must Be Utilized ..26-15026.107.3 Deed of Trust, Utilization Met ....................................................26-15026.107.4 Value of ORP over $6,000, Utilization Requirements Met ........26-15026.107.5 Excess ORP Over $6,000, Not Eligible .....................................26-15026.107.6 ORP Value Under $6,000, Utilization Not Met ..........................26-151

26.108Life Estate [MEPM 9A] .............................................................................26-151

26.109Definitions ................................................................................................26-152Life Estate ............................................................................26-152Life Tenant/Beneficiary ........................................................26-152Grantor/Trustor ....................................................................26-152Remainderman ....................................................................26-152Revocable ............................................................................26-153Irrevocable ...........................................................................26-153

26.110Life Estate Interest in Real Property ........................................................26-153Principal Residence .............................................................26-153


Medi-CalMedi-Cal

Other Real Property (ORP) ..................................................26-153Verification ...........................................................................26-153

26.111When to Evaluate.....................................................................................26-153

26.112Method of Evaluation ...............................................................................26-15426.112.1 Revocable Life Estate ...............................................................26-15426.112.2 Irrevocable/Other Life Estates...................................................26-15526.112.3 Determination of Past Value......................................................26-156

26.113Life Estate Value Table ............................................................................26-157

26.114Property Assessments [50142.5] .............................................................26-15826.114.1 Property Assessment Application and Statement of Facts .......26-15926.114.2 Completing the Property Assessment .......................................26-160

26.115Property [50167].......................................................................................26-16126.115.1 When Required .........................................................................26-16126.115.2 Verification Required .................................................................26-161

Market value of real property other than home ....................26-161Value of Stocks, Bonds, and Mutual Funds .........................26-162U.S. Savings Bonds .............................................................26-162Deeds of Trusts, Mortgages and Promissory Notes. ...........26-162Value of Nonexempt Vehicles. .............................................26-163Nonexempt Insurance Policies ............................................26-163Nonexempt jewelry (NMV over $100 each piece) ................26-163Burial Trusts or Pre-Paid Burial Contract .............................26-163Nonexempt Property Held in Trust .......................................26-163Value of Oil Leases ..............................................................26-163

27. DDSD................................................................................................................27-1

27.1 Federally Disabled Persons [50167, Proc. 22C] ..........................................27-127.1.1 Overview .......................................................................................27-127.1.2 Definition .......................................................................................27-127.1.3 Duration.........................................................................................27-227.1.4 Other Linkage................................................................................27-2

27.2 DDSD Referral Not Required ......................................................................27-2

27.3 Who Should Not Be Referred to DDSD........................................................27-3

27.4 DDSD Referral Required..............................................................................27-4

27.5 Clients Alleging Disability .............................................................................27-627.5.1 MC 210..........................................................................................27-727.5.2 Blindness ......................................................................................27-827.5.3 Client's Statement .........................................................................27-827.5.4 RSDI/SSI Pending.........................................................................27-8


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27.5.5 Presumptive Disability ...................................................................27-9

27.6 Promptness ..................................................................................................27-9

27.7 RSDI/SSI Pending......................................................................................27-10

27.8 Retro Onset Dates......................................................................................27-10

27.9 Disability Determination Service Division (DDSD) Referral Limited by SSA Decision27-1127.9.1 Overview .....................................................................................27-1127.9.2 Conditions ...................................................................................27-1227.9.3 Screening Form...........................................................................27-1327.9.4 Completion of MC 223 or MC 223C ............................................27-1327.9.5 Informing Notice/NOAs................................................................27-1327.9.6 Referring Clients to Social Security.............................................27-1427.9.7 SSA Approves Disability After Originally Denying Claim.............27-1427.9.8 Discontinuance of SSA Disability Benefits - “Cessation of Disability”27-15

Social Security Appeal Process .............................................27-15EW Action ..............................................................................27-15

27.9.9 Discontinuance of SSI/SSP Disability Benefits - “Non-Disability Reasons”27-16

27.10 Disability Determination Service Division (DDSD) Decision Chart .............27-1727.10.1 SSA/DDSD-SP Client Referral Chart ..........................................27-18

27.11 Other Linkage.............................................................................................27-19

27.12 Presumptive Eligibility (PD) ........................................................................27-19

27.13 Deceased DDSD Applicants ......................................................................27-20

27.14 Determining Substantial Gainful Activity (SGA) .........................................27-2027.14.1 Background/Definition .................................................................27-2027.14.2 When to Apply SGA Procedures .................................................27-2127.14.3 Presumptive Disability and SGA .................................................27-2127.14.4 Retroactive Medi-Cal and SGA ...................................................27-2227.14.5 SGA Does Not Apply...................................................................27-2227.14.6 Income In-Kind and SGA.............................................................27-2327.14.7 Procedures ..................................................................................27-2327.14.8 Impairment-Related Work Expenses (IRWEs) ............................27-24

Conditions ..............................................................................27-24MC 272 ..................................................................................27-25MC 273 ..................................................................................27-25Budgeting IRWE ....................................................................27-25

27.14.9 Types of IRWE ............................................................................27-26Attendant Care .......................................................................27-26Transportation Costs ..............................................................27-27Medical Devices .....................................................................27-27Prosthesis ..............................................................................27-27Work-Related Equipment and Assistants ..............................27-27


Medi-CalMedi-Cal

Residential Modifications .......................................................27-28Drugs, Medical Services, Diagnostic Procedures, and Medical Supplies ....................................................................27-28Non-Medical Appliances/Devices ..........................................27-28Other Items and Services ......................................................27-28

27.14.10 Work Subsidies ...........................................................................27-28Subsidies: ..............................................................................27-29

27.14.11 Medi-Cal Budget..........................................................................27-2927.14.12 Unsuccessful Work Attempt (UWA) ............................................27-3027.14.13 Example of an SGA Determination .............................................27-30

27.15 Disability Referral Checklist........................................................................27-31

27.16 DDSD — Providing EW Observations........................................................27-33

27.17 Use of MC 221 or DHS 7045......................................................................27-33

27.18 Guidelines for Observations .......................................................................27-3327.18.1 General........................................................................................27-3327.18.2 Physical Mobility..........................................................................27-3427.18.3 Physical Appearance...................................................................27-3427.18.4 Other Physical Problems.............................................................27-3427.18.5 Special Senses............................................................................27-3527.18.6 Mental and Emotional Status ......................................................27-35

27.19 DDSD — Disability Evaluation Forms ........................................................27-36

27.20 Forms/Documents to be Included in the DDSD Packet .............................27-3627.20.1 List of Forms................................................................................27-3627.20.2 List of Documents........................................................................27-37

Medical Records ....................................................................27-37SSA Documents .....................................................................27-37Death Certificate ....................................................................27-38

27.21 “What You Should Know About Your Medi-Cal Disability Application” (MC 017)27-3827.21.1 Purpose .......................................................................................27-38

27.22 “90-Day Status Letter” (MC 179) ................................................................27-3827.22.1 Purpose .......................................................................................27-38

27.23 “Authorization for Release of Information” (MC 220) ....................................................................................................27-3927.23.1 Purpose .......................................................................................27-3927.23.2 How Many? .................................................................................27-3927.23.3 Completion Requirements...........................................................27-39

Appropriate Actions ................................................................27-39Inappropriate Actions .............................................................27-39

27.23.4 Signature Requirements..............................................................27-39Exceptions/Special Situations ................................................27-40


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27.23.5 Reminders ...................................................................................27-4127.23.6 Revocation ..................................................................................27-42

27.24 “Disability Determination and Transmittal” (MC 221) ....................................................................................................27-4227.24.1 Completion Requirements...........................................................27-42

Items 1-4 and 7 ......................................................................27-42Item 2 .....................................................................................27-43Item 5 .....................................................................................27-43Item 6 .....................................................................................27-43Item 8 .....................................................................................27-43Item 9 .....................................................................................27-43Item 10 ...................................................................................27-43Items 11, 12 ...........................................................................27-44Items 13-20 ............................................................................27-44

27.25 “DDSD Pending Information Update” (MC 222) .........................................27-4427.25.1 Purpose .......................................................................................27-4427.25.2 Types of Changes to Report .......................................................27-45

27.26 “Applicant's Supplemental Statement of Facts for Medi-Cal” (MC 223) .....27-4527.26.1 Purpose .......................................................................................27-4527.26.2 Impact of Prior SSA Decision ......................................................27-4527.26.3 Completion Requirements: Part I — Personal Information .........27-46

Item 1a ...................................................................................27-46Item 1b ...................................................................................27-46Item 1c ...................................................................................27-46Item 1d ...................................................................................27-46Item 1e ...................................................................................27-46Items 1f-1g .............................................................................27-46Items 2a-2b ............................................................................27-46Item 3 .....................................................................................27-47Item 4a-4b ..............................................................................27-47

27.26.4 Part II — Medical Information......................................................27-47Item 5a - 5d ............................................................................27-47Item 6 .....................................................................................27-47Items 7-8 ................................................................................27-47Item 9 .....................................................................................27-48Item 10 ...................................................................................27-48Item 11 ...................................................................................27-48Item 12 ...................................................................................27-48Item 13 ...................................................................................27-49

27.26.5 Part III — Social and Educational Information.............................27-49Item 14 ...................................................................................27-49Item 15a - 15c ........................................................................27-49Item 16 ...................................................................................27-49

27.26.6 Part IV — Work History ...............................................................27-50Item 17a - 17b ........................................................................27-50


Medi-CalMedi-Cal

27.26.7 Part V — Signature and Certification ..........................................27-50

27.27 “Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age of 18” (MC 223C)..................................................................................................27-5127.27.1 Purpose .......................................................................................27-5127.27.2 Impact of Prior SSA Decision ......................................................27-5127.27.3 Completion Requirements: Part 1 — Personal Information ........27-51

Item A .....................................................................................27-51Item B .....................................................................................27-52Item C ....................................................................................27-52Item D ....................................................................................27-52Items E-F ...............................................................................27-52Item G ....................................................................................27-52Item H ....................................................................................27-52Item I ......................................................................................27-52

27.27.4 Part 2 — The Child’s Illnesses, Injuries, or Medical Conditions ..27-53Item A .....................................................................................27-53

27.27.5 Part 3 — Social Security/SSI Information....................................27-53Items A-D ...............................................................................27-53

27.27.6 Part 4 — Special Sources and School Information .....................27-53Item A .....................................................................................27-53Item B .....................................................................................27-53Item C ....................................................................................27-53Item D ....................................................................................27-54Item E .....................................................................................27-54Item F .....................................................................................27-54Item G ....................................................................................27-54Item H ....................................................................................27-54Item I ......................................................................................27-54

27.27.7 Part 5 — Medical Information......................................................27-55Item A .....................................................................................27-55Item B .....................................................................................27-55

27.27.8 Part 6 — Medications ..................................................................27-5627.27.9 Part 7 — Tests ............................................................................27-5627.27.10 Part 8 — Work History.................................................................27-5627.27.11 Part 9 — Remarks.......................................................................27-5627.27.12 Part 10 — Signature and Certification.........................................27-57

27.28 “SGA Worksheet” (MC 272) .......................................................................27-57

27.29 “Work Activity Report” (MC 273) ................................................................27-57

27.30 “Medi-Cal Report on Adult/Child With Allegation of HIV” (DHCS 7035 A / DHCS 7035 C)27-58

27.31 “Worker Observations - Disability” (DHCS 7045) .......................................27-58

27.32 “DDSD Transmittal” (SCD 1475) ................................................................27-5827.32.1 Users of SCD 1475 .....................................................................27-5927.32.2 Online Form.................................................................................27-59


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27.32.3 Instructions for Completion..........................................................27-59

27.33 DDSD — EW Procedures ..........................................................................27-60

27.34 Recording DDSD Pending..........................................................................27-60

27.35 Sending the DDSD Packet .........................................................................27-61

27.36 DDSD Address/ Phone...............................................................................27-61

27.37 Delayed DDSD Referrals ...........................................................................27-6227.37.1 Background .................................................................................27-6227.37.2 Procedure....................................................................................27-6227.37.3 Packets Rejected by DDSD ........................................................27-6327.37.4 DDSD Actions When Referral is Received..................................27-6327.37.5 Reporting Changes to DDSD ......................................................27-64

27.38 DDSD Decisions.........................................................................................27-6527.38.1 Is Disabled...................................................................................27-6627.38.2 Is Not Disabled ............................................................................27-6627.38.3 No Determination ........................................................................27-6727.38.4 “No Determination” (Noncooperation by Doctor).........................27-69

27.39 DDSD Status Reports ................................................................................27-6927.39.1 Description ..................................................................................27-69

Pending List ...........................................................................27-70Closed List .............................................................................27-70

27.39.2 Basis Codes ................................................................................27-70Allowance Basis Codes (Disability Approved) .......................27-71Denial Basis Codes (Disability Denied) .................................27-71No Determination Basis Codes ..............................................27-72“Z” Codes ...............................................................................27-72

27.39.3 Monitoring Requirements ............................................................27-7227.39.4 SSPMs ........................................................................................27-7227.39.5 Follow-up Action - EW Supervisors and EWs .............................27-7327.39.6 DDSD Decision Needed..............................................................27-73

27.40 DDSD Inquiries...........................................................................................27-7327.40.1 District Office DDSD Liaison .......................................................27-7327.40.2 Medi-Cal Program Coordinator ...................................................27-74

27.41 DDSD Referral Packets..............................................................................27-7427.41.1 Full Packet...................................................................................27-7427.41.2 Limited Packet.............................................................................27-7427.41.3 Options to Process Disability Evaluation Referral Packets .........27-75

27.42 DDSD — Special Referrals ........................................................................27-75

27.43 Limited DDSD Referral ...............................................................................27-7527.43.1 Allowable Circumstances ............................................................27-75


Medi-CalMedi-Cal

27.43.2 Required Forms...........................................................................27-76

27.44 DDSD Referral for a Retro Month ..............................................................27-7727.44.1 New Applicant .............................................................................27-7727.44.2 DDSD Pending ............................................................................27-7727.44.3 After DDSD Approval ..................................................................27-77

27.45 Referral for Former SSI/SSP Recipient - Discontinued for Reasons Other than “Cessation of Disability”..............................................................................27-7827.45.1 Purpose .......................................................................................27-7827.45.2 DDSD Referral ............................................................................27-7827.45.3 DDSD Approval ...........................................................................27-7927.45.4 No Decision .................................................................................27-79

27.46 Referral for Former SSI/SSP Recipient - “Cessation of Disability” .............27-7927.46.1 Purpose .......................................................................................27-7927.46.2 DDSD Referral ............................................................................27-8027.46.3 No Decision .................................................................................27-80

27.47 DDSD — Reexaminations, Redeterminations, and Reevaluations............27-81

27.48 RSDI and Disability ....................................................................................27-8127.48.1 Overview .....................................................................................27-8127.48.2 Verification Requirement .............................................................27-81

Intake .....................................................................................27-81Redetermination .....................................................................27-82

27.48.3 Follow-Up ....................................................................................27-82

27.49 Determined Disability ................................................................................27-8227.49.1 Overview .....................................................................................27-8227.49.2 Types of Referrals to DDSD........................................................27-82

27.50 Reexaminations..........................................................................................27-8327.50.1 No Federal Decision Involved .....................................................27-8327.50.2 Federal Decision Involved ...........................................................27-84

Exception ...............................................................................27-8527.50.3 HIV Exception..............................................................................27-85

27.51 Redeterminations .......................................................................................27-86

27.52 Reevaluations.............................................................................................27-8727.52.1 DDSD Independent Review Claim ..............................................27-8827.52.2 DDSD Adopted SSA’s Decision ..................................................27-88

New Condition ........................................................................27-88Same Condition .....................................................................27-88

27.53 DDSD Referral Chart..................................................................................27-8927.53.1 Reexamination Referral Procedures ...........................................27-89

Responsibility Chart ...............................................................27-89


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27.53.2 Redetermination Referral Procedures.........................................27-9127.53.3 Reevaluation Referral Procedures ..............................................27-92

27.54 Failure to Cooperate...................................................................................27-93

27.55 Reexaminations on Appealed DDSD Denials ............................................27-93

27.56 DDSD — Presumptive Disability (PD)........................................................27-94PD Criteria .............................................................................27-95

27.57 Effective Date .............................................................................................27-95

27.58 3 Month Retro.............................................................................................27-96

27.59 Federal Denial ............................................................................................27-96

27.60 Presumptive Disability (PD) Categories .....................................................27-97

27.61 HIV/AIDS Policy .......................................................................................27-101

27.62 Presumptive HIV/AIDS Procedures..........................................................27-101

27.63 HIV/AIDS, Adults (Presumptive Criteria Met) ...........................................27-102

27.64 HIV/AIDS, Children, Birth Through Age 17 (Presumptive Criteria Met)....27-104

27.65 EW Grants PD..........................................................................................27-105

27.66 EW Requests PD Consideration from DDSD (For Urgent Case Requests)27-105

27.67 Urgent Case Request...............................................................................27-10627.67.1 DDSD Criteria to Grant PD for Urgent Case Requests .............27-106

27.68 Procedures for Urgent Case Request ......................................................27-107

27.69 Examples of Situations Requiring Urgent Case Request .........................27-108

27.70 Follow-Up/Expediting Decisions...............................................................27-109

27.71 Verification Requirement ..........................................................................27-109

27.72 Blindness and Disability [50167 (a) (1), MEPM Article 22]......................................................................................27-11027.72.1 When Required .........................................................................27-11027.72.2 Documentation Required...........................................................27-110

27.73 Presumptive Disability (PD) Checklist ......................................................27-111

28. Pickle and Aged, Blind, and Disabled (ABD) Programs..............................28-1

28.1 Pickle Amendment - Lynch v. Rank..............................................................28-1When to Screen .......................................................................28-1

28.1.1 Pickle Forms..................................................................................28-2


Medi-CalMedi-Cal

28.1.2 Verification of SSI/SSP Termination Date .....................................28-2

28.2 Treatment of Income for Pickle ....................................................................28-3Earned Income .........................................................................28-4

28.3 Manual Pickle Eligibility Determination Process...........................................28-5Screening an ABD Couple .......................................................28-6

28.3.1 VTR - Value of One Third Reduction.............................................28-7Definition ..................................................................................28-7When to Use VTR ....................................................................28-7Do NOT apply VTR if the Pickle client: ....................................28-7SSI/SSP Payment Levels ........................................................28-7

28.3.2 PMV - Presumed Maximum Value ................................................28-8Definition ..................................................................................28-8When to Apply the PMV ...........................................................28-8

28.3.3 The DHCS 7044, Statement of Living Arrangement .....................28-828.3.4 Rebutting the PMV ........................................................................28-828.3.5 Examples of VTR and PMV:..........................................................28-928.3.6 Sharing ..........................................................................................28-928.3.7 ISM Values ....................................................................................28-928.3.8 Excluded Types of ISM ...............................................................28-11

28.4 Resource Limits..........................................................................................28-1228.4.1 Determining Value of a Resource ...............................................28-1228.4.2 Resource Limits for Couples .......................................................28-12

Both spouses potentially Pickle eligible: ................................28-12Ineligible spouse, income deemed: ........................................28-12Ineligible spouse, income not deemed: ..................................28-12

28.4.3 Do not count the separate property of the ineligible spouse. It is the applicant's responsibility to prove separate property.SSI Treatment of Resources28-13

28.5 Pickle Eligible Child ....................................................................................28-1628.5.1 Resource Eligibility ......................................................................28-18

28.6 COBRA - Widow Pickle ..............................................................................28-1828.6.1 Background .................................................................................28-1828.6.2 Widow Pickle Screening Test......................................................28-18

28.7 Disabled Widow(er)s ..................................................................................28-1928.7.1 Background .................................................................................28-1928.7.2 DHCS Actions .............................................................................28-1928.7.3 DHCS 7089, Screening Worksheet.............................................28-1928.7.4 Criteria.........................................................................................28-1928.7.5 Verification Requirements ...........................................................28-2028.7.6 Budgeting ....................................................................................28-2028.7.7 Annual Redetermination (RD) .....................................................28-2128.7.8 Ineligibility....................................................................................28-21

28.8 Pickle Tickler System .................................................................................28-21


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28.8.1 MEDS Coding Requirements ......................................................28-22Individuals Discontinued from SSI/SSP after 1/1/87 ..............28-22Individuals Discontinued from SSI/SSP after 7/1/03 ..............28-22

28.8.2 Recording Potential Pickle Eligibles on MEDS............................28-22Correcting Potential Pickle Eligibility on MEDS .....................28-22

28.8.3 Pickle Tickler Process .................................................................28-23Pickle Tickler Report ..............................................................28-23Approvals ...............................................................................28-23Ineligibility ..............................................................................28-24

28.9 Disabled Adult Child (DAC) ........................................................................28-2428.9.1 DAC Screening Test....................................................................28-2428.9.2 Budgeting ....................................................................................28-2528.9.3 Aid Codes....................................................................................28-25

28.10 Aged and Disabled Federal Poverty Level (A&D FPL) Program................28-2528.10.1 Eligibility Criteria..........................................................................28-2628.10.2 Referral of Blind Applicants .........................................................28-26

DDSD Referral .......................................................................28-2628.10.3 Scope of Benefits and Aid Codes................................................28-2628.10.4 Eligibility Determination for Individuals and Couples...................28-2728.10.5 Eligibility For Couples that Fail the First Income Test .................28-28

Second Budget ......................................................................28-28Switching Status ....................................................................28-28Example .................................................................................28-28January COLA .......................................................................28-29

28.10.6 MFBU Requirements...................................................................28-3028.10.7 Notices of Action (NOA) Requirements.......................................28-30

Approval of Benefits ...............................................................28-30Discontinuance of Benefits ....................................................28-30

28.11 Federal Poverty Level for the Blind (FPLB) Program .................................28-3028.11.1 Eligibility Criteria..........................................................................28-3028.11.2 Verification...................................................................................28-3128.11.3 Manual Eligibility..........................................................................28-3128.11.4 Medically Needy ..........................................................................28-3128.11.5 Notice of Action ...........................................................................28-3128.11.6 Retroactive Benefits ....................................................................28-32

29. Long Term Care (LTC)....................................................................................29-1

29.1 Definitions.....................................................................................................29-129.1.1 Community Spouse .......................................................................29-129.1.2 Institutionalized Spouse ................................................................29-129.1.3 Community Spouse Monthly Income Allowance (CSMIA) ............29-229.1.4 Community Spouse Resource Allowance (CSRA)........................29-229.1.5 Registered Domestic Partners/ Same-Sex Spouse ......................29-2


Medi-CalMedi-Cal

29.2 LTC Facilities................................................................................................29-329.2.1 Skilled Nursing Facility (SNF)........................................................29-329.2.2 Intermediate Care Facility (ICF) ....................................................29-329.2.3 Institution for Mental Diseases (IMD) ............................................29-329.2.4 Acute Level of Care at Hospitals ...................................................29-4

29.3 Continuous Period of Institutionalization ......................................................29-4Verifying the Continuous Period of Institutionalization .............29-4

29.4 Long Term Care Status ................................................................................29-429.4.1 Continuous Period of Institutionalization vs. LTC Status...............29-5

Example of Continuous Period of Institutionalization ...............29-5Example of LTC Status ............................................................29-5

29.5 Incompetent Individuals in LTC ....................................................................29-529.5.1 Who Can Complete the Application ..............................................29-629.5.2 DHCS 7068 ...................................................................................29-729.5.3 County of Responsibility................................................................29-7

CalWIN Entries ........................................................................29-7

29.6 Notices of Action (NOA) ...............................................................................29-829.6.1 LTC MC NOAs ..............................................................................29-829.6.2 NOAs and ARs for Competent Clients ..........................................29-8

29.7 Benefits Identification Card (BIC) .................................................................29-8

29.8 California Residency ....................................................................................29-9

29.9 Eligibility for Individuals in an Institution for Mental Disease (IMD) ..............29-9

29.10 ...........................................................................Medically Indigent Adults29-1029.10.1 Retroactive Eligibility ...................................................................29-1029.10.2 Medi-Cal Identification Card ........................................................29-11

DDSD Approvals ....................................................................29-11Terminating Benefits ..............................................................29-11

29.10.3 EW Responsibilities for MIA ........................................................29-11APD Program .........................................................................29-11

29.11 Notification of Admittance to LTC Facility...................................................29-12

29.12 MFBU Determination..................................................................................29-1329.12.1 Adults in LTC...............................................................................29-13

LTC Person with a Community Spouse .................................29-13LTC Couple ............................................................................29-13Single LTC Individual .............................................................29-13Medically Indigent Adults in LTC ............................................29-13

29.12.2 Children in LTC ...........................................................................29-14Medically Indigent Children ....................................................29-15

29.13 Property Determinations for LTC Individuals..............................................29-15


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29.13.1 Property MFBU Determination for Adults ....................................29-15Couples With No Children ......................................................29-15Single Parent Households .....................................................29-15Two-Parent Households ........................................................29-16

29.13.2 Property Determination for Children............................................29-16

29.14 CSRA .........................................................................................................29-1729.14.1 Calculation of the CSRA..............................................................29-17

Maximum CSRA ....................................................................29-17Court Order ............................................................................29-18Fair Hearing ...........................................................................29-18Total Property ........................................................................29-19

29.14.2 Transfer of the CSRA to the Community Spouse........................29-19Transfer Period ......................................................................29-19

29.14.3 Adding to the CSRA ....................................................................29-2029.14.4 Undue Hardship for Establishing CSRA......................................29-2029.14.5 Married vs. Separated for Purposes of Applying CSRA..............29-2129.14.6 EW Actions in Determining CSRA...............................................29-2129.14.7 CSRA Examples..........................................................................29-21

Example 1: CSRA Includes Separate Property of Community Spouse 29-21Example 2: Court Order .........................................................29-22Example 3: Undue Hardship Exists .......................................29-22

29.15 Transfers of Property..................................................................................29-2329.15.1 Look-Back Period ........................................................................29-2329.15.2 Disqualifying Transfers................................................................29-2329.15.3 Non-Disqualifying Transfers ........................................................29-24

Hospice Care .........................................................................29-25Other Reasons .......................................................................29-25

29.15.4 Reviewing the Look-Back Period ................................................29-2629.15.5 Periods of Ineligibility...................................................................29-26

General Rules ........................................................................29-26Average Private Pay Rate ......................................................29-27MC 176 PI ..............................................................................29-27Sample MC 176 PI for the Example Above ...........................29-29Period of Ineligibility (POI) Referral Procedures ....................29-30CalWIN Entries ......................................................................29-31

29.15.6 Consecutive Transfers ................................................................29-3129.15.7 MEDS Restriction Coding............................................................29-32

29.16 Property Rules............................................................................................29-3329.16.1 Separate Property .......................................................................29-3329.16.2 Community Property....................................................................29-3329.16.3 Inter-spousal Agreements ...........................................................29-34

Inter-spousal Agreement Requirements ................................29-34Limitations of the Inter-spousal Agreement ...........................29-35Advising Applicants/Recipients ..............................................29-35

29.16.4 Division of Community Property ..................................................29-36


Medi-CalMedi-Cal

29.16.5 Automatic Division Rules.............................................................29-36

29.17 Principal Residence....................................................................................29-3829.17.1 Intent to Return............................................................................29-3829.17.2 Sibling or Child Over Age 21 in Home.........................................29-3829.17.3 List and Lien Property Exemption ...............................................29-39

List and Lien Requirements ...................................................29-3929.17.4 Transfer of Nonexempt Principal Residence by Institutionalized Persons29-40

29.18 Income Allocations .....................................................................................29-4029.18.1 Dependent Family Members .......................................................29-40

Proof of Dependency .............................................................29-4129.18.2 Maximum Allocation to Community Spouse................................29-41

Court Order ............................................................................29-41Fair Hearing ...........................................................................29-42

29.18.3 Verification of Community Spouse Allocation..............................29-4229.18.4 Verification of Dependent: Family Member Maximum Base Allocation29-4229.18.5 Total Allocation............................................................................29-42

29.19 Income Allowances ....................................................................................29-4329.19.1 Maintenance Needs ....................................................................29-4329.19.2 Medicare......................................................................................29-4329.19.3 Other Health Care (OHC) Premiums...........................................29-4329.19.4 Therapeutic Wages .....................................................................29-4429.19.5 Upkeep of Home .........................................................................29-4429.19.6 Support of a Disabled Relative....................................................29-4529.19.7 Veterans’ Aid and Attendance.....................................................29-45

Retroactive Payments ............................................................29-46Institutionalized Veteran with NO Community Spouse or Minor Child(ren) 29-46Institutionalized Veteran with a Community Spouse and/or Minor Child(ren) 29-47$90 VA Pension, Veteran in LTC ...........................................29-47

29.20 California Partnership-Approved LTC Insurance Policy or Certificate........29-4729.20.1 Service Summaries .....................................................................29-4829.20.2 Duration of Property Exemption ..................................................29-48

29.21 Budgeting ...................................................................................................29-48LTC Person with a Community Spouse ................................29-48

29.21.1 Hand Budgets..............................................................................29-49MC 176 M-LTC ......................................................................29-49MC 176 W Worksheet A ........................................................29-49MC 176 W Worksheet B ........................................................29-49

29.22 Long Term Care SOC Re-Computation .....................................................29-49

29.23 Super-Liability Individuals ..........................................................................29-5029.23.1 Super-Liability Determination ......................................................29-5029.23.2 Per Diem Chart Rates .................................................................29-50


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29.24 Voluntary Payment Program ......................................................................29-51

29.25 Court Orders...............................................................................................29-5229.25.1 Craig v. Bonta..............................................................................29-52

Public Guardian Referral for Incompetent Clients ..................29-52Long Term Care (LTC) Individuals .........................................29-53

29.25.2 Hunt v Kizer.................................................................................29-5329.25.3 Johnson v. Rank .........................................................................29-53

Necessary Non-Covered Services .........................................29-53Payment for Necessary Non-Covered Services ....................29-54“Important Notice About Your Medi-Cal Benefits” ..................29-54Johnson v. Rank Payments to Clients ...................................29-54

29.25.4 Pickle v. Rank..............................................................................29-5529.25.5 Reese v Kizer .............................................................................29-55

Issue ......................................................................................29-55Decision .................................................................................29-55

29.25.6 LTC Prejudice Cases ..................................................................29-55Issue ......................................................................................29-55

29.26 Managed Care Disenrollment When Entering LTC ....................................29-5629.26.1 Responsible Relative...................................................................29-56

30. Medicare Coverage.........................................................................................30-1

30.1 Medicare - Part A & Part B ...........................................................................30-130.1.1 Overview .......................................................................................30-130.1.2 Covered Services ..........................................................................30-1

Part A .......................................................................................30-1Part B .......................................................................................30-1

30.1.3 Persons Eligible.............................................................................30-2Part A .......................................................................................30-2Part B .......................................................................................30-2

30.1.4 Premiums ......................................................................................30-3Part A .......................................................................................30-3Part B .......................................................................................30-3

30.2 How Medicare And Medi-Cal Work Together ...............................................30-430.2.1 Crossover Claims ..........................................................................30-430.2.2 Medicare Deductibles....................................................................30-530.2.3 Other Services...............................................................................30-5

30.3 The Medicare Card.......................................................................................30-530.3.1 Description ....................................................................................30-530.3.2 Medicare Claim Number................................................................30-530.3.3 Issuance ........................................................................................30-6

30.4 Persons Required to Apply for Medicare [50777].........................................30-730.4.1 General..........................................................................................30-7


Medi-CalMedi-Cal

30.4.2 Undocumented Non-Citizen ..........................................................30-730.4.3 Application Requirements .............................................................30-7

Part A .......................................................................................30-730.4.4 Acceptance....................................................................................30-8

Part B .......................................................................................30-830.4.5 CalWIN..........................................................................................30-9

30.5 Verifying Application for Medicare [50777]...................................................30-930.5.1 SC 169 ..........................................................................................30-930.5.2 CalWIN Client Correspondence ....................................................30-930.5.3 Timeframes .................................................................................30-1030.5.4 Client Refusal ..............................................................................30-1030.5.5 Disenrollment ..............................................................................30-1030.5.6 Verifications.................................................................................30-10

30.6 Enrollment Periods .....................................................................................30-1130.6.1 Introduction..................................................................................30-1130.6.2 Initial Enrollment Period ..............................................................30-11

Persons Age 65 .....................................................................30-11Aged Noncitizens Who Meet Their 5 Years U.S. Residency .30-11Persons Eligible for Medi-Cal (ABD-MN/SSI/CALWORKS) ...30-12

30.6.3 General Enrollment Period ..........................................................30-12

30.7 Medicare Coding ........................................................................................30-12

30.8 Medi-Cal Beneficiaries with Medicare and Supplemental Insurance Coverage (OHC).................................................30-1330.8.1 Option..........................................................................................30-1330.8.2 Client and EW Action ..................................................................30-13

30.9 Medicare Buy-In .........................................................................................30-1430.9.1 Definition Of Buy-In [50777] ........................................................30-14

Part A .....................................................................................30-14Part B .....................................................................................30-14

30.9.2 Persons Eligible for “Buy-In”........................................................30-1430.9.3 Persons Ineligible for “Buy-In” .....................................................30-1530.9.4 Individuals With SOC ..................................................................30-15

Voluntary Disenrollment .........................................................30-15Medicare Part B Enrollment Requirement .............................30-16Income Deduction ..................................................................30-16Retroactive Reimbursement ..................................................30-16Budgeting ...............................................................................30-17Intake .....................................................................................30-17Continuing ..............................................................................30-17

30.9.5 Buy-In Procedures - Budgeting ...................................................30-17Initiating Buy-In ......................................................................30-17Buy-In Effective Date .............................................................30-18Premium Reimbursement ......................................................30-19


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Verification .............................................................................30-19SOC Adjustment ....................................................................30-19

30.10 MEDS [INQB] Screen.................................................................................30-19

30.11 Buy-In Alerts/Messages ............................................................................30-2030.11.1 Requirements ..............................................................................30-20

30.12 Use of the DHCS 6166...............................................................................30-2030.12.1 When to Use................................................................................30-2030.12.2 Situations Requiring the Use of the DHCS 6166.........................30-2130.12.3 EW Action....................................................................................30-2130.12.4 Completing the DHCS 6166 ........................................................30-2230.12.5 Contacting Medicare Buy In Unit.................................................30-2230.12.6 EW Follow-Up .............................................................................30-22

30.13 Medi-Cal Buy-In Chart ................................................................................30-23Medi-Cal Buy-In Chart ...........................................................30-23

30.14 Medicare Savings Programs ......................................................................30-25

30.15 Qualified Medicare Beneficiary (QMB) Program ........................................30-2530.15.1 Background .................................................................................30-2530.15.2 General Eligibility Criteria ............................................................30-2630.15.3 Two Basic Groups of QMBs........................................................30-2630.15.4 When to Evaluate for QMB..........................................................30-2730.15.5 Effective Date of Eligibility ...........................................................30-28

Pre-Approved QMBs ..............................................................30-2930.15.6 Verification of Medicare Part A....................................................30-3030.15.7 “Conditional” Medicare Part A .....................................................30-3130.15.8 MC 176 QMB-3 ...........................................................................30-3130.15.9 QMB Property Determination ......................................................30-32

Rules ......................................................................................30-3330.15.10 Other Requirements ....................................................................30-3430.15.11 Notices of Action .........................................................................30-35

Approvals ...............................................................................30-35Denials/ Discontinuances NOA ..............................................30-35Erroneous Discontinuance .....................................................30-36

30.15.12 ICTs.............................................................................................30-36QMB Only ..............................................................................30-36SSI QMBs ..............................................................................30-36

30.15.13 SSI QMBs....................................................................................30-37General ..................................................................................30-37Application Forms ..................................................................30-37SSI QMB Mail-In Referral Procedure .....................................30-37Other Referrals ......................................................................30-38Application Requirements ......................................................30-38Income Determination ............................................................30-39Verification of Medicare Part A ..............................................30-39


Medi-CalMedi-Cal

Redetermination (RDs) ..........................................................30-40Discrepancies ........................................................................30-40Whereabouts Unknown Discontinuance ................................30-41

30.16 Specified Low-Income Medicare Beneficiary (SLMB) Program .................30-4130.16.1 Background .................................................................................30-4130.16.2 Effective Date ..............................................................................30-4130.16.3 Benefit .........................................................................................30-4230.16.4 Eligibility Criteria..........................................................................30-42

Medicare Part A .....................................................................30-42Property .................................................................................30-42Income ...................................................................................30-43Citizen/ Noncitizen Status ......................................................30-43Other Requirements ...............................................................30-43

30.16.5 Dual Eligibility ..............................................................................30-44ABD-MN .................................................................................30-44SSI/SSPs, SLMB Does NOT Apply .......................................30-44

30.16.6 When to Evaluate ........................................................................30-4430.16.7 NOAs...........................................................................................30-45

SLMB Only .............................................................................30-45ABD-MN and SLMB (Dual Eligibles) ......................................30-45

30.17 Qualifying Individual (QI-1) Program ..........................................................30-4530.17.1 Background .................................................................................30-4530.17.2 Overview .....................................................................................30-4630.17.3 Effective Date ..............................................................................30-4630.17.4 Retroactive QI-1 Benefits ............................................................30-4630.17.5 Benefit .........................................................................................30-4630.17.6 Eligibility Criteria..........................................................................30-47

Medicare Part A .....................................................................30-47Property .................................................................................30-47Income ...................................................................................30-48Citizen/ Noncitizen Status ......................................................30-48Other Requirements ...............................................................30-48

30.17.7 When to Evaluate ........................................................................30-4930.17.8 NOAs...........................................................................................30-4930.17.9 Dual Eligibility ..............................................................................30-49

Rule ........................................................................................30-49

30.18 QMB/SLMB/QI Income Determination and Budgeting Rules .....................30-5030.18.1 Income Rules, General................................................................30-5030.18.2 Budgeting, MC 176-1 QMB/SLMB/QI..........................................30-5030.18.3 Budgeting, MC 176-2A QMB/SLMB/QI .......................................30-5130.18.4 IRWE...........................................................................................30-5230.18.5 QMB/SLMB/QI Budgeting Sequence Chart ................................30-53

30.19 Qualified Disabled Working Individuals (QDWI) Program ..........................30-5630.19.1 Background .................................................................................30-56


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30.19.2 Effective Date ..............................................................................30-5630.19.3 Benefit .........................................................................................30-5630.19.4 Medicare Part A...........................................................................30-5630.19.5 Eligibility Criteria..........................................................................30-57

Conditions ..............................................................................30-57Other Requirements ...............................................................30-57Property Limit .........................................................................30-58Citizen/ Noncitizen Status ......................................................30-58Income Limit ...........................................................................30-58

30.20 Medicare Part D Prescription Drug Program............................................30-5930.20.1 Part D Enrollment ........................................................................30-5930.20.2 Prescription Drug Plan (PDP)......................................................30-5930.20.3 Enrollment in a Plan ....................................................................30-60

Medicare Beneficiaries with Other Health Coverage (OHC) ..30-60Medicare Beneficiaries who Have Medigap Policies .............30-61

30.20.4 Costs ...........................................................................................30-6130.20.5 Low Income Subsidy (LIS) Assistance ........................................30-61

LIS and Medi-Cal Share-of-Cost (SOC) Calculation ..............30-6230.20.6 Responsible Agency....................................................................30-6330.20.7 Information/Referral Resources ..................................................30-6330.20.8 Implementation............................................................................30-63

All Offices ...............................................................................30-63Eligibility Staff .........................................................................30-64Process Flow .........................................................................30-64

30.20.9 Santa Clara Family Health Plan (SCFHP) Medicare Plan...........30-65

30.21 Medicare Plus Choice (M+C) Premium Payment Program........................30-65

30.22 Low Income Subsidy Applications..............................................................30-6630.22.1 Application Date ..........................................................................30-6630.22.2 Denial ..........................................................................................30-6730.22.3 Processing Timeframe ................................................................30-6730.22.4 Retroactive Benefits ....................................................................30-6730.22.5 Continuing / Pending Cases........................................................30-6830.22.6 Intake Process.............................................................................30-6830.22.7 Documentation ............................................................................30-7130.22.8 Forms ..........................................................................................30-72

SCD 2269 ..............................................................................30-72SCD 2270 ..............................................................................30-72

31. Medically Needy (MN) & Medically Indigent (MI)..........................................31-1

31.1 AFDC-MN — Overview of Linkage...............................................................31-131.1.1 Definition .......................................................................................31-131.1.2 Nonparent Caretaker Relative (50085) .........................................31-2

Nonparent Caretaker Relative who is a Spouse or Parent ......31-231.1.3 Examples of Linkage .....................................................................31-2


Medi-CalMedi-Cal

Example 1: ...............................................................................31-2Example 2: ...............................................................................31-3Example 3: ...............................................................................31-3Example 4: ...............................................................................31-3Example 5: ...............................................................................31-4Example 6: ...............................................................................31-4Example 7: ...............................................................................31-4Example 8: ...............................................................................31-5

31.2 AFCD-MN (Non-MAGI) ................................................................................31-531.2.1 Who is eligible for the AFDC-MN program....................................31-531.2.2 Treatment of Income and Property for AFCD-MN.........................31-6

31.3 ABD-MN (Non-MAGI) Linkage .....................................................................31-631.3.1 General..........................................................................................31-631.3.2 Aged [50221] .................................................................................31-731.3.3 Blind [50219] .................................................................................31-731.3.4 Disabled [50167, 50223] ...............................................................31-731.3.5 ABD Linkage Chart........................................................................31-9

31.4 Cash/Medi-Cal Differences To Keep In Mind ...............................................31-931.4.1 Deprivation ..................................................................................31-1031.4.2 Linkage to Medi-Cal when the Only Child is on SSI/SSP............31-1031.4.3 No Work Registration Requirement.............................................31-1031.4.4 Medi-Cal Family Budget Unit (MFBU) .........................................31-10

Unmarried Minor Parent in the Home ....................................31-10Caretaker Relative .................................................................31-11

31.4.5 Linkage When Parents are Sponsored Aliens.............................31-11

31.5 CalWORKs Case, Family Member Potentially Eligible for Medi-Cal ........................................31-1131.5.1 CalWORKs Case Active -

Certain Family Members Ineligible or Excluded ..........................31-1131.5.2 Entire CalWORKs Case to be Discontinued ...............................31-12

31.6 Medically Indigent Categories ....................................................................31-13

31.7 Property and Income ..................................................................................31-13

31.8 Age .............................................................................................................31-14

31.9 MIA Exceptions ..........................................................................................31-14

31.10 Medically Indigent Child .............................................................................31-14

31.11 Blind or Disabled Child [50251] ..................................................................31-15

31.12 Foster Children...........................................................................................31-15

31.13 Adopted Children........................................................................................31-15


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31.14 Other Foster/Adopted Children ..................................................................31-16

31.15 Processing MIA Applications......................................................................31-16

31.16 MIC or MIA Determination..........................................................................31-16

31.17 Treatment of MIA Pregnant Women and Their Newborns .........................31-1731.17.1 Verify Pregnancy and Expected Date of Confinement (EDC) .....31-1731.17.2 Eligibility for MIA Pregnant Women.............................................31-1731.17.3 Determine Eligibility for the Newborn ..........................................31-18

31.18 Sneede v Kizer ...........................................................................................31-1831.18.1 Background .................................................................................31-1831.18.2 Definition “Sneede Case” ............................................................31-1931.18.3 Not Optional ................................................................................31-1931.18.4 Examples.....................................................................................31-20

Child with separate income ....................................................31-20Stepparent case .....................................................................31-20Nonparent Caretaker Relative ...............................................31-20

31.18.5 Separate Determinations.............................................................31-2131.18.6 Denial or Discontinuance of Sneede ...........................................31-2131.18.7 General Procedures ....................................................................31-2231.18.8 Implementation Date ...................................................................31-23

31.19 Sneede Screening......................................................................................31-2331.19.1 Property.......................................................................................31-2331.19.2 Income.........................................................................................31-24

31.20 Responsible Relative Determination ..........................................................31-2431.20.1 MC 175-2.....................................................................................31-24

31.21 Income and Property Allocations, General .................................................31-2531.21.1 General Allocation Rule...............................................................31-2531.21.2 Property Allocation Rule..............................................................31-2531.21.3 Income Allocation Rule................................................................31-2531.21.4 Property and Income...................................................................31-2631.21.5 Allocations Not Allowed...............................................................31-2631.21.6 Allocation Example......................................................................31-2631.21.7 Property/Income are Separate ....................................................31-2731.21.8 Treatment of Children..................................................................31-27

31.22 Mini Budget Unit Determination..................................................................31-2831.22.1 Definition .....................................................................................31-2831.22.2 Property/Income MBUs are Separate .........................................31-2831.22.3 Rules for All Cases......................................................................31-2931.22.4 Specific MBU Determinations......................................................31-29

Married Couple and Mutual Children (No Stepchildren) ........31-29Married Spouses (Stepparent), Mutual and Separate Children ...............................................31-30


Medi-CalMedi-Cal

Married Parents, Only the Separate Children of One Parent Want Medi-Cal ...31-30Single Parent, Children ..........................................................31-31Unmarried Parents, Mutual and Separate Children ...............31-31Minor Mother With Child(ren), Living With Her Parent(s) .......31-32

31.22.5 Parent(s)' MBU............................................................................31-3231.22.6 Child(ren)s' MBU .........................................................................31-3231.22.7 Non-Parent Caretaker Relative Households ...............................31-33

Linkage Rules ........................................................................31-33MBU Determinations ..............................................................31-33

31.22.8 MC 175-4.....................................................................................31-34

31.23 Maintenance Need Income Levels and Property Limits .............................31-3531.23.1 General........................................................................................31-3531.23.2 Full Amount .................................................................................31-3531.23.3 Prorated Amount .........................................................................31-3631.23.4 Formula .......................................................................................31-3631.23.5 Prorated Maintenance Need Income Levels and Property Limits31-37

31.24 Property Determination ..............................................................................31-3731.24.1 General........................................................................................31-3731.24.2 Property Allocations ....................................................................31-37

Married Couple With Only Mutual Children ............................31-38Stepparent Household ...........................................................31-38Unmarried Couple With Mutual Children ...............................31-38

31.24.3 When Only One Property Exemption Applies .............................31-3831.24.4 Exemptions for Unmarried Couples ............................................31-3931.24.5 Exemption for Single/Married Parent(s) ......................................31-3931.24.6 Exemptions for Other Caretaker Relative....................................31-3931.24.7 Changing Exemptions .................................................................31-3931.24.8 Jointly Held Assets ......................................................................31-40

Example 1: .............................................................................31-40Example 2: .............................................................................31-40

31.24.9 Procedure....................................................................................31-41Example 1 ..............................................................................31-41Example 2 ..............................................................................31-42

31.25 Income Determination ................................................................................31-4331.25.1 General........................................................................................31-4331.25.2 Support Payments.......................................................................31-4331.25.3 Unearned Income In-Kind ...........................................................31-4431.25.4 Earned Income In-Kind................................................................31-4531.25.5 $50 Child/ Spousal Support Deduction .......................................31-4531.25.6 Dependent Care Deduction.........................................................31-4631.25.7 Other Health Coverage Premium................................................31-4631.25.8 ABD-MN Deductions ...................................................................31-46

Married Couple ......................................................................31-46Unmarried Couple ..................................................................31-46


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Blind/Disabled Child ...............................................................31-4631.25.9 Income Determination Procedure................................................31-4731.25.10 PA/ Other PA...............................................................................31-48

31.26 Federal Poverty Level and Property Waiver Programs (100%/133%/ 200% Income Disregard)31-4931.26.1 General........................................................................................31-4931.26.2 Family Size..................................................................................31-4931.26.3 Income.........................................................................................31-4931.26.4 Property.......................................................................................31-5031.26.5 Procedure to Determine FPL Eligibility........................................31-5031.26.6 Examples.....................................................................................31-50

31.27 Share of Cost Considerations/NOAs..........................................................31-5131.27.1 Multiple Shares of Cost ...............................................................31-5131.27.2 Responsible Relative's Medical Expenses..................................31-5131.27.3 Children's Medical Expenses ......................................................31-5231.27.4 Required Informing......................................................................31-5231.27.5 Example of Medical Expenses ....................................................31-5231.27.6 Hunt v Kizer.................................................................................31-5231.27.7 Adjusting the SOC.......................................................................31-53

Situation 1 ..............................................................................31-53Situation 2 ..............................................................................31-53

31.27.8 Sneede NOAs .............................................................................31-53

31.28 Sneede Budget Examples..........................................................................31-5431.28.1 Example 1 ...................................................................................31-5431.28.2 Example 2 ...................................................................................31-5431.28.3 Example 3 ...................................................................................31-55

31.29 Sneede Maintenance Need Income Levels (MNIL) and Property Limits....31-56

32. 250% Working Disabled Program (250% WDP) ...........................................32-1

32.1 Definitions.....................................................................................................32-132.1.1 Child ..............................................................................................32-132.1.2 Family Income...............................................................................32-132.1.3 In-Kind Support and Maintenance (ISM) .......................................32-232.1.4 Presumed Maximum Value (PMV) ................................................32-232.1.5 Substantial Gainful Activity (SGA).................................................32-232.1.6 Spousal/Parental Deeming............................................................32-232.1.7 SSI/SSP ........................................................................................32-232.1.8 Value of the One -Third Reduction (VTR) .....................................32-2

32.2 Eligibility Criteria...........................................................................................32-3Family Income ..........................................................................32-3

32.2.1 Disability Determination.................................................................32-432.2.2 Immigration Status ........................................................................32-4


Medi-CalMedi-Cal

32.2.3 Property Determination .................................................................32-532.2.4 Net Non-Exempt Property Test/SSI Property Test........................32-632.2.5 Retained Earned Income...............................................................32-632.2.6 Income Determination ...................................................................32-7

SSI Income Test ......................................................................32-7250% Federal Poverty Level Test ............................................32-8

32.2.7 SSA Disability Income that Converts to Retirement Income .........32-9

32.3 Eligibility Determination Procedures...........................................................32-1032.3.1 Identifying Potential Eligibles for the 250% WDP........................32-1032.3.2 Twenty-Six Weeks of Temporary Unemployment .......................32-1032.3.3 No Face-To-Face Requirement...................................................32-1032.3.4 Informing Requirement................................................................32-1132.3.5 Retroactive Benefits ....................................................................32-1132.3.6 Establishing a MEDS Record ......................................................32-1132.3.7 Other Requirements ....................................................................32-12

32.4 Monthly Premiums......................................................................................32-1332.4.1 Premium Amount Determination .................................................32-1432.4.2 Premium Collection System ........................................................32-15

Determining Eligibility and Amount of Premium .....................32-15Payment Options ...................................................................32-15Third Party Liability Branch ....................................................32-15TPLB is responsible for collecting the required premium payments and reporting this information to MEDS. .............................................................32-15Collection of Premiums ..........................................................32-15Information Technology Services Division .............................32-16

32.4.3 Termination of the 250% Working Disabled Program .................32-1632.4.4 Penalty Period .............................................................................32-16

32.5 Benefits Identification Card for 250% WDP................................................32-17

32.6 Continuing Activities ...................................................................................32-1732.6.1 Reporting Changes .....................................................................32-1732.6.2 Redeterminations ........................................................................32-1732.6.3 Discontinuance for Reasons Other than Non-payment of Premiums32-17

32.7 Notices of Action (NOAs) ...........................................................................32-17Notification .............................................................................32-17

32.8 SSI Methodology ........................................................................................32-1832.8.1 Determining Net Non-exempt Income.........................................32-18

In-Kind Support and Maintenance .........................................32-18In-Kind Support and Maintenance - Sharing ..........................32-19Follow These Guidelines When Using the VTR and PMV Method 32-21

32.9 Budgeting Examples ..................................................................................32-2132.9.1 Example I - An Individual.............................................................32-2132.9.2 Example II - Child With Ineligible Parents ...................................32-22


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32.9.3 Example III - Eligible Individual With Ineligible Spouse (aged) ...32-23

32.10 CalWIN Entries...........................................................................................32-2532.10.1 Collect Case Individual Detail......................................................32-2532.10.2 Twenty-Six Weeks of Temporary Unemployment Entries...........32-2632.10.3 Separately Identifiable Account Entries.......................................32-2632.10.4 Conversion of RSDI Disability to RSDI Retirement Entries.........32-27

32.11 Questions and Answers .............................................................................32-29

33. Share of Cost (SOC) ......................................................................................33-1

33.1 Share of Cost (SOC)—Overview..................................................................33-133.1.1 Definition [50653] ..........................................................................33-133.1.2 When a Share of Cost Must Be Determined .................................33-1

33.2 Actions on the Share of Cost........................................................................33-233.2.1 Client Responsibility [50657] .........................................................33-233.2.2 Provider Responsibility [50657].....................................................33-233.2.3 EW Responsibility [50657] ............................................................33-3

33.3 Change in the Share of Cost (SOC) ............................................................33-333.3.1 Changes Which Decrease the SOC .............................................33-333.3.2 Changes Which Increase the SOC ...............................................33-4

33.4 Processing Cases When the SOC is Retroactively Reduced ......................33-5

33.5 Reimbursement From The Provider .............................................................33-6

33.6 Case Situations ............................................................................................33-833.6.1 Adjustment of Future Share of Cost Amount.................................33-8

Case Situation 1 .......................................................................33-8Case Situation 2 .......................................................................33-9

33.6.2 Provider Reimbursement of Share of Cost....................................33-9Case Situation 3 .......................................................................33-9Case Situation 4 .....................................................................33-10Case Situation 5 .....................................................................33-10Case Situation 6 .....................................................................33-11

33.6.3 Share of Cost Adjustment Over a Year Ago................................33-11Case Situation 7 .....................................................................33-11

33.7 Repayment of SOC for Poverty Level Program Eligibles ...........................33-1333.7.1 FPL Program Effective Dates......................................................33-1433.7.2 Share Of Cost Partially or Fully Met ............................................33-14

Process (Less than 12 months)) ............................................33-14Process (More than 12 months) .............................................33-15

33.8 Hunt v. Kizer (Applying Old Medical Bills to the Share of Cost) .................33-16

33.9 Policy..........................................................................................................33-16


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33.9.1 Exception.....................................................................................33-17

33.10 Definitions...................................................................................................33-1733.10.1 Current Medical Bill .....................................................................33-1733.10.2 Old Medical Bill............................................................................33-1733.10.3 Month Incurred ............................................................................33-1733.10.4 Unpaid, Old Medical Bill ..............................................................33-1733.10.5 Medical Bills, Medical Expenses .................................................33-18

33.11 Qualifying Criteria.......................................................................................33-1833.11.1 Liability for Debt...........................................................................33-1833.11.2 One Time Only Rule....................................................................33-1933.11.3 Other Health Coverage ...............................................................33-1933.11.4 MFBU ..........................................................................................33-1933.11.5 IHSS............................................................................................33-1933.11.6 Interest Charges..........................................................................33-1933.11.7 No Payment Required .................................................................33-19

33.12 Verification Requirements ..........................................................................33-2033.12.1 Original Medical Bills ...................................................................33-2033.12.2 “Original” Bills versus Photocopies..............................................33-2133.12.3 Other Substitute Billing Statements.............................................33-2133.12.4 Contact to Provider......................................................................33-2133.12.5 Affidavit........................................................................................33-2233.12.6 Credit Card Statements...............................................................33-22

33.13 Incomplete Information...............................................................................33-23

33.14 Denial of Medical Bill(s) ..............................................................................33-23

33.15 Limitations on SOC Adjustments................................................................33-2433.15.1 Must Meet SOC...........................................................................33-2433.15.2 Future Use...................................................................................33-2433.15.3 Consecutive Months....................................................................33-2533.15.4 Past Months ................................................................................33-25

33.16 SOC Adjustment ........................................................................................33-25Paid or Unpaid Current Month’s Medical bills ........................33-25Unpaid Old Medical Bills ........................................................33-26Methods of SOC Adjustment .................................................33-26

33.16.1 CalWIN Adjustment .....................................................................33-2633.16.2 Adjustments through MEDS........................................................33-27

33.17 Discontinued Cases ...................................................................................33-27

33.18 Examples....................................................................................................33-2833.18.1 Intake...........................................................................................33-28

SOC Applicant, No Retroactive Coverage .............................33-28SOC Applicant, Retroactive Coverage Requested ................33-28


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33.18.2 Continuing ...................................................................................33-29Saving Old and Current Bills to Apply in a Future Month .......33-29Ineligible Member of MFBU ...................................................33-29

33.18.3 Intake and/or Continuing .............................................................33-29Client Fails to Provide Timely Documentation .......................33-29Old Medical Expenses for Persons No Longer in the MFBU .33-29

34. Court Orders: Sneede v Kizer........................................................................34-1

34.1 Overview ......................................................................................................34-134.1.1 Background ...................................................................................34-134.1.2 Definition “Sneede Case” ..............................................................34-134.1.3 Not Optional ..................................................................................34-234.1.4 Examples.......................................................................................34-2

Child with separate income ......................................................34-2Stepparent case .......................................................................34-2Nonparent Caretaker Relative .................................................34-2

34.1.5 Separate Determinations...............................................................34-334.1.6 Denial or Discontinuance of Sneede .............................................34-434.1.7 General Procedures ......................................................................34-434.1.8 Implementation Date, New Applicants ..........................................34-534.1.9 Implementation Date, Continuing Cases.......................................34-634.1.10 Retroactive Sneede.......................................................................34-6

Background ..............................................................................34-6Claim Period ............................................................................34-7Intake Requirement ..................................................................34-7Continuing Requirement ..........................................................34-7Processing the MC 175 R-8 .....................................................34-8Treatment of Payments ............................................................34-8

34.1.11 Responsibility for Processing ........................................................34-8Current Sneede Cases ............................................................34-8New Applicants ........................................................................34-8Responsibility for Processing Continuing Cases .....................34-9Responsibility for Processing ...................................................34-9Sneede EW ..............................................................................34-9

34.2 Sneede Screening......................................................................................34-1034.2.1 Property.......................................................................................34-1034.2.2 Income.........................................................................................34-10

34.3 Responsible Relative Determination ..........................................................34-1134.3.1 MC 175-2.....................................................................................34-11

34.4 Income and Property Allocations, General .................................................34-1234.4.1 General Allocation Rule...............................................................34-1234.4.2 Property Allocation Rule..............................................................34-1234.4.3 Income Allocation Rule................................................................34-1234.4.4 Property and Income...................................................................34-12


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34.4.5 Allocations Not Allowed...............................................................34-1334.4.6 Allocation Example......................................................................34-1334.4.7 Property/Income are Separate ....................................................34-1434.4.8 Treatment of Children..................................................................34-14

34.5 Mini Budget Unit Determination..................................................................34-1534.5.1 Definition .....................................................................................34-1534.5.2 Property/Income MBUs are Separate .........................................34-1534.5.3 Rules for All Cases......................................................................34-1534.5.4 Specific MBU Determinations......................................................34-16

Married Couple and Mutual Children (No Stepchildren) ........34-16Married Spouses (Stepparent), Mutual and Separate Children ...............................................34-16Married Parents, Only the Separate Children of One Parent Want Medi-Cal ...34-17Single Parent, Children ..........................................................34-17Unmarried Parents, Mutual and Separate Children ...............34-18Minor Mother With Child(ren), Living With Her Parent(s) .......34-18

34.5.5 Parent(s)' MBU............................................................................34-1934.5.6 Child(ren)s' MBU .........................................................................34-1934.5.7 Non-Parent Caretaker Relative Households ...............................34-1934.5.8 MC 175-4.....................................................................................34-21

34.6 Maintenance Need Income Levels and Property Limits .............................34-2234.6.1 General........................................................................................34-2234.6.2 Full Amount .................................................................................34-2234.6.3 Prorated Amount .........................................................................34-2234.6.4 Formula .......................................................................................34-2334.6.5 Chart............................................................................................34-23

34.7 Property Determination ..............................................................................34-2534.7.1 General........................................................................................34-2534.7.2 Property Allocations ....................................................................34-25

Married Couple With Only Mutual Children ............................34-25Stepparent Household ...........................................................34-25Unmarried Couple With Mutual Children ...............................34-26

34.7.3 When Only One Property Exemption Applies .............................34-2634.7.4 Exemptions for Unmarried Couples ............................................34-2634.7.5 Exemption for Single/Married Parent(s) ......................................34-2634.7.6 Exemptions for Other Caretaker Relative....................................34-2734.7.7 Changing Exemptions .................................................................34-2734.7.8 Jointly Held Assets ......................................................................34-27

Example 1: .............................................................................34-27Example 2: .............................................................................34-28

34.7.9 Procedure....................................................................................34-28Example 1 ..............................................................................34-29Example 2 ..............................................................................34-30


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34.8 Income Determination ................................................................................34-3134.8.1 General........................................................................................34-3134.8.2 Support Payments.......................................................................34-3234.8.3 Unearned Income In-Kind ...........................................................34-3234.8.4 Earned Income In-Kind................................................................34-3334.8.5 $50 Child/ Spousal Support Deduction .......................................34-3334.8.6 Dependent Care Deduction.........................................................34-3434.8.7 Other Health Coverage Premium................................................34-3434.8.8 ABD-MN Deductions ...................................................................34-34

Married Couple ......................................................................34-34Unmarried Couple ..................................................................34-34Blind/Disabled Child ...............................................................34-34

34.8.9 Income Determination Procedure................................................34-3534.8.10 PA/ Other PA...............................................................................34-36

34.9 Federal Poverty Level Programs (100/133/ Income Disregard) .................34-3734.9.1 General........................................................................................34-3734.9.2 Family Size..................................................................................34-3734.9.3 Income.........................................................................................34-3734.9.4 Procedure to Determine FPL Eligibility........................................34-3834.9.5 Examples.....................................................................................34-39

34.10 Share of Cost Considerations/NOAs..........................................................34-3934.10.1 Multiple Shares of Cost ...............................................................34-3934.10.2 Responsible Relative's Medical Expenses..................................34-3934.10.3 Children's Medical Expenses ......................................................34-4034.10.4 Required Notice...........................................................................34-4034.10.5 Example of Medical Expenses ....................................................34-4034.10.6 Hunt v Kizer.................................................................................34-4034.10.7 Adjusting the SOC.......................................................................34-41

Situation 1 ..............................................................................34-41Situation 2 ..............................................................................34-41

34.10.8 Sneede NOAs .............................................................................34-42

34.11 Sneede Budget Examples..........................................................................34-4234.11.1 Example 1 ...................................................................................34-4234.11.2 Example 2 ...................................................................................34-4334.11.3 Example 3 ...................................................................................34-44

34.12 Sneede Maintenance Need Income Levels (MNIL) and Property Limits....34-45

35. Pregnant Women, Infants, and Children ......................................................35-1

35.1 Overview - Continued Eligibility for Pregnant Women and Infants ..............35-135.1.1 Affected Persons ...........................................................................35-235.1.2 Eligibility, General..........................................................................35-335.1.3 Eligibility for Pregnant Women ......................................................35-335.1.4 Adding Newborns, General ...........................................................35-4


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35.1.5 General Newborn Referrals...........................................................35-4Medi-Cal Notice of Newborn Referral Form (SCD 1374) .........35-5

35.1.6 Baby Gateway Referrals ...............................................................35-6Baby Gateway Referral Procedure ..........................................35-6

35.1.7 Unmarried Fathers - MN/MI Medi-Cal ...........................................35-9MFBU .......................................................................................35-9Income/Property .......................................................................35-9U-Parent Linkage ...................................................................35-10Information Provided ..............................................................35-10

35.1.8 Sneede........................................................................................35-1135.1.9 Medical Support Enforcement .....................................................35-1135.1.10 Three Month Retroactive.............................................................35-11

Example 1: .............................................................................35-1235.1.11 Break In Aid.................................................................................35-1235.1.12 Intercounty Transfers (ICTs) .......................................................35-1335.1.13 Whereabouts Unknown...............................................................35-1335.1.14 Annual Redeterminations ............................................................35-1335.1.15 Increased Income, Pregnant Woman (MN/MI Programs) ...........35-1435.1.16 Increased Income, Infants (MN/MI Programs) ............................35-1535.1.17 Increased Income,

PA/Other PA Recipients/Section 1931(b)....................................35-1635.1.18 Determining MFBUs/SOC ...........................................................35-16

Example 1 ..............................................................................35-17Example 2 ..............................................................................35-17Example 3 ..............................................................................35-17Example 4 ..............................................................................35-18Change in MFBU Size ...........................................................35-18

35.2 Deemed Eligibility for Infants......................................................................35-1835.2.1 Overview .....................................................................................35-1835.2.2 Program Eligibility........................................................................35-19

Residency ..............................................................................35-20Deficit Reduction Act (DRA) of 2005 ......................................35-20Infants Born to Minor Consent Mothers .................................35-20Infant Born to Youths Receiving Adoption Assistance Program (AAP) Benefits 35-20

35.2.3 Retroactive Eligibility ...................................................................35-21Example 1: .............................................................................35-21Example 2: .............................................................................35-22Example 3: .............................................................................35-22Example 4: .............................................................................35-22

35.2.4 Infant’s SOC/No SOC..................................................................35-22Example 1: Mother eligible for no SOC Restricted Benefits ..35-23Example 2: Mother Eligible for no SOC Medi-Cal ..................35-23Example 3: Mother’s SOC Unmet in the Birth Month .............35-23Example 4: Mother’s SOC Met in the Birth Month: ................35-24Example 5: Mother’s SOC Reduced ......................................35-24


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Example 6: Mother Met Her SOC in the Birth Month, Change in MFBU 35-2435.2.5 Expedited Enrollment ..................................................................35-2535.2.6 Activating DE for the Infant..........................................................35-2635.2.7 Reporting Requirements .............................................................35-2635.2.8 Change in County of Residence..................................................35-2635.2.9 DE Infant Approaches Age One Year .........................................35-27

Example: ................................................................................35-2735.2.10 Discontinued Family Reapplies During SB 87 Process...............35-2735.2.11 Rescind DE Due to Loss of Contact............................................35-28

Example 1: .............................................................................35-28Example 2: .............................................................................35-28

35.3 CHDP Gateway DE Infant Enrollment Process..........................................35-2935.3.1 MEDS Alerts................................................................................35-2935.3.2 Exception Eligibles Report ..........................................................35-30

35.4 Continuous Eligibility for Children (CEC)....................................................35-3135.4.1 CEC Program Eligibility Rules.....................................................35-3135.4.2 CEC Exceptions ..........................................................................35-3235.4.3 The 12 Month CEC Period ..........................................................35-3235.4.4 Guaranteed CEC Period .............................................................35-3235.4.5 CEC Aid Codes ...........................................................................35-3335.4.6 Changes Reported During The CEC Period ...............................35-33

Decrease in Income Reported in SOC Month Prior to Annual RD 35-3435.4.7 Ineligibility for All Medi-Cal Programs after CEC ends ................35-34

Healthy Kids ...........................................................................35-3435.4.8 Annual Redetermination Following a Period of CEC...................35-3535.4.9 CEC Retroactive Eligibility...........................................................35-35

SOC in Month of Application and Zero SOC in Retroactive Month 35-35Eligibility Established Prior to Retroactive Request ...............35-36CEC Begins in a Retro Month/CEC Guaranteed Period Ends Prior to RD 35-36Examples of Retroactive CEC ...............................................35-37

35.4.10 Linkage to Section 1931(b) Medi-Cal Program ...........................35-3835.4.11 CEC for Infants Under Age One..................................................35-38

DE Eligible Infant No Longer Residing With Medi-Cal Eligible Mother 35-3935.4.12 Children Discontinued from CalWORKs......................................35-3935.4.13 Children Losing Foster Care Eligibility ........................................35-3935.4.14 Children Losing SSI Cash-Based Medi-Cal ................................35-4035.4.15 CEC and Transitional Medi-Cal (TMC)........................................35-40

TMC and 1931(b) Recipients .................................................35-40Impact of CEC on TMC ..........................................................35-41

35.4.16 CEC Procedures .........................................................................35-4135.4.17 Redeterminations Not Completed Timely....................................35-4235.4.18 Intercounty Transfers ..................................................................35-4335.4.19 CEC When a Child Leaves the Home.........................................35-4335.4.20 Discontinuance for Whereabouts Unknown ................................35-4435.4.21 Request for CEC Discontinuance................................................35-44


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35.5 Extended Medi-Cal Eligibility for Former Foster Youth (FFY) 18 to 26 Years of Age35-4535.5.1 Background .................................................................................35-4535.5.2 Who is Eligible.............................................................................35-46

Eligible Youth 18-26 ...............................................................35-4635.5.3 Youth Not Eligible for FFY...........................................................35-4735.5.4 General Eligibility Rules ..............................................................35-47

Deemed Eligible Infant with FFY Youth .................................35-4935.5.5 FFY and CalHEERS....................................................................35-5035.5.6 Hospital Presumptive Eligibility Program.....................................35-5135.5.7 Self Attestation ............................................................................35-51

Not Eligible for FFY ................................................................35-5235.5.8 MFBU Rules ................................................................................35-5335.5.9 Income of FFY Child Who Resides With Their Parents and Other Family Members

35-5335.5.10 Retroactive Eligibility ...................................................................35-5335.5.11 FFY and CalWORKs ...................................................................35-5435.5.12 FFY and SSI................................................................................35-5435.5.13 District Office Procedures............................................................35-55

Application Process ...............................................................35-55Forms/Verifications/Notices of Action (NOAs) .......................35-55Phone Application Requests ..................................................35-56Independent Living Program (ILP) .........................................35-56NOAa .....................................................................................35-56

35.5.14 Redeterminations ........................................................................35-5735.5.15 No Longer Eligible for FFY Medi-Cal and Approach 26 ..............35-57

35.6 Safely Surrendered Baby Law....................................................................35-58

35.7 Pregnancy ..................................................................................................35-5935.7.1 Verification Required ...................................................................35-59

Self-Attestation of Pregnancy ................................................35-59Paper Pregnancy Verification ................................................35-60

36. FPL Programs .................................................................................................36-1

36.1 60-Day Postpartum Program........................................................................36-136.1.1 Program Overview.........................................................................36-136.1.2 Eligibility Requirements .................................................................36-136.1.3 Period of Eligibility .........................................................................36-236.1.4 Dual Eligibility and Postpartum......................................................36-236.1.5 Pregnancy Definition/Verification Requirements ...........................36-236.1.6 Women Eligible for 60-Day Postpartum ........................................36-3

Medically Indigent (MI) Women (e.g. Aid Code 86, 87) ...........36-3Medically Needy (MN) Women (e.g., Aid Code 34, 37) ...........36-3Public Assistance (PA) or Other PA Recipient (TMC) .............36-4Minors, Whose Pregnancy Terminates ....................................36-4

36.1.7 Women Ineligible for 60-Day Postpartum......................................36-5


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36.1.8 Issuing Postpartum When Pregnancy Ends..................................36-636.1.9 Discontinuance of 60-Day Postpartum Benefits............................36-7

36.2 Income Disregard Program ..........................................................................36-936.2.1 Who is Eligible...............................................................................36-936.2.2 Background .................................................................................36-1036.2.3 Retroactive Benefits ....................................................................36-1036.2.4 Period of Eligibility .......................................................................36-10

Pregnant Women ...................................................................36-10Infants ....................................................................................36-11

36.2.5 Scope of Benefits and Aid Codes................................................36-11Pregnant Women ...................................................................36-11Infants ....................................................................................36-12

36.2.6 Income Determination, Budgeting ...............................................36-1236.2.7 Pregnant Minors, Parental Income Disregard .............................36-1336.2.8 Approvals & Denials ....................................................................36-1436.2.9 Exceptions...................................................................................36-14

Continued Eligibility ................................................................36-14Property Waiver Program ......................................................36-15

36.2.10 MFBU Requirements...................................................................36-15Pregnant Women ...................................................................36-15Infants ....................................................................................36-15

36.2.11 MFBU Examples .........................................................................36-1636.2.12 Notices of Action .........................................................................36-26

Approvals ...............................................................................36-26Discontinuances .....................................................................36-27Discontinuance of Income Disregard & Another Program .....36-27Denials ...................................................................................36-27

36.2.13 Minor Consent .............................................................................36-2836.2.14 Hospitalized Infants .....................................................................36-2836.2.15 Midyear Status Report (MSR) .....................................................36-29

36.3 133% Program for Children Ages One Through Five.................................36-3036.3.1 Definition .....................................................................................36-3036.3.2 Application for the 133% Program...............................................36-30

Intake .....................................................................................36-30Continuing Cases ...................................................................36-31

36.3.3 Period of Eligibility .......................................................................36-3136.3.4 Scope of Benefits ........................................................................36-3236.3.5 Eligibility Determination ...............................................................36-3236.3.6 Approvals and Denials ................................................................36-3336.3.7 MFBU Requirements...................................................................36-34

MFBU Example: .....................................................................36-3436.3.8 Notice of Action Requirements....................................................36-35

Approval of Benefits ...............................................................36-35Discontinuance of 133% Benefits Only ..................................36-35

36.4 100% Program ...........................................................................................36-35


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36.4.1 Who is Eligible.............................................................................36-3536.4.2 Effective Date ..............................................................................36-3636.4.3 Period of Eligibility .......................................................................36-3636.4.4 Scope of Benefits ........................................................................36-3736.4.5 Eligibility Determination ...............................................................36-3736.4.6 Approvals & Denials ....................................................................36-3836.4.7 MFBU Requirements...................................................................36-3836.4.8 Notice of Action Requirements....................................................36-38

Approval of Benefits ...............................................................36-38Discontinuance of 100% Benefits Only ..................................36-39

36.5 Property Waiver Program...........................................................................36-4036.5.1 Background .................................................................................36-4036.5.2 Property Waiver Program Criteria ...............................................36-41

Pregnant Women and Infants ................................................36-41Children One to Six Years .....................................................36-41Children Six to Nineteen ........................................................36-42

36.5.3 Scope of Coverage......................................................................36-4236.5.4 Property Verification Not Required..............................................36-4336.5.5 Income Generated From Waived Property..................................36-43

Rental Income from Real Property .........................................36-4336.5.6 Determining Eligibility for Property Waiver ..................................36-44

Zero Share-of-Cost and Property Waiver ..............................36-4536.5.7 Denials ........................................................................................36-4636.5.8 Discontinuance............................................................................36-4636.5.9 Property Changes .......................................................................36-4736.5.10 Income Increases ........................................................................36-47

Pregnant women and Infants are exempt ..............................36-4736.5.11 Examples.....................................................................................36-47

Pregnant Woman with an Absent Parent ...............................36-47Unmarried Couple with an Unborn .........................................36-48Married Couple with Mutual Children, Continuing Case ........36-48Unmarried Mother Applicant With Two Children ....................36-49

36.6 Optional Targeted Low-Income Children’s Program ..................................36-4936.6.1 Who is Eligible.............................................................................36-5036.6.2 Application for the OTLIC............................................................36-5036.6.3 Scope of Benefits ........................................................................36-5036.6.4 Premiums ....................................................................................36-52

Premium Collection ................................................................36-53Missed Payments ...................................................................36-53

36.6.5 Non-Payment of Premium Process .............................................36-54Premium Waiver and Refund Requests .................................36-57

36.6.6 Non-Payment of Premium Questions and Answers ....................36-5936.6.7 Bridging for AIM-Linked Infant.....................................................36-60

37. Transitional Medi-Cal/Four-Month Continuing ............................................37-1


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37.1 Overview ......................................................................................................37-137.1.1 Who Qualifies for TMC..................................................................37-1

Qualifying Criteria ....................................................................37-1Non-Qualifying CalWORKs Discontinuance Reasons .............37-2Definitions/Who Qualifies for TMC ...........................................37-3

37.1.2 Ineligible Individuals ......................................................................37-437.1.3 Adding an Individual to Existing TMC............................................37-537.1.4 Individuals Leaving the Home .......................................................37-537.1.5 Non-MAGI MC MFBU Composition...............................................37-6

Optional TMC Members ...........................................................37-637.1.6 MAGI MC Tax Filing Household....................................................37-637.1.7 Return to CalWORKs ....................................................................37-637.1.8 EW Procedures .............................................................................37-737.1.9 TMC Informing Flyer......................................................................37-8

37.2 Initial Six Months of TMC .............................................................................37-8Establishing Initial TMC Months ...............................................37-9

37.3 Additional Six Months of TMC ......................................................................37-9

37.4 TMC Status Report.....................................................................................37-1137.4.1 Good Cause Determinations .......................................................37-1237.4.2 Incomplete TMC Status Reports .................................................37-1237.4.3 Status Report Verification Requirements ....................................37-1337.4.4 Non-Exempt Earned Income.......................................................37-1337.4.5 Determining Average Net Non-Exempt Earned Income..............37-14

TMC Status Report Worksheet ..............................................37-14

37.5 Termination of TMC....................................................................................37-16

37.6 Transitional Medi-Cal and CEC..................................................................37-1637.6.1 CEC after TMC............................................................................37-1637.6.2 When CEC Does Not Apply after TMC .......................................37-17

37.7 Redetermination Due to Loss of TMC Eligibility .........................................37-18Processing the Redetermination Packet ................................37-18

37.8 Aid Code after TMC Discontinuance ..........................................................37-19

37.9 Questions and Answers .............................................................................37-20

37.10 Four-Month Continuing...............................................................................37-2137.10.1 Qualifying Criteria........................................................................37-2137.10.2 Period of Eligibility .......................................................................37-2237.10.3 Eligibility Conditions ....................................................................37-2237.10.4 Ineligibility for Four-Month Continuing.........................................37-2337.10.5 Inter County Transfer (ICT) .........................................................37-23

38. Minor Consent.................................................................................................38-1


Medi-CalMedi-Cal

38.1 Child Abuse Reporting Requirements ..........................................................38-238.1.1 Mandatory Reporting.....................................................................38-238.1.2 Reporting Numbers .......................................................................38-2

38.2 Confidentiality...............................................................................................38-338.2.1 Confidentiality for Applications Received by Mail, Email, Fax, and Any Other Means

38-3

38.3 Definition of “Child” for Minor Consent ........................................................38-4

38.4 Who Can Apply ............................................................................................38-438.4.1 Adults ............................................................................................38-538.4.2 Other Services...............................................................................38-5

38.5 Existing Public Assistance Case ..................................................................38-6

38.6 Application Requirements ............................................................................38-638.6.1 Forms ............................................................................................38-7

38.7 Eligibility Criteria ..........................................................................................38-738.7.1 Citizenship/Alien Status.................................................................38-838.7.2 Identity...........................................................................................38-838.7.3 Responsible Relatives...................................................................38-838.7.4 Other Health Coverage .................................................................38-938.7.5 Health Care Options....................................................................38-1038.7.6 Income.........................................................................................38-1038.7.7 Property.......................................................................................38-1038.7.8 Case Rules..................................................................................38-1138.7.9 Maintenance Need ......................................................................38-1138.7.10 Minor Consent Aid Codes ...........................................................38-1138.7.11 Notice of Action ...........................................................................38-1238.7.12 Period of Eligibility .......................................................................38-1238.7.13 Reporting Responsibility..............................................................38-13

38.8 Pregnant Minors .........................................................................................38-1338.8.1 Verification...................................................................................38-1338.8.2 Unmarried Father ........................................................................38-1338.8.3 Newborn ......................................................................................38-1438.8.4 Pregnant Minor Needing Services Other Than Pregnancy Services38-14

No Share of Cost ...................................................................38-14Share of Cost .........................................................................38-14

38.8.5 Continued Eligibility .....................................................................38-15Mothers ..................................................................................38-15Infants ....................................................................................38-15

38.8.6 Postpartum Benefits ....................................................................38-15

38.9 Mental Health Applicants............................................................................38-1638.9.1 Applicants....................................................................................38-1638.9.2 Mental Health Statement.............................................................38-17


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38.9.3 Eligibility ......................................................................................38-1838.9.4 Mental Health Treatment Limitations...........................................38-18

38.10 ............................................................................. Monthly Reapplications38-18

38.11 .................................................................................Issuance Procedures38-1938.11.1 Paper Benefits Identification Card...............................................38-1938.11.2 Approvals in CalWIN ...................................................................38-1938.11.3 MEDS Online Procedures ...........................................................38-1938.11.4 Benefits Identification Card Mail Procedures ..............................38-20

38.12 .............................................Inter County Transfer and Ex Parte Process38-20

39. .....................................................................Specific Institutional Programs39-1

39.1 Public Institutions .........................................................................................39-139.1.1 Inmates of a Public Institution .......................................................39-139.1.2 Inmates Who May be Eligible for Medi-Cal Benefits .....................39-239.1.3 Inmates Ineligible for Medi-Cal Benefits........................................39-339.1.4 Inmates Under Penal Code ...........................................................39-439.1.5 Fleeing Felon.................................................................................39-439.1.6 Inmate ...........................................................................................39-5

39.2 Other Institutions ..........................................................................................39-539.2.1 Institution .......................................................................................39-539.2.2 Medical Institution..........................................................................39-539.2.3 Non-medical Institution..................................................................39-539.2.4 Tuberculosis Institution .................................................................39-639.2.5 Intermediate care facility ...............................................................39-639.2.6 Child Care Institution .....................................................................39-639.2.7 Institution for the Mentally Retarded..............................................39-639.2.8 Community Care Facility ...............................................................39-739.2.9 Publicly Operated Community Residence.....................................39-839.2.10 Alternatively Sentenced.................................................................39-8

Situation # 1: ............................................................................39-9Situation # 2: ............................................................................39-9Situation # 3: ............................................................................39-9Situation # 4: ............................................................................39-9

39.2.11 Status Considerations ...................................................................39-9

39.3 Special Institutional Eligibility Summary Chart ...........................................39-10

39.4 Authorized Representative .........................................................................39-1239.4.1 Authorized Representative During Incarceration.........................39-1239.4.2 Authorized Representative After Release ...................................39-1339.4.3 Cancellation of the Authorized Representative ...........................39-13

39.5 Pre-Release Application (AB720)...............................................................39-1339.5.1 CDCR and SD AB720 Application Process Responsibilities.......39-14


Medi-CalMedi-Cal

AB720 County Jail (SCD 2363 A): .........................................39-15AB720 Health Trust (SCD 2363 B) ........................................39-16AB720 Prison: 39-17AB720 Parole: 39-18

39.5.2 SSA AB720 Application Process Responsibilities.......................39-1839.5.3 MC 0025 form..............................................................................39-2039.5.4 AB720 Health Trust Application ..................................................39-2139.5.5 AB720 Application procedures ....................................................39-2139.5.6 AB720 Verifications .....................................................................39-23

Household and Tax Filing Status ...........................................39-23Income ...................................................................................39-23Identity ...................................................................................39-23Citizenship/Immigration Status ..............................................39-23SSN ........................................................................................39-23Property .................................................................................39-24Residency ..............................................................................39-24

39.5.7 AB720 Pre-Release Questions and Answers..............................39-24

39.6 Medi-Cal Inmate Eligibility Program (MCIEP) ............................................39-2639.6.1 State MCIEP................................................................................39-2639.6.2 County MCIEP.............................................................................39-2639.6.3 Eligibility Requirements ..............................................................39-2739.6.4 Summary of Responsibilities .......................................................39-27

CCHCS or SD staff need to: ..................................................39-27DHCS or SSA staff need to: ...................................................39-27Billing and County Responsibility ...........................................39-28

39.6.5 County Involvement with MCIEP State Inmates..........................39-29State Inmates and Parole ......................................................39-29Inpatient Services for Pregnant Inmates ................................39-29MCIEP Beneficiary Applies for MC After Release .................39-30Open MC Case ......................................................................39-30

39.6.6 State Inmate Aid Codes ..............................................................39-3039.6.7 County Inmate Aid Codes ...........................................................39-3139.6.8 MCIEP Application Process ........................................................39-3339.6.9 MCIEP Cover Letter ....................................................................39-37

39.7 Medical Parole and Compassionate Release ............................................39-38Eligibility for Medical Parole for State Inmates .......................39-38

39.7.1 State Inmate Aid Codes for Medical Parole ................................39-3939.7.2 County Medical Probation/Compassionate Release ...................39-4039.7.3 County Inmate Compassionate Release and Medical Probation Eligibility Effective

Dates and Termination Dates......................................................39-4139.7.4 County Inmate Aid Code Medical Probation and Compassionate Release39-41

39.8 Special Institutional Programs MEDS Functionality ...................................39-4239.8.1 MCIEP MEDS Functionality ........................................................39-42


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In and Out Dates ....................................................................39-42Retroactive Eligibility/Eligibility Effective Date .......................39-42

39.8.2 County Inmate Compassionate Release and Medical Probation MEDS39-43MEDS Worker Alert ................................................................39-43MEDS Functionality ...............................................................39-43

39.9 Juveniles in Public Institutions....................................................................39-4439.9.1 Disposition...................................................................................39-4439.9.2 Before Disposition .......................................................................39-4439.9.3 After Disposition ..........................................................................39-4539.9.4 Nature of the Facility ...................................................................39-4539.9.5 Sample Disposition Orders..........................................................39-4539.9.6 SB 1469 Pre-Release Application Process for Wards in County Juvenile Facilities

39-4639.9.7 SB 1469 Application Process ......................................................39-4639.9.8 Eligibility Requirements ...............................................................39-4739.9.9 MBA SB 1469 Juvenile Intake Procedures .................................39-4839.9.10 Foster Care .................................................................................39-5139.9.11 Medi-Cal Inmate Eligibility Program NOAs..................................39-52

40. Refugees/TCVAP ............................................................................................40-1

40.0.1 Persons Identified by the Federal Government as Refugees........40-140.0.2 Children of Refugees Identified by the Federal Government as Refugees40-240.0.3 Cuban/Haitian Entrants Identified as Refugees ............................40-240.0.4 Persons Not Identified by the Federal Government as Refugees .40-3

40.1 Medi-Cal Eligibility Period.............................................................................40-440.1.1 Cash-Linked Medi-Cal and RMA/EMA..........................................40-440.1.2 Refugee Medical Assistance (RMA)/Entrant Medical Assistance (EMA)40-4

Eligibility Criteria ......................................................................40-4Social Security Number Requirement ......................................40-5

40.1.3 Eligibility at Date of Application .....................................................40-5

40.2 Beginning Date of Aid of RMA/EMA Eligibility ..............................................40-6

40.3 Eligibility Determination ................................................................................40-840.3.1 Program Determination .................................................................40-840.3.2 Specific Considerations.................................................................40-840.3.3 Financial Requirements.................................................................40-9

Exempt Income and Property ..................................................40-9Clarifications ..........................................................................40-10

40.3.4 Refugee Cash Assistance (RCA) Entrant Cash Assistance (ECA)40-11

40.4 Alleged Disability ........................................................................................40-12

40.5 RMA/EMA Discontinuance .........................................................................40-12

40.6 Retroactive RMA/EMA Eligibility ................................................................40-13


Medi-CalMedi-Cal

40.7 Sponsor/VOLAG Contact ...........................................................................40-1440.7.1 Role of Resettlement Agency......................................................40-1440.7.2 Intake Procedure .........................................................................40-1540.7.3 Resettlement and Matching Grants.............................................40-15

40.8 Lost Boys of Sudan ....................................................................................40-16

40.9 Afghan and Iraqi Special Immigrants .........................................................40-1640.9.1 Special Immigrant RMA Period of Eligibility ................................40-1640.9.2 Documentation Requirements.....................................................40-1740.9.3 Refugees Discontinued from SSI ................................................40-17

40.10 Tuberculosis (TB) Program ........................................................................40-17

40.11 Managed Care............................................................................................40-1840.11.1 Mental Health Managed Care Program.......................................40-18

40.12 Adjustment of Status for Refugees.............................................................40-18

40.13 Unaccompanied Refugee Minor.................................................................40-1840.13.1 Eligibility ......................................................................................40-1940.13.2 Application...................................................................................40-1940.13.3 URM Eligibility Criteria.................................................................40-2040.13.4 URM Duration of Eligibility...........................................................40-2040.13.5 URM Redetermination.................................................................40-2140.13.6 Retro-MC.....................................................................................40-2140.13.7 Inter-County Transfers ................................................................40-21

40.14 TCVAP (T Visa/U Visa) ..............................................................................40-2140.14.1 TCVAP Definitions.......................................................................40-23

Severe form of trafficking in persons .....................................40-23Derivative Relatives ...............................................................40-23

40.14.2 TCVAP Eligibility .........................................................................40-2340.14.3 TCVAP Documentation ...............................................................40-2440.14.4 Trafficking Victim (T Visa) ...........................................................40-25

T VISA Period of Eligibility .....................................................40-25T Visa Documentation ............................................................40-25Office of Refugee Resettlement Certification .........................40-26T Visa Holder .........................................................................40-26

40.14.5 Family Members of Severe Trafficking Victims ...........................40-27T Visa Eligibility Chart ............................................................40-28

40.14.6 Survivors of Domestic Violence and Other Serious Crimes (U Visa)40-29U Visa Period of Eligibility ......................................................40-29U Visa Holder .........................................................................40-29U Visa Documentation ...........................................................40-29U Visa Eligibility Chart ............................................................40-30

40.14.7 TCVAP Aid Codes.......................................................................40-3040.14.8 TCVAP Alien Eligibility Codes .....................................................40-31

Citizenship Alien Indicator/Code ............................................40-31


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40.14.9 TCVAP Process ..........................................................................40-3140.14.10 TCVAP Termination of Benefits ..................................................40-3340.14.11 TCVAP Notices ...........................................................................40-33

41. State/County Administered Health Insurance Programs............................41-1

41.1 Medi-Cal Access Program (MCAP)..............................................................41-1Overview ..................................................................................41-1Purpose ....................................................................................41-1Eligibility Criteria ......................................................................41-1

41.1.1 Income/Property Criteria ...............................................................41-2Limits ........................................................................................41-2Family size ...............................................................................41-2Total Family Income .................................................................41-2Examples .................................................................................41-3Verification of income ...............................................................41-3MCAP Subscriber Contribution Chart ......................................41-3Property ...................................................................................41-3

41.1.2 Subscriber Contribution.................................................................41-4Payments .................................................................................41-4Discount ...................................................................................41-4Mandatory Payment .................................................................41-4Penalty .....................................................................................41-4Second Payment ......................................................................41-4Discount ...................................................................................41-5

41.1.3 Care Providers/Covered Services .................................................41-5Participants ..............................................................................41-5Coverage .................................................................................41-5

41.1.4 Application Review........................................................................41-5Where Located .........................................................................41-5Section 1 ..................................................................................41-6Section 2 ..................................................................................41-6Section 3 ..................................................................................41-6Section 4 ..................................................................................41-7Section 5 ..................................................................................41-7Pregnancy Certification ............................................................41-7MCAP Application Assistance Fee ..........................................41-7Checklist ..................................................................................41-7EW Notification ........................................................................41-8Mail To .....................................................................................41-8

41.2 Presumptive Eligibility for Pregnant Women (Proc 5M)......................................................................................................41-941.2.1 Background ...................................................................................41-9

Overview ..................................................................................41-941.2.2 Eligibility Criteria............................................................................41-9

Period of Eligibility ..................................................................41-10


Medi-CalMedi-Cal

41.2.3 PE Covered Services ..................................................................41-1141.2.4 PE Enrollment .............................................................................41-11

PE Enrollment Forms .............................................................41-1141.2.5 PE Application Process for Medi-Cal ..........................................41-1241.2.6 Retroactive Coverage..................................................................41-1441.2.7 Other ...........................................................................................41-14

General Information ...............................................................41-14

41.3 Healthy Families Program (HFP) ...............................................................41-1541.3.1 Background .................................................................................41-1541.3.2 Effective Dates ............................................................................41-15

Transition Phases ..................................................................41-1541.3.3 Transition.....................................................................................41-16

Transition Aid Codes ..............................................................41-16Premiums ...............................................................................41-17

41.3.4 Medi-Cal Determinations.............................................................41-17Continuous Eligibility for Children (CEC) ...............................41-18

41.3.5 Transition Process.......................................................................41-1841.3.6 Informing Notices ........................................................................41-19

Welcome Packet ....................................................................41-19Beneficiary Identification Cards .............................................41-19

41.3.7 Single Point of Entry....................................................................41-20Accelerated Enrollment (AE) ..................................................41-20

41.4 Healthy Kids ...............................................................................................41-21Description .............................................................................41-21Purpose ..................................................................................41-21Scope of Coverage ................................................................41-21Eligibility Criteria ....................................................................41-22

41.5 Santa Clara County Children’s Health Initiative .........................................41-2241.5.1 Overview .....................................................................................41-22

Toll-Free Number ...................................................................41-2341.5.2 CHI Screening Process at Intake ................................................41-23

Role of the Application Assistor .............................................41-2341.5.3 CHI Screening Process at Redetermination................................41-25

Role of the Continuing EW .....................................................41-2541.5.4 CHI Review Process ...................................................................41-2641.5.5 Release of Information ................................................................41-2741.5.6 CHI Forms and Materials ............................................................41-27

41.6 Accelerated Enrollment (AE) for Children .................................................41-2841.6.1 Scope of Coverage and Aid Code...............................................41-2841.6.2 Children Ineligible for AE.............................................................41-2941.6.3 Informing Notices ........................................................................41-2941.6.4 AE MEDS Record........................................................................41-2941.6.5 Reporting Approvals to MEDS ....................................................41-3041.6.6 Termination of AE........................................................................41-30


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41.7 CHDP Gateway Program ...........................................................................41-3141.7.1 Background .................................................................................41-3141.7.2 Pre-Enrollment by CHDP Providers ............................................41-31

41.8 Breast and Cervical Cancer Treatment Program (BCCTP)........................41-3541.8.1 Federal BCCTP...........................................................................41-36

Ineligibility for federal BCCTP ................................................41-36Federal BCCTP Health Insurance Coverage Limitations .......41-37

41.8.2 State-Funded BCCTP .................................................................41-3741.8.3 Referrals to BCCTP.....................................................................41-3841.8.4 Referring BCCTP Applicants to DDSD........................................41-3941.8.5 Referring Beneficiaries ................................................................41-4041.8.6 BCCTP Categories......................................................................41-41

Categories for Females (only) Who Are Less Than 65 Years of Age 41-42Category for Males or Females .............................................41-44

41.8.7 Processing BCCTP Determinations ............................................41-45Applicants with a DDSD Referral ...........................................41-45Applicants without a DDSD Referral ......................................41-46Denial NOA ............................................................................41-46Processing Chart ...................................................................41-47Medi-Cal Recipient Eligible for Federal BCCTP and NOA .....41-47Full Scope with a Disability Packet ........................................41-48Restricted Medi-Cal with a Disability Packet ..........................41-48Disability Determination for Applicant or Recipient Approved Federal BCCTP 41-48BCCTP Processing Chart for Medi-Cal Beneficiaries ............41-49

41.8.8 Medi-Cal Discontinuance NOA....................................................41-50MC 351 and MC 239 A ..........................................................41-51

41.8.9 Retroactive Benefits ....................................................................41-5141.8.10 Annual Redetermination (RD) for BCCTP Eligibility....................41-5141.8.11 State Hearings and Appeals........................................................41-5141.8.12 Managed Care for BCCTP Beneficiaries.....................................41-5241.8.13 Recipients Ineligible for BCCTP..................................................41-52

Time Frame ............................................................................41-5341.8.14 Beneficiaries Ineligible for federal or state BCCTP .....................41-53

CalWIN Process .....................................................................41-55

41.9 Every Woman Counts (EWC) Program......................................................41-55Eligibility Criteria: ...................................................................41-55

41.10 Health Care Coverage Assistance Program ..............................................41-57Application: ............................................................................41-57Verifications: ..........................................................................41-58

41.10.1 Ability to Pay Determination Program .........................................41-5841.10.2 Valley Care..................................................................................41-5941.10.3 Discount Program........................................................................41-5941.10.4 Waiver Program ..........................................................................41-5941.10.5 Inpatient Financial Services ........................................................41-60


Medi-CalMedi-Cal

42. State Waiver Programs and Limited Services ............................................42-1

42.1 Waiver Programs (Proc. 19-D] .....................................................................42-142.1.1 Background ...................................................................................42-142.1.2 Overview .......................................................................................42-142.1.3 DHS In-Home Operations (IHO)....................................................42-242.1.4 Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) Program42-242.1.5 Personal Care Services Program (PCSP).....................................42-2

42.2 Department of Developmental Services - Home and Community-Based (DDS-HCBS) Waiver42-342.2.1 Background ...................................................................................42-3

Benefits ....................................................................................42-4Requirements ...........................................................................42-4

42.2.2 Medi-Cal Eligibility .........................................................................42-6Application Referrals ................................................................42-6“Public Agency” Representative ...............................................42-6MFBU Determination ...............................................................42-7DDS-HCBS Aid Codes .............................................................42-7Reporting Responsibilities .......................................................42-7Budgeting Methodology ...........................................................42-7Retro Medi-Cal .........................................................................42-8

42.2.3 Procedure......................................................................................42-8DDS-HCBS Determination For a New Applicant .....................42-8DDS-HCBS Determination for a Currently Eligible Medi-Cal Recipient ...................................................................42-9Notices of Action (NOAs) .......................................................42-10Referring Agency ...................................................................42-10Release of Information ...........................................................42-10Redeterminations (RDs) ........................................................42-10Termination of DDS-HCBS Waiver ........................................42-11

42.3 Model Nursing Facility (Model-NF) Waiver.................................................42-11

42.4 Model IHO Waiver ......................................................................................42-11Requirements .........................................................................42-12

42.4.1 Medi-Cal IHO Waiver Inquiries....................................................42-1242.4.2 DHS In-Home Operations (IHO) - Initial Screening.....................42-13

When Medical Requirements are Met ....................................42-1342.4.3 EW - Medi-Cal Eligibility Determination.......................................42-13

Institutional Deeming .............................................................42-13MFBU Determination .............................................................42-13Medi-Cal IHO Waiver Aid Codes ...........................................42-14Reporting Responsibilities .....................................................42-14Budget Methodology ..............................................................42-14Medi-Cal IHO Waiver Approval and Beginning Date of Aid ...42-14Notice of Action Requirement ................................................42-15Referring Agency ...................................................................42-15


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42.5 Multipurpose Senior Service Program (MSSP) Waiver ..............................42-1542.5.1 Benefits .......................................................................................42-1642.5.2 Eligibility Requirements ...............................................................42-1642.5.3 Referring Agency.........................................................................42-17

Release of Information ...........................................................42-1742.5.4 Redeterminations (RD)................................................................42-1742.5.5 Termination of MSSP Waiver ......................................................42-1742.5.6 Eligibility Determination ...............................................................42-1842.5.7 MFBU Determination...................................................................42-1942.5.8 MSSP Process ............................................................................42-19

MSSP Determination For a New Applicant ............................42-19MSSP Determination for a Currently Eligible Medi-Cal Recipient 42-20

42.5.9 MSSP Examples .........................................................................42-21Example 1 ..............................................................................42-21Example 2 ..............................................................................42-21Example 3 ..............................................................................42-21

42.6 Additional Waiver Programs.......................................................................42-2142.6.1 In-Home Medical Care Services (IHMC) Waiver.........................42-22

Eligibility Requirements ..........................................................42-22Referring Agency ...................................................................42-22

42.6.2 Nursing Facility (NF) Services Waiver.........................................42-22Eligibility Requirements ..........................................................42-23Referring Agency ...................................................................42-23

42.6.3 Acquired Immune Deficiency Syndrome (AIDS) Waiver .............42-23Eligibility Requirements ..........................................................42-23Referring Agency ...................................................................42-24

42.7 Severely Impaired Working Individuals Program (Aid Code 8G) ............................................................................................42-2442.7.1 Background .................................................................................42-2442.7.2 Eligibility Requirements ...............................................................42-24

Model Waiver Referral ...........................................................42-2542.7.3 Procedure....................................................................................42-25

42.8 Limited Services Due to Program Abuse [Proc. 19-A] ...............................42-2542.8.1 Background .................................................................................42-2542.8.2 DHS Responsibility......................................................................42-2642.8.3 County Responsibility..................................................................42-2642.8.4 Medi-Cal Benefits Issuances.......................................................42-27

42.9 Limited Services for MIAs in SNF/ICF [Proc. 19-C]....................................42-2742.9.1 Background .................................................................................42-2742.9.2 County Responsibility..................................................................42-2742.9.3 Medi-Cal Benefits ........................................................................42-2842.9.4 Retroactive Medi-Cal...................................................................42-2842.9.5 Undocumented Immigrants in LTC..............................................42-28


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43. Special Treatment Programs.........................................................................43-1

43.1 General.........................................................................................................43-1

43.2 Referrals to VMC..........................................................................................43-1

43.3 Definitions.....................................................................................................43-243.3.1 Medi-Cal Special Treatment Program — ONLY Beneficiary.........43-243.3.2 Medi-Cal Special Treatment Program — SUPPLEMENT

Beneficiary.....................................................................................43-243.3.3 Dialysis ..........................................................................................43-243.3.4 Parenteral Hyperalimentation .......................................................43-343.3.5 Annual Net Worth ..........................................................................43-343.3.6 Percentage Obligation...................................................................43-3

43.4 Eligibility Requirements ................................................................................43-443.4.1 Reporting Responsibilities.............................................................43-443.4.2 Medicare Application Requirements..............................................43-5

MSTP for Dialysis Coverage ....................................................43-5MSTP for TPN Coverage .........................................................43-5Follow-Up on Medicare Applications ........................................43-6Eligibility for the Medicare Dialysis Program ............................43-6Things to Remember ...............................................................43-7

43.5 Aid Codes.....................................................................................................43-7

43.6 Annual Net Worth [50825] ............................................................................43-743.6.1 Determination of Annual Net Worth...............................................43-8

Whose Property/Income to Include ..........................................43-8Excluded/Exempt Property ......................................................43-8

43.7 Determination of Percentage Obligation [50827] .........................................43-943.7.1 Example: MSTP - Only..................................................................43-9

43.8 Share-of-Cost MSTP-Supplement Program [50831] ..................................43-10

43.9 MC 176-D Instructions for Completion .......................................................43-1143.9.1 Part I: Identification......................................................................43-1143.9.2 Part II: Eligibility Requirements - Summary.................................43-1143.9.3 Part III: Annual Net Worth Computations ....................................43-11

Percentage Obligation Determination — Part III, Section D .43-12

43.10 Establishing a MEDS Record .....................................................................43-12

43.11 Status Reports............................................................................................43-12

43.12 Annual Redetermination.............................................................................43-13

43.13 Notice of Action ..........................................................................................43-13

43.14 Tuberculosis Program ................................................................................43-13


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43.14.1 Background .................................................................................43-1343.14.2 Program Benefits.........................................................................43-1343.14.3 Covered Services ........................................................................43-1443.14.4 Aid Code......................................................................................43-1443.14.5 Effective Date ..............................................................................43-1443.14.6 Who Is Eligible.............................................................................43-14

General ..................................................................................43-14Dually Eligible ........................................................................43-15

43.14.7 Role of TB Providers ...................................................................43-15

43.15 TB Eligibility Criteria ...................................................................................43-1643.15.1 General........................................................................................43-1643.15.2 Income Limit ................................................................................43-1643.15.3 Resource Limit ............................................................................43-1643.15.4 Citizen/Alien Status .....................................................................43-1743.15.5 Undocumented Persons..............................................................43-1743.15.6 Certification of TB Infection .........................................................43-1743.15.7 Other Requirements ....................................................................43-1743.15.8 TB Child.......................................................................................43-1843.15.9 “Ineligible Spouse/Child” .............................................................43-1843.15.10 Married Person............................................................................43-19

43.16 TB Application Process ..............................................................................43-1943.16.1 Introduction..................................................................................43-1943.16.2 TB Application Packet .................................................................43-1943.16.3 TB Application (MC 274TB).........................................................43-2043.16.4 TB Applications Initiated by Clinics .............................................43-2043.16.5 Homeless Applicant.....................................................................43-2143.16.6 Persons in LTC............................................................................43-2143.16.7 Plastic BIC...................................................................................43-2143.16.8 TB NOAs .....................................................................................43-2143.16.9 Retroactive Benefits ....................................................................43-22

43.17 TB Property Determination and Examples .................................................43-2243.17.1 TB Property Limit.........................................................................43-2243.17.2 MC 278TB/ MC 279TB................................................................43-2243.17.3 Single Person ..............................................................................43-2343.17.4 Married Couple............................................................................43-2343.17.5 Child, Under 18 ...........................................................................43-2343.17.6 Parental Deeming........................................................................43-2343.17.7 MC 279TB, Instructions, Child.....................................................43-24

43.18 TB Income Determination & Budgeting Examples .....................................43-2543.18.1 TB Income Standards..................................................................43-2543.18.2 FBR Rates/SSI Standard Allocation............................................43-2543.18.3 Financial Eligibility .......................................................................43-2543.18.4 Deemed Income Rules................................................................43-2643.18.5 Child's Income.............................................................................43-27


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43.18.6 MC 282TB, Instructions...............................................................43-2843.18.7 MC 280TB, Instructions...............................................................43-29

43.19 TB Continuing Activities .............................................................................43-3143.19.1 Midyear Status Reports (MSR) ...................................................43-3143.19.2 Redetermination ..........................................................................43-3143.19.3 Active Cases ...............................................................................43-3143.19.4 Ineligible Persons ........................................................................43-31


45. Diligent Search/Estate Recovery/Fraud Referrals .......................................45-1

45.1 Diligent Search .............................................................................................45-145.1.1 Referral to Public Guardian or Conservator ..................................45-145.1.2 Disability Determination Referral...................................................45-145.1.3 Diligent Search Review .................................................................45-2

Persons With Identification ......................................................45-2Persons Without Identification .................................................45-2

45.1.4 Name.............................................................................................45-345.1.5 Aid Code........................................................................................45-345.1.6 Birth Date ......................................................................................45-345.1.7 Social Security Number.................................................................45-345.1.8 Health Insurance Claim Number ...................................................45-445.1.9 Address .........................................................................................45-445.1.10 Case Processing ...........................................................................45-4

45.2 Estate Recovery ...........................................................................................45-445.2.1 Estate Recovery Claims ................................................................45-5

Claims Included in the Estate Recovery for Clients Who Pass Away 45-5Claims that are Not Included in the Estate Recovery ..............45-5Notification of Client’s Death ....................................................45-6Claims that DHCS May Not Pursue .........................................45-6Definition of Estate for Clients Who Pass Away on or Before December 31, 2016 45-7 Definition of Estate for Clients Who Pass Away on or After January 1, 2017 45-7DHCS Informing Notice ............................................................45-7Access to Estimated Recoverable MC Expenses ....................45-7

45.2.2 Hardship Waiver............................................................................45-7On or Before December 31, 2016 ............................................45-7On or After January 1, 2017 .....................................................45-7Application for Hardship Waiver ...............................................45-8

45.2.3 Liens..............................................................................................45-8Property Lien Referral to DHCS ...............................................45-8Voluntary Repayments .............................................................45-9Post-Death Claim .....................................................................45-9Monthly Payments ...................................................................45-9


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45.2.4 What Happens When a Medi-Cal Client Passes Away .................45-945.2.5 Frequently Asked Questions .......................................................45-10

45.3 Medi-Cal Fraud Referrals ...........................................................................45-12

46. Other Health Coverage (OHC) ......................................................................46-1

46.1 Introduction [50761]......................................................................................46-146.1.1 Background ...................................................................................46-146.1.2 Definition .......................................................................................46-1

46.2 Client Responsibility .....................................................................................46-146.2.1 Reporting.......................................................................................46-146.2.2 Fraud Referrals .............................................................................46-2

46.3 EW Responsibility ........................................................................................46-346.3.1 Informing .......................................................................................46-346.3.2 Identification ..................................................................................46-346.3.3 EW Actions....................................................................................46-446.3.4 Good Cause ..................................................................................46-546.3.5 Reporting OHC Changes or New Policy .......................................46-646.3.6 Removing OHC .............................................................................46-8

Verification ...............................................................................46-8OHC Termination/Removal Process ........................................46-9

46.4 Insurance Policies Requiring OHC Identification........................................46-10Cancer Only ...........................................................................46-10TRI-CARE (formerly known as CHAMPUS) ..........................46-10Dental Only ............................................................................46-10Employment-Related .............................................................46-10ERISA (Employee Retirement Income Security Act) .............46-10Group Health ..........................................................................46-10Health .....................................................................................46-11Hospital ..................................................................................46-11Indemnity ...............................................................................46-11Long-Term Care .....................................................................46-11Major Medical .........................................................................46-11Medical Support .....................................................................46-11Medicare Supplemental .........................................................46-11PHP/HMO ..............................................................................46-11Prescription ............................................................................46-12Student Health .......................................................................46-12Surgical ..................................................................................46-12Vision .....................................................................................46-12

46.5 COBRA.......................................................................................................46-1246.5.1 Continuation of Benefits ..............................................................46-1246.5.2 Employers Affected .....................................................................46-13


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46.5.3 Notification Requirements ...........................................................46-1346.5.4 Payment of Premium...................................................................46-1346.5.5 Termination of Coverage.............................................................46-13

46.6 Insurances Not Included as OHC...............................................................46-1346.6.1 Unavailable..................................................................................46-1346.6.2 Other ...........................................................................................46-14

46.7 Health Insurance Premium Payment (HIPP) Program ...............................46-1546.7.1 Definition .....................................................................................46-1546.7.2 HIPP Qualifications .....................................................................46-1546.7.3 EW Action....................................................................................46-16

Completing the online application ..........................................46-1646.7.4 DHCS Responsibility ...................................................................46-1846.7.5 HIPP Approved............................................................................46-1846.7.6 Client Disenrolls from OHC voluntarily ........................................46-18

46.8 HIPP Questions and Answers ....................................................................46-1946.8.1 Referral Process..........................................................................46-1946.8.2 High Cost Medical Condition .......................................................46-1946.8.3 Approval ......................................................................................46-1946.8.4 Past Due Premiums ....................................................................46-2046.8.5 Non-Medi-Cal Family Member ....................................................46-2046.8.6 Requirement to Apply..................................................................46-2046.8.7 Insurance Lapsed........................................................................46-20

46.9 OHC Identification by DHCS ......................................................................46-2146.9.1 DHCS ..........................................................................................46-2146.9.2 Discrepancies..............................................................................46-21

46.10 OHC Billing Methods ..................................................................................46-2146.10.1 General........................................................................................46-2146.10.2 Cost Avoidance ...........................................................................46-2246.10.3 PHP, HMO, Triwest .....................................................................46-22

46.11 Cost Avoidance Coverage..........................................................................46-2346.11.1 Identification ................................................................................46-2346.11.2 DHCS Responsibility ...................................................................46-2346.11.3 EW Responsibility .......................................................................46-2346.11.4 Recording OHC in CalWIN and MEDS .......................................46-2346.11.5 Effective Date of Cost Avoidance................................................46-24

46.12 OHC Information on Medi-Cal Records.....................................................46-2446.12.1 OHC/HIAR SCREEN on MEDS ..................................................46-2446.12.2 Providers .....................................................................................46-2546.12.3 Information Lacking .....................................................................46-2546.12.4 EW Responsibility .......................................................................46-2546.12.5 Verification...................................................................................46-2646.12.6 Temporary OHC Removal...........................................................46-27


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46.13 Removal of OHC Codes for Victims of Domestic Violence ........................46-2746.13.1 Problem.......................................................................................46-2746.13.2 EW Responsibility .......................................................................46-27

Removing the OHC Code from MEDS ...................................46-28Removing OHC Information from CalWIN .............................46-28

46.14 OHC for Foster Care/Adoption Assistance Children ..................................46-2946.14.1 Problem.......................................................................................46-2946.14.2 OHC Coding Changes.................................................................46-2946.14.3 SSI Children ................................................................................46-2946.14.4 Recording OHC in CalWIN..........................................................46-30

46.15 Repayment for Medical Services................................................................46-3046.15.1 Rule .............................................................................................46-3046.15.2 Endorse Checks ..........................................................................46-3046.15.3 Provider Overpayments (OP) Program ......................................46-3146.15.4 DHCS Recovery ..........................................................................46-31

46.16 Kaiser Dues Subsidy Program ...................................................................46-3146.16.1 Definition .....................................................................................46-3146.16.2 Eligibility Criteria..........................................................................46-3246.16.3 How To Apply ..............................................................................46-32

46.17 Kaiser Permanente Steps Plan ..................................................................46-3346.17.1 Eligibility Criteria..........................................................................46-3346.17.2 Income Limit ................................................................................46-3446.17.3 How to Apply ...............................................................................46-34

47. Third Party Liability (TPL) ..............................................................................47-1

47.1 Applicant/Client Responsibility [50771] ........................................................47-147.1.1 Assignment....................................................................................47-147.1.2 Potential Third Party Liability Claims.............................................47-147.1.3 Notification of Third Party Liability .................................................47-1

47.2 EW Responsibility ........................................................................................47-247.2.1 Workers’ Compensation ................................................................47-247.2.2 Procedure......................................................................................47-2

47.3 When DHCS Receives a Third Party Payment ............................................47-3


49. Benefits Identification Cards, Overpayments, Billing & LOA (BOBLOA)..49-1

49.1 Medi-Cal Identification Cards .......................................................................49-1The Benefits Identification Card ...............................................49-1The Paper Identification Card ..................................................49-2

49.1.1 California Eligibility Verification System and Claim Management System (CA-EV/CMS)


Medi-CalMedi-Cal

49-2Medi-Cal Eligibility Verification .................................................49-3

49.1.2 BIC Use/Authorization Use............................................................49-3Authorization for use ................................................................49-4

49.2 Medi-Cal Identification Card Format.............................................................49-549.2.1 BIC format .....................................................................................49-5

Front of the BIC ........................................................................49-5Back of the BIC ........................................................................49-6Signature Requirements ..........................................................49-6

49.2.2 The Paper Card.............................................................................49-649.2.3 Client Index Number......................................................................49-7

49.3 MEDI Reserve System .................................................................................49-7

49.4 Non SSI/SSP Medi-Cal Identification Card Issuance ...................................49-849.4.1 BIC issuance for Non-SSI/SSP Clients .........................................49-849.4.2 Paper Card Issuance for Non-SSI/SSP Clients.............................49-8

49.5 Disposition of Returned Medi-Cal Cards ......................................................49-9Returned (Undeliverable) Cards ..............................................49-9EW Responsibilities .................................................................49-9

49.6 Non SSI/SSP Medi-Cal Identification Card Replacement ............................49-949.6.1 BIC Replacement ..........................................................................49-949.6.2 Temporary Cards ........................................................................49-10

49.7 SSI/SSP Medi-Cal Identification Cards ......................................................49-1049.7.1 SSI/SSP Initial BIC Issuance.......................................................49-1049.7.2 SSI/SSP BIC Replacement .........................................................49-11

49.8 Share of Cost Record System....................................................................49-1249.8.1 Share of Cost Online Record ......................................................49-12

SOCO Transactions ...............................................................49-12Share of Cost Reversal ..........................................................49-13

49.9 Service Restrictions for Medi-Cal Abuse/Codes and Messages ................49-13

49.10 BIC/CIN Information on MEDS Screens.....................................................49-1449.10.1 INQM and INQ1 Screens ............................................................49-14

BIC Issue Date .......................................................................49-14Paper ID Card Issue Date ......................................................49-14

49.10.2 MOPI Screen...............................................................................49-1449.10.3 SOCR Screen..............................................................................49-14

49.11 Copayment .................................................................................................49-15

49.12 Release of Medi-Cal Eligibility Information to Providers.............................49-1649.12.1 Medi-Cal Eligibility Data System (MEDS)....................................49-1749.12.2 Information Which May be Released to a Provider .....................49-17


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49.12.3 Ineligible Individual ......................................................................49-1849.12.4 Request for Medi-Cal Eligibility Information for a Deceased Individual49-18

49.13 Out-of-State Billing .....................................................................................49-1849.13.1 Medi-Cal Card Use......................................................................49-1949.13.2 Prior Authorization.......................................................................49-1949.13.3 Claims Procedure........................................................................49-19

49.14 Overpayment Overview..............................................................................49-2049.14.1 Definition of Potential Overpayments ..........................................49-2149.14.2 Causes of Potential Overpayments.............................................49-2249.14.3 No Overpayment Exists...............................................................49-22

49.15 Overpayment Rules....................................................................................49-2349.15.1 Overpayment Responsibility in Cases with Authorized Representative49-24

49.16 Determining Overpayment Period ..............................................................49-2449.16.1 Overpayment Examples ..............................................................49-25

49.17 Determining Usage.....................................................................................49-26

49.18 Types of Potential Medi-Cal Overpayments...............................................49-2649.18.1 Potential Overpayment Due to Incorrect Income or Household Situations49-27

Required Action for Incorrect Income or Household Situations 49-2749.18.2 Potential Overpayment Due to Total Ineligibility..........................49-28

Calculating Overpayment Due to Total Ineligibility ................49-2849.18.3 Potential Overpayment Due to Increased SOC (Non-MAGI) ......49-29

Calculating Overpayments Due to Increased SOC ................49-2949.18.4 Potential Overpayment Due to Excess Property (Non-MAGI).....49-29

Calculating Overpayments Due to Excess Property ..............49-29Computation ...........................................................................49-29

49.18.5 Potential Overpayments Due to Unreported Other Health Coverage (OHC)49-30Calculating Overpayments Due to Unreported Other Health Coverage (OHC) 49-30

49.18.6 CalWORKs Ineligibility ................................................................49-30Calculating Overpayments due to CalWORKs Ineligibility - Excess Property 49-31CalWORKs Ineligibility - All Other Reasons (Property Within Medi-Cal Reserve Limits) ...................................................................................49-31

49.18.7 Potential Overpayments Due to CalWORKs Fraud.....................49-32

49.19 CalWIN .......................................................................................................49-32Re-evaluation of SOC or Eligibility .........................................49-32Recording of Potential Overpayment to DHCS in CalWIN .....49-32

49.20 Overpayment Referral Procedures.............................................................49-3349.20.1 Where to Send Referrals.............................................................49-3449.20.2 Required Forms For Overpayment Referral Packets ..................49-3449.20.3 Forms and Instructions for Completion .......................................49-35

“Confidential Medi-Cal Complaint Report” (MC 609) .............49-35“Medi-Cal Potential Overpayment Reporting Work Sheet - Income or Other Health


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Coverage” (MC 224 A) .........................................................49-36Section 1 - Case Information .................................................49-36Section II - Possession of Other Health Coverage ................49-37Section III - Income Overpayment Computation ....................49-37Section IV - County Worker Comments .................................49-37Section V - County Worker Completing the Form ..................49-37“Medi-Cal Potential Overpayment Reporting Work Sheet - Property” (MC 224 B) 49-37Section 1 - Case Information .................................................49-37Section II - Property ...............................................................49-38Section III - Overpayment Computation .................................49-38Section IV - Summary ............................................................49-38Section V - County Worker Comments ..................................49-38Section VI - County Worker Completing the Form .................49-38

49.21 Overpayment Examples ............................................................................49-3849.21.1 Potential Overpayment - Income.................................................49-3849.21.2 Potential Overpayment - Property ...............................................49-40

49.22 Letter of Authorization ................................................................................49-4149.22.1 Error ...........................................................................................49-4349.22.2 Provider Billing Error ...................................................................49-4349.22.3 Letter of Authorization Examples ................................................49-4349.22.4 Letter of Authorization Process ...................................................49-4449.22.5 SSI/SSP Letter of Authorization Process ....................................49-45

49.23 SSI Advocacy - Letters of Authorization.....................................................49-47

50. Court Orders ...................................................................................................50-1

50.1 Beltran v Rank - Transfer of Property...........................................................50-150.1.1 Issue..............................................................................................50-150.1.2 Decision.........................................................................................50-1

50.2 Craig v Bontá - Loss of SSI/SSP..................................................................50-150.2.1 Issue..............................................................................................50-150.2.2 Decision.........................................................................................50-150.2.3 Ex Parte Redetermination Process ...............................................50-1

Ex Parte Review ......................................................................50-2Direct Contact ..........................................................................50-2Request for Information ...........................................................50-3When Written Requests are Not Required ...............................50-3

50.2.4 MC 355 or SCD 2350 Timelines....................................................50-350.2.5 When an Ex Parte Redetermination is Not Necessary..................50-450.2.6 Craig v Bontá Redetermination Process .......................................50-450.2.7 Case Assignment for Craig v Bontá ..............................................50-550.2.8 DDSD Disability Referral Packets .................................................50-550.2.9 Aid Codes Under State Control .....................................................50-6


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50.2.10 Exception Eligibles Report ............................................................50-650.2.11 Identification of Craig v Bontá Clients Groups by Codes ..............50-6

Loss of SSI/SSP Due to Disability Group ................................50-7Disabled Adult Child (DAC) Group ...........................................50-7Disabled Adult Widow(er)s Group ............................................50-8Pickle Group ............................................................................50-8All Other Discontinued from SSI/SSP Benefits ........................50-8

50.2.12 Alleged Disability ...........................................................................50-850.2.13 ICTs and Craig v Bontá Clients .....................................................50-850.2.14 CEC and Craig v Bontá Children...................................................50-950.2.15 Annual Redetermination................................................................50-950.2.16 IHSS and Craig v Bontá Clients ..................................................50-1050.2.17 Forms ..........................................................................................50-10

MC Informational Craig v Bontá Packet .................................50-1050.2.18 Questions and Answers ..............................................................50-11

50.3 Crawford v Rank - Multiple Dwelling Home................................................50-1250.3.1 Issue............................................................................................50-1250.3.2 Decision.......................................................................................50-12

50.4 Edwards v Kizer (also known as Edwards v Myers)...................................50-1250.4.1 Issue............................................................................................50-1250.4.2 Decision.......................................................................................50-1250.4.3 Persons Affected .........................................................................50-13

RCA/ECA and Edwards .........................................................50-1350.4.4 Auto CalWIN/MEDS Conversion .................................................50-1350.4.5 General Requirements ................................................................50-1450.4.6 Discontinuing Individuals from CalWORKs/RCA/ECA ................50-1450.4.7 Discontinuing CalWORKs/RCA/ECA Case and Information on File50-1550.4.8 MFBU Considerations .................................................................50-15

50.5 Gibbins v Rank ...........................................................................................50-1550.5.1 Issue............................................................................................50-1550.5.2 Decision.......................................................................................50-16

50.6 Ibarra v Dawson .........................................................................................50-1650.6.1 Issue............................................................................................50-1650.6.2 Effective Date ..............................................................................50-16

50.7 Johnson v Rank..........................................................................................50-1650.7.1 Issue............................................................................................50-1650.7.2 Decision.......................................................................................50-16

50.8 King v McMahon.........................................................................................50-1750.8.1 Issue............................................................................................50-1750.8.2 Treatment of Payments ...............................................................50-17

50.9 Ball v Swoap ..............................................................................................50-1750.9.1 Issue............................................................................................50-17


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50.9.2 Decision.......................................................................................50-1750.9.3 Treatment of Payments ...............................................................50-17

50.10 Lomeli v. Shewry ......................................................................................50-1850.10.1 Issue............................................................................................50-1850.10.2 Settlement ...................................................................................50-1850.10.3 Informing Notices ........................................................................50-1850.10.4 MC 19A .......................................................................................50-1850.10.5 MC 19..........................................................................................50-18

50.11 Ramos v Myers ........................................................................................50-1950.11.1 Issue............................................................................................50-19

50.12 Saldivar v McMahon ..................................................................................50-1950.12.1 Issue............................................................................................50-1950.12.2 Decision.......................................................................................50-19

50.13 Hunt v Kizer ..............................................................................................50-1950.13.1 Issue............................................................................................50-1950.13.2 Decision.......................................................................................50-2050.13.3 EW Instructions ...........................................................................50-20

50.14 Radcliffe v. Coye et al. ...............................................................................50-2050.14.1 Issue............................................................................................50-2050.14.2 Decision.......................................................................................50-20

50.15 Sawyer v Shalala, Anderson, Belshé, and Gould ......................................50-2150.15.1 Issue............................................................................................50-2150.15.2 Decision.......................................................................................50-2150.15.3 Retroactive ..................................................................................50-21

50.16 Tinoco v Belshé .........................................................................................50-2150.16.1 Issue............................................................................................50-2150.16.2 Decision.......................................................................................50-2150.16.3 Retroactive ..................................................................................50-21

50.17 Gamma v Belshé .......................................................................................50-2250.17.1 Issue............................................................................................50-2250.17.2 Decision.......................................................................................50-2250.17.3 Retroactive ..................................................................................50-22

50.18 Ramirez v. Belshé.......................................................................................50-2350.18.1 Issue............................................................................................50-2350.18.2 Decision.......................................................................................50-23

50.19 Latino Coalition for a Healthy California v. Belshé......................................50-2350.19.1 Issue............................................................................................50-2350.19.2 Decision.......................................................................................50-2350.19.3 Retroactive ..................................................................................50-24


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50.20 Pettit v. Bontá .............................................................................................50-2450.20.1 Decision.......................................................................................50-2450.20.2 Retroactive ..................................................................................50-24
