County Medi-Cal Eligibility Questions and Answers

The management and operations of California’s Medi-Cal program has always been complicated. When California decided to expand Medi-Cal health insurance under the Affordable Care Act, it became even more complicated. Two years after the launch of Covered California and expanded Medi-Cal, California’s Department of Health Care Services and each of California’s fifty-eight counties, that individually administer Medi-Cal managed health plans for eligible residents, are still grappling with numerous questions regarding eligibility, enrollment, and the integration with the Covered California application.

County Medi-Cal eligibility questions and answers

In an effort to help county eligibility workers quickly and properly trouble-shoot problems people might be experiencing with Medi-Cal eligibility and enrollment, the Department of Health Care Services put together a spread sheet of questions received by county eligibility workers with a corresponding answer to resolve the issue. Many of the problems occurring revolve around the multiple computer programs and databases that Medi-Cal uses to determining eligibility and track enrollment in a health plan. The massive Medi-Cal operation was further challenged by the Covered California CalHEERS (California Healthcare Enrollment, Eligibility & Retention System) online enrollment system.

Covered California passes Medi-Cal to counties

In addition to some of the quirks of the CalHEERS program for determining eligibility for the ACA premium assistance tax credits, the program also hands-off individuals deemed Medi-Cal eligible to their respective county for enrollment. But eligibility for Medi-Cal is far more complicated than just income as Medi-Cal has programs for pregnant women, the elderly, and children.

Once the county eligibility worker receives the information from Covered California and then works to cross reference information in other databases, program eligibility can be denied or enhanced depending on the individual’s circumstances. This is in addition to the limitations of CalHEERS communicating with Medi-Cal. There are hundreds of questions and answers in the spreadsheet.

Medi-Cal and Covered California conflicts

A review of the county questions reveals a variety of different conflicts between the Covered California CalHEERS program and the Medi-Cal MEDS and SAWS programs. From what I can glean from reading through some of the queries is that the CalHEERS program is not necessarily providing all the necessary information for final eligibility. There may be issues with an applicant stating she is pregnant, the age of the applicant, or data that doesn’t match. It is also apparent that Department of Health Care Services is working with Covered California to resolve many of these issue and conflicts between their own MEDS and SAWS programs.

The questions and answers are heavily peppered with acronyms and technical terms exclusive to the Medi-Cal operations and management. I’ve provided a short list of some of the acronyms, and when possible, a short definition. You can use the find tool in spreadsheet to find snippets of text that might be applicable to your situation. But don’t assume you’ll find an answer to a specific problem you might be encountering either with Medi-Cal or Covered California. However, the scenarios presented, with the corresponding answers, might shed some light on how Medi-Cal is working to resolve some of the problems.

Medi-Cal managers are also experiencing the challenges of working with the Covered California program. In one answer to a question about dual enrollment (showing enrolled in Medi-Cal and a Covered California health plan), the response includes, “There are no CC staff to work the MEDS alerts.” This admission of dual enrollment has made me wonder if Medi-Cal is paying health plan premiums for an individual enrolled in a Medi-Cal at the same time that the consumer is enrolled in a private health plan with premium assistance.

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Also available at – www.dhcs.ca.gov/services/medi…/Co-OPS…/CO_Ops_Call_Log_030116.xls

Here is just a sampling of some of the hundreds of questions posed by County Eligibility Workers (CEW) and the answers from the Department of Health Care Services.

Eligibility

We processed a February RE [re-enrollment] and determined this customer ineligible to MAGI [MAGI Medi-Cal] and discontinued him the last day in February.

• CalHEERS did not recognize he had MAGI as the IAT says “ineligible” as opposed to discontinue.
• The EW [Eligibility Worker] did not request a MAGI determination with a reason of “lost health coverage” and so no place holder aid code for APTC [Advance Premium Tax Credits] was given.
• No MAGI discontinuance NOA [Notice of Action] was generated.
• No denial NOA for APTC generated.
• All the customer got was a “no linkage” NOA which stated he might get a NOA about other MC programs so he waited. By the time he called to see what was going on we were past the Special Enrollment Period (SEP).

Customer has no unpaid MC bills for March, April or May.

1. How do I get him signed up for APTC going forward? Lie about the lost OHC date to create an SEP?
2. Is there a waiver of penalty for the individual mandate to have coverage for administrative error? He’ going to be without coverage for more than 3 months presuming his APTC doesn’t start until July or August 1st.
3. For the future: What reason do we use in CalHEERS so that we can process the case if someone applies timely (during open enrollment or SEP), but we work the app outside of open enrollment or SEP? Or as in this case, if we make an error and discover it after the time has passed?”

Department of Health Care Services Answer

“If the scenario described below occurs with an application date that was in Covered California’s Open Enrollment period, please follow the Process Guide that was distributed.

If, however, the application date was not during our OE period, please hold for more information. We are researching per e-mail with subject “FW: Question from Napa county” sent 6/15/15.”

1095 Forms

“This is in reference to the call today regarding calls we have received from clients about their 1095 forms. The following is an example we received from one of our workers:

Customer was mailed out the Eligibility Tax form 1095 B and it is not providing the correct information. Customer’s 2 children both had coverage for the full year and that information does show correctly in MEDS. The 1095 was sent for only one child and only showing for 2 months of coverage.

What recourse do clients have to appeal the information reflected on the 1095 from Covered California?”

DHCS Answer

“We would have to know more about this case. Depending on the Aid Code, the full coverage received may not be considered MEC. For example, in another similar case, the children were showing T1 for Jan, T2 for Feb (both are Presumptive Elig), the rest of the year was T7. The 1095 only showed coverage for Jan/Feb as most PE full scope services meet MEC. The T7 is an undoc aid code for full scope no SOC for children 6-19. Months March thru Dec did not have MEC met as undocumented status is exempt from the individual mandate.

The only contention available is whether or not the eligibility determination that lead to the program they qualified for was accurate. Depending on the BRE, the person may or may not be in the wrong Aid Code, but that is just speculation without more information.

The 1095-A is not appealable. However, consumers can dispute the information contained on the 1095-A. This link http://www.coveredca.com/members/form-1095-a/provides information regarding the 1095-A and a link to the dispute form. The dispute form is only for reporting issues with a consumer’s enrollment information, eg, coverage start and end dates, APTC applied by month. If a consumer’s personal information, such as name, DOB, SSN, or address, need correction, then the Service Center or CEWs can take that action.”

Pregnancy

We have a case in which the customer was approved for aid code M9 in 6/2015 with an expected delivery date in 2/2016. In 11/2015, she received a notice from Covered California stating she would no longer be eligible to APTC effective 1/2016. She is now filing for a hearing at the county level to dispute this notice, as she wants to remain ATPC eligible. Is there a regulation that can be provided to our Appeals Specialist that can support this hearing action? We are unable to find anything, as well. In addition, are you aware of any “grandfather” law that may protect our customer from being discontinued mid-pregnancy from her health plan with Covered California?

DHCS Answer

M9 provides the beneficiary with all medically necessary services if billed with a diagnosis code. Beneficiaries eligible for MEC Medi-Cal are not eligible for Qualified Health Plan (QHP) with Advanced Premium Tax Credit (APTC), unless they are pregnant and already enrolled in a QHP. See attached State Health Official Letter 14-002 .

Medi-Cal and Covered California Enrollment

I have heard several references in the last few weeks regarding Covered California X codes rolling in MEDS for “tracking” purposes. We see many cases where it appears just by looking at MEDS that the customer is both enrolled in CCA/APTC coverage and MAGI at the same time. These cases then have to be researched further by accessing CalHEERS and attempting to find out if/when the customer stopped being covered. Could this issue be corrected so that MEDS only shows X code coverage for months that the customer actually was covered by CCA/APTC?

DHCS Answer

This is an ongoing problem since the implementation of ACA. CalHEERS was having technical problems with the HX40 transactions to end the MEDS record. That issue has since been resolved except for those transactions that are prior to the fix and for current rejected transactions (reasons that any 40 transaction may fail). There are no CC staff to work the MEDS alerts. The process explained to counties is to submit a Remedy ticket, along with verification that the CC aid code should be terminated. We then send those requests to CalHEERS technical staff for resolution. This process will continue until there are CC staff to work MEDS alerts on failed transactions, and then we will depend on CC to correct those eligibility months.

Soft Pause

“Due to system functionality issues DHCS has informed counties persons may be left in the soft pause until their next renewal, unless the person would like to enroll into a Covered CA health plan. Regardless if MAGI eligibility was due to admin error.

Pease confirm this continues to be the current direction.

Brief description of your current understanding of the questioned policy:

Example: Client is currently receiving MAGI benefits, reports a change in income which now makes them APTC eligible. CalHEERS places client in soft pause. We would leave the client in soft pause until their next renewal unless the client wants APTC eligibility and to enroll in a health plan.”

DHCS Answer

Counties should process soft pause cases as directed in prior ACWDL. If a person is placed in Soft pause they are to assess the person for Non-MAGI programs as appropriate, then request a remedy ticket with CalHEERS to lift the soft pause so they can take the appropriate action of either putting them in a Non-MAGI program or forwarding them to CalHEERS for APTC. They are not to wait until their renewal date to take action. ACWDL 14-18

MCAP Pregnancy CalHEERS

“CalHEERS is sending referrals that include determinations for eligibility to the MCAP Program.

1. What do counties do with the referrals where MCAP alone or in combination with other Medi-Cal program eligibility is being determined?
2. How do counties know if MAXIMUS is taking responsibility for MCAP applicants coming from Covered California?
3. Will there be instructions from DHCS on what to do with MCAP referrals coming from CalHEERS now that CalHEERS is programed to make MCAP determinations?

Brief description of your current understanding of the questioned policy:

4. MCAP replaced AIM and is being administered in Phase 1 by MAXIMUS. Phase 2 will involve counties sometime in 2016.

Follow-up: By referrals I meant that our staff are seeing CalHEERS referrals in the form of unsolicited DERs with MCAP determinations on them. Any time a MAGI determination is run by CalHEERS a DER is generated. The EW will normally get the DER and act on it. They are not necessarily getting calls. The EW will review the DER to authorize the MAGI results, run EDBC in the SAWS, and link the CalHEERS and SAWS cases to generate the appropriate Notice of Action.  

In one case Covered CA indicated income verification was missing and requested it with a deadline to return it for the completion of the MCAP determination. Then eventually the MCAP was going to be denied by Covered CA for the pregnant woman applicant and her husband due to excess reported income for other programs, and failure to verify income to determine the premium amount for MCAP.

Question: Should EWs (counties) just ignore the MCAP determinations since they are not the counties’ responsibility?”

DHCS Answer

“1. The system of record for MCAP is CalHEERS, and these calls should not be sent or redirected to the counties. We have elevated this issue to CalHEERS and Covered California, who will advise staff not to direct MCAP calls to the counties.

2. MAXIMUS will case manage, but the system of record is CalHEERS.
3. Instructions and training materials for MCAP have been provided to CalHEERS and Covered California.
4. This is accurate, but there is no date for Phase 2 implementation.

Follow-up:

Yes, MCAP pending eligible information should not be reported to the counties via a DER. There may need to be a defect reported to your SAWS. The counties do not need to verify eligibility for MCAP. MAXIMUS is responsible for this case management role.”

Moving from one county to another

“We are finding an increase of MAGI MC ICT’s where the individual did not report to their prior county that they had earnings or income so they are running with a MAGI Medi-Cal aid code. The clients are also coming into our regional offices and applying for CalFresh benefits. When they see the worker for their CalFresh they report their income, this is before the ICT can be completed. Now we have income already in our system which would make the client ineligible to MAGI Medi-Cal, and would place them on a Covered California plan with Premium Tax Credits. How are counties supposed to handle this type of situation? Should the original county convert the individual to the APTC plan? Can the receiving deny the incoming ICT and assist the client with selecting a plan instead?

Brief description of your current understanding of the questioned policy:

My understanding of the ICT process is that the receiving county must pick up the same benefits that were being issued by the sending county. This is difficult to do if the sending county was issuing incorrect benefits due to a client not reporting their income timely.”

DHCS Answer

In this scenario, the Sending County was not aware of the change in the individual’s income prior to the ICT. The Receiving county should complete the ICT based on information that was originally provided by the Sending County. Once the ICT is complete and the beneficiary’s Medi-Cal eligibility is established in the new county, if the Receiving county has new information from the beneficiary or other case files indicating that there is a change in circumstances in addition to the county change that could affect ongoing eligibility, the receiving county will initiate the change of circumstances redetermination and run the CalHEERS business rules engine to determine any effect on ongoing eligibility for insurance affordability programs and generate and send the appropriate notices

From a letter discussing a reconciliation process of Med-Cal Eligibility Data System

Although CalHEERS can send the first eligibility directly to MEDS when all verifications are verified at intake through the Covered CA portal, that eligibility is transferred to the county of residence through eHIT. Counties are the responsible entities for case management of county administered Medi-Cal eligibility; therefore, reconciliation of county administered Medi-Cal programs would always be based on a match between the county systems and MEDS. DHCS understands the county concerns regarding eligibility from CalHEERS going directly to MEDS. However, if recon were to take place, it would be between the eligibility systems to make sure that the eligibility matches. CalHEERS/MEDS recon would be a future enhancement. The current SAWS/MEDS recon efforts will not include Covered CA aid codes.

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Medi-Cal Acronyms

• ACWDL: All County Welfare Director’s Letter
• CalHEERS: Covered California Healthcare Enrollment, Eligibility, and Retention System
• CIN: Client Index Number
• DHCS: Department of Health Care Services
• HCP: Medi-Cal Managed Health Care Plan
• MAGI: Modified Adjusted Gross Income – sometimes referred to as MAGI Medi-Cal in county correspondence or the individual is eligible for the expanded Medi-Cal based solely on their income.
• Non-MAGI Medi-Cal: These are Medi-Cal health care programs that are based not only on income, but may also consider assets such as savings accounts, cars, homes, etc.
• MCED: Medi-Cal Eligibility Division
• MCOD: Medi-Cal Managed Care Operations Division
• MEDIL: Medi-Cal Eligibility Division Information Letter
• MEDS: Medi-Cal Eligibility Data System
• MOPI: MEDS Online Provider Inquiry
• NOA: Notice of Action
• POS: Point of Source
• SAWS: Statewide Automated Welfare System
• Soft Pause: when an individual or family is determined eligible for Medi-Cal the Covered California is put into soft pause or the consumer is locked out of changing any information in the application to change the Medi-Cal determination.
• SCI: Statewide Client Index

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