Update : Medi-Cal Midyear Status Report Questions & Answers

Transcription

1 Santa Clara County Social Services Agency page 1 Date: 07/29/11 References: ACWDL Cross-References: Clerical: Handbook Revision: N/A No Yes Midyear Status Report Questions & Answers Background The California Department of Health Care Services (DHCS) has provided clarifications of the Midyear Status Report (MSR) process and new policy for certain MSR situations. Policy The following policy clarifications/instructions were provided by DHCS: Good Cause Timeframes Question: Does a Medi-Cal beneficiary have three good cause months to submit the MSR? Answer: Title 22, CCR Section 50175(c) - Good Cause, does not specify the duration of months a beneficiary has for submitting a late MSR. The county must evaluate the circumstances of each case to determine whether the client had good cause for failing to meet MSR requirements. If good cause is found, and the client is otherwise eligible, eligibility must be reinstated. This clarifies existing policy. Exemption Based on Disability Question: What is the requirement for a disabled person to be exempt from MSR reporting? Answer: According to Section (d) Welfare and Institutions Code (WIC), beneficiaries whose eligibility is based on disability are exempt from MSR reporting.therefore, any individual who has applied on the basis of disability or is known to be disabled is exempt from the MSR requirement, regardless of Aid Code. This amends existing policy. NOTE: CalWIN currently applies the exemption based on the receipt of a disability based Aid Code. Example: Disabled Mom, Absent Father, 1931(b)-liked 2N Aid Code - Mom should be exempt from MSR.

2 page 2 Exemption Based on Pregnancy ACWDL states To qualify for an exemption from MSR requirements based on pregnancy, a non-exempt beneficiary must notify a county eligibility worker that she is pregnant prior to the county sending the MSR or during the MSR process. EXAMPLE: MSR is due February 2011; Client fails to submit MSR by the due date; Client became pregnant in April 2011; Client reports her pregnancy in April Question: When reporting her pregnancy in April 2011, does the pregnant woman become exempt from the MSR that was due in February 2011? Answer: No. The woman was not pregnant prior to or during the MSR process in February. If she failed to submit the MSR by the due date, or during the 30 days after discontinuance, her discontinuance is still in effect for February If the woman reports that she is pregnant in April and wants Medi-Cal services, she would need to reapply unless the MSR is submitted and good cause is established. Question: If she had become pregnant during the MSR process and notified the county, would she be exempt from the Feb MSR? Answer: Yes. If a beneficiary is pregnant during the MSR process AND notifies the county of her pregnancy, she would be exempt from MSR requirements. This clarifies existing policy. Informing Requirements Question: A father is discontinued for failure to provide the MSR. Within 30 days after his discontinuance, he submits the completed MSR. The county reviews the MSR and finds the father is no longer eligible. What type of written correspondence is sent to the father to inform him that his Medi-Cal remains discontinued? Answer: The county shall: Send an informational letter to the client on county letterhead informing him that the county received the MSR and reviewed all available information for eligibility to all Medi-Cal programs. Inform the client of the reason he/she continues to be ineligible for Medi-Cal and direct the client to the hearing rights on the previously released discontinuance Notice of Action (NOA). Do not send a second NOA, as the original discontinuance action still stands. Note in the case record that the MSR was submitted and reviewed as if it were submitted timely and note that the beneficiary remains ineligible for Medi-Cal and state the reason. Do not issue a new NOA as there has been no change in eligibility. This clarifies existing policy. [Refer to the draft form on page 7]

3 page 3 Rescinding the Discontinuance During SB 87 Timeframe Question: Can the county rescind the Medi-Cal case when an MSR is received within 30 days after the discontinuance? Answer: Different consortia systems accomplish the MSR evaluation in different ways during the 30 days after discontinuance. If the SAWS system is programmed to rescind the discontinuance in order to work the case, that is acceptable with the stipulation that a MEDS transaction is NOT sent to activate eligibility until completion of the case evaluation and continued eligibility is established. This clarifies existing policy. Incomplete MSR and DE/CEC Question: If an incomplete MSR is received, counties follow the SB 87 process. Would the entire case be discontinued due to the inability to establish ongoing eligibility? Answer: No, the entire case would not be discontinued if there are beneficiaries in the case who are exempt from MSR requirements. If, after completing the SB 87 process, ongoing eligibility cannot be established, send a timely NOA to discontinue only the non-exempt Medi-Cal beneficiaries. These individuals become ineligible members of the Medi-Cal Family Budget Unit (MFBU). Exempt beneficiaries remain eligible, and in the same Aid Code, with the exception of children. Since children are protected by Continuous Eligibility for Children (CEC), they should be immediately placed in a CEC Aid Code (7K or 7J), until their next annual redetermination (RD) with the exception of Deemed Eligible (DE) infants. Because there is no specific DE infant Aid Code, the infant will continue in his/her current Aid Code. This policy is not specific to incomplete MSRs only. It also applies when a COMPLETE MSR is received and no ongoing eligibility exists, as well as when NO MSR is returned. This establishes new policy that supersedes any previous policy to keep children in their existing Aid Code until their next RD. Client Applies for CalWORKs During the MSR Due Month Question: If a beneficiary applies for CalWORKs during the MSR Due Month and fails to submit the MSR, and the CalWORKs application is subsequently denied, when is the MSR due? Answer: The beneficiary is discontinued from Medi-Cal at the end of the MSR Due Month for failure to submit an MSR. The MSR was not submitted timely; therefore, there is no future MSR due date. Only beneficiaries receiving CalWORKs are exempt from MSR reporting, not beneficiaries applying for CalWORKs. Beneficiaries who fail to comply with Medi-Cal reporting requirements shall be discontinued. However, Medi-Cal eligibility must be evaluated using information from the CalWORKs denial as follows:

4 page 4 CalWORKs Application Denied During MSR Due Month: If a SAWS 2 is submitted during the MSR Due Month, and CalWORKs is denied, follow the SB 87 process. Rescind the pending Medi-Cal discontinuance action for non-receipt of the MSR and evaluate the information in the denied CalWORKs application to determine Medi-Cal eligibility. If no eligibility exists, issue a timely NOA for discontinuance of Medi-Cal benefits. CalWORKs Application Denied within 30 Days of Discontinuance for Failure to Submit the MSR: If a SAWS 2 is submitted within 30 days after the discontinuance for failure to provide the MSR and the CalWORKs application is denied, do not reinstate Medi-Cal until an eligibility determination is completed using the SB 87 process. The information in the denied CalWORKs application must be reviewed for Medi-Cal eligibility. If eligibility exists, restore Medi-Cal benefits without a break in aid. If no eligibility exists, the discontinuance NOA for failure to submit the MSR stands. Advise the client that the case was evaluated using the new case information from the denied CalWORKs application, and there was no continued Medi-Cal eligibility. Note: If information is missing on the SAWS 2, determine if there is enough information to determine Medi-Cal eligibility. If not, complete the three step SB 87 process to obtain the information needed to make a determination. MEDS Termination Codes Question: If the MSR is incomplete, and the case is discontinued, Term Reason 64 is sent to MEDS. If the MSR is not received, and the case is discontinued, Term Reason 60 is sent to MEDS. Is this correct? Answer: No. MEDS Term Reason 60 (Refuse to Provide QR7 or Medi-Cal Status Report) is not applicable to the MSR. If the beneficiary is discontinued for failure to submit the MSR, Term Reason 64 (Failure to Submit a Medi-Cal Midyear Status Report) must be used. If the beneficiary is discontinued due to an incomplete MSR after completing the SB 87 process, Term Reason 61 (Failed to Provide Necessary Information) must be used. This is new policy that supersedes previous instructions. Individual Turns 21 During the MSR Month Question: A child is turning 21 in month 5 which is the MSR Mail Month. Is the child exempt from the current MSR process or non-exempt since the child will be 21 in the Due Month? Answer: As the beneficiary is 21 on the first day of the MSR Due Month, he/she is no longer exempt from the MSR requirement. Complete the SB 87 process to determine if there is other Medi-Cal linkage. The beneficiary should not be automatically discontinued for

5 page 5 turning 21, without a review of all evidence of eligibility. The returned MSR can be used as part of the ex parte review, but may not be used instead of completing the SB 87 process. This clarifies existing policy. Missing Information Question: How is the SB 87 process applied with the MSR and missing information? Answer: When the MSR is received incomplete because it indicates changes have occurred and lacks information about the changes, or has blank sections, counties must follow the SB 87 process. If the MSR is incomplete, the SB 87 process must be followed in accordance with WIC (i) and (j). The process is as follows: 1. Complete an ex parte review or all available case files, open or closed for all family members, within the last 45 days, including CalWORKs, CalFresh, GA, CAPI, IHSS, Refugee, etc. 2. If the ex parte review does not provide sufficient information to establish eligibility, attempt telephone contact with the beneficiary. 3. If telephone contact is not successful, mail the MC 355 form, giving the client 20 days to return the missing information. 4. If, within the 20 days, the beneficiary returns some of the missing information, but additional information is still required, then send a second notice (MC 355 or SCD 50), giving the client an additional ten days to return all missing information, before a 10-day discontinuance NOA is sent. 5. If the missing information is not submitted, send the client a10-day discontinuance NOA. 6. If the client submits the missing information within the ten days, evaluate the information to determine if there is continued eligibility. 7. If continued eligibility exists, rescind the discontinuance action. This does not change the practice of allowing for a 30-day cure period for the discontinued individual to submit missing information for evaluation without having to reapply for Medi-Cal benefits. This clarifies existing policy. Adding a Non-Exempt Person Question: When a non-exempt person is added to an existing Medi-Cal case, when should the MSR be sent? Answer: When a non-exempt beneficiary is added to an existing case within month one, two, three, or four, the consortia system (CalWIN) will have sufficient time to send an MSR for this person.

6 page 6 If a non-exempt beneficiary is added to an existing case in month five or six, there is insufficient time for CalWIN to send this person an MSR in month five which would be due in month six. Since the EW conducted a Medi-Cal eligibility determination during the add-a-person process, there is no need to conduct another eligibility review midyear. The next review would occur at the annual RD. Therefore, an MSR should not be sent to anyone in the case file. If the MSR is inadvertently mailed, do not discontinue non-exempt beneficiaries for failure to submit an MSR, as the requested information will be received via the add-a-person process which meets midyear reporting requirements. This establishes new policy. End of Postpartum Exemption Question: If a postpartum exemption ends June 30, the same month the MSR would be scheduled to be mailed, would the woman be required to complete the MSR in July, or would the MSR be due in August (based on the CalWORKs scenario where CalWORKs recipients discontinued for not completing the second QR7 must still meet the six month reporting requirement for MC)? Answer: If the pregnancy postpartum period ends in month five or six from the initial application or most recent RD, the client is exempt for that specific MSR, and is not required to report again until the next scheduled RD. This establishes new policy for the purpose of simplification. Implementation These changes/clarifications are effective immediately upon receipt of this Update. Forms A new MSR Review form (SCD 50 MSR) was developed for use in place of the SCD 50 in situations where the client submits the MSR after the discontinuance action and no eligibility exists. A copy of the SCD 50 MSR is attached to this Update for reference purposes. Other Programs This policy only applies to the Medi-Cal program. UMESH POL, DIRECTOR CalWIN Division KATHERINE BUCKOVETZ, DIRECTOR Department of Employment and Benefit Services Contact Person(s): Alice Turney, Medi-Cal Program Coordinator, (408)

7 County of Santa Clara Social Services Agency Date: Case Number: Worker Number: Worker File Number: Worker Phone Number: Office Hours: MSR REVIEW FOR: You were discontinued from Medi-Cal on for not submitting your Midyear Status Report (MSR). On you submitted your MSR. The county reviewed your MSR, as well as all information available to us about your circumstances, to evaluate you for all Medi-Cal programs on and found that you are not eligible for Medi-Cal because. Your Medi-Cal discontinuance date has therefore not changed. You have the right to appeal this decision. Please review the back side of your discontinuance Notice of Action sent to you on. You have 90 days from, the date your discontinuance Notice of Action was mailed to you, to file your appeal. If your circumstances change, you may re-apply for Medi-Cal. SCD 50 MSR (07/11)