Medi-Cal Pararegs

400-8 State must specify a single State agency to administer Medicaid program, and that agency must not delegate to others outside agency authority to exercise administrative discretion, or issue policies, rules, and regulations on program matters (42 CFR 431.10(b), (c))

401-1 After NOA denying Medi-Cal eligibility due to excess property, applicant may still establish eligibility up to three years later, and county must rescind and issue benefits including NOA if necessary (ACWDL 97-41)

404-1 Requirements for denial NOA (ACWDL 97-48)

404-2 Required language on NOAs denying due to excess property (ACWDL 97-41)

404-3 Required county actions, and required NOA language, after approval of retroactive Principe benefits (ACWDL 97-41)

404-4 When an NOA must be sent in regard to “medical services” (51014.1(a))

404-4A Contents of the required NOA for reduction or termination of “medical services” (51014.1(c), (i))

404-4B APP requirements when there is a timely filing after proposed reduction or termination of “medical services” (51014.2(a), (b))

404-5 NOA requirements when a CalWORKs discontinuance occurs 7/1/01 and following (ACWDL 01-17; SB 87)

404-6 BICs have replaced Medi-Cal cards and MC 177 forms as of 6/1/97; NOA is required before discontinuance can occur (ACWDL 96-06; Denti-Cal Bulletin, Vol. 13, No. 13; Bowman v. Belshé)

Application/Cooperation

410 Application/Cooperation

411 Attitude / Courtesy / Harassment

414 County duty to assist

415 Applicant / Recipient duty to cooperate

416 Status reports

417 Continuing benefits (Edwards / 4-month AFDC / TMC)

418 Intercounty / Interprogram transfers

410-1 Time period for processing applications; reasons for extension of such limits (50177(a))

410-1A County must refer disability application to DED within 10 days (ACWDL 93-50; Radcliffe v. Cahill)

410-1C After NOA denying Medi-Cal eligibility due to excess property, applicant may still establish eligibility up to three years later, and county must rescind and issue benefits including NOA if necessary (ACWDL 97-41)

410-2 Circumstances under which persons other than applicant or spouse may complete application documents (50163(a))

410-2A Definition of “applicant” (50021)

410-2B Definition of “competent” (50032)

410-2C Application defined; county duty to complete SAWS I when applicant calls in to apply for Medi-Cal (50022; ACWDL 00-31)

410-2D Medi-Cal form 210 available in English and 10 other languages (ACWDL 01-68)

410-3 Face-to-face interview necessary only at time of application and not required when adding adults to MFBU; totally eliminated effective July 1, 2000 (50157(a); ACWDL 99-36, 00-17, 00-31)

410-3A Elimination of face-to-face interview except when good cause or fraud exist (ACWDL 00-31)

410-3B Beneficiary is a person determined eligible for Medi-Cal (50024)

410-4 Procedure for withdrawal of Medi-Cal application (50155)

410-5 Persons who may file an application (50143(a))

410-6 County duty to accept and promptly act on applications; who may file applications (50141, 50143)

410-7 Application as a basis for determination, applicant's duty to provide necessary additional information; county's duty to assist in this process (50171)

410-8 County welfare department the agent of CDHS (50004(c))

410-9 Requirements to protect applicants' right to apply when welfare offices closed on normal working days (Blanco v. Anderson and Belshé)

410-9A Requirement to provide for filing applications on normal working days implemented (Blanco v. Anderson; ACL 94-108, 95-08)

410-10 Medi-Cal must continue for beneficiaries discontinued from Title II or SSI at least for 65 days, and if appeal is filed and is subject to federal review, until “FINAL” decision (i.e., no more appeals can be filed) is rendered (ACWDL 97-28)

410-11 SSI former recipients are PA recipients until appeal rights are terminated, even if they transfer to AFDC/TANF and then are discontinued from AFDC/TANF (ACWDL 97-28)

410-12 No longer disabled SSI/SSP recipients to be treated akin to Edwards discontinuances (ACWDL 97-28)

410-13 County of responsibility when eligibility is not based on being part of a family or on family income (50125)

410-13A County which accepts application, but is not county of responsibility, may still process application with consent of applicant, and initiate ICT (50135)

410-14 Requirement to outstation EWs at Disproportionate Share Hospitals and Federally Qualified Health Centers (ACWDL 98-13)

410-15 Required county actions, and required NOA language, after approval of retroactive Principe benefits (ACWDL 97-41)

410-16 Notice to be sent when re-evaluation of Medi-Cal eligibility occurs (W&IC 14005.31(b))

410-17 What happens when Medi-Cal benefits are transferred from one program to another, and required notice (W&IC 14005.32(a))

410-17A Written TMC notice must be given to CalWORKs and 1931(b) recipients when Medi-Cal eligibility is determined and six months thereafter, or when they are terminated due to failure to meet reporting responsibilities (ACWDL 01-45)

410-18 When re-evaluation shall not re-occur after loss of Medi-Cal eligibility; continuation of benefits when evaluation is occurring; required notices (W&IC 14005.37)

410-18A County requirements after denying or discontinuing CalWORKs/1931(b) benefits, including ex parte responsibilities (ACWDL 01-36)

410-18B Specific mandate to use Form MC 355 as request for information form, contents of the form, time limits, county requirements (ACWDL 01-39)

410-18C Required SB 87 procedures for counties evaluating Medi-Cal eligibility (ACWDL 02-59, 07-24)

410-18D Required MC355 process (ACWDL 07-24)

410-18E County must reevaluate eligibility under other Medi-Cal categories if eligibility ceases under one category; aid pending continues, effective 7/1/01 (50183(a); MEPM 4-0-3; W&IC 14005.31, .32, .37; ACWDL 02-59)

410-18F Medi-Cal beneficiary may continue to receive Medi-Cal after SSI/SSP discontinuance based on “no longer disabled” if he/she alleges a new disability (ACWDL 04-31)

410-18G Steps county must follow in different circumstances regarding annual redetermination form (ACWDL 06-16)

410-18H County must follow SB 87 process if annual redetermination packet is returned as undeliverable (ACWDL 06-16)

410-18I If person who no longer has linkage to Medi-Cal program but alleges disability on MC210 RV, county must continue Medi-Cal (ACWDL 06-17)

410-19 If county is sure that there is no need to transfer eligibility to another Medi-Cal program, no redetermination necessary but documentation must occur and notice must be sent (W&IC 14005.39)

411-1 Purpose of Medi-Cal Program is to provide, to the extent practicable, health care benefits to eligible persons (W&IC 14000)

411-2 County must act with courtesy, consideration, and respect (W&IC 10500)

413-4 Medi-Cal form 210 available in English and 10 other languages (ACWDL 01-68)

414-1 Duties of counties which have a procedure for screening applicants (50142)

414-2 IHSS and AFDC applicants not required to submit separate application. If AFDC or IHSS is approved, Medi-Cal is automatic (50145)

414-3 Persons or families denied Medi-Cal under any program other than SSI/SSP shall be reviewed for any other type of eligibility (50180)

414-4 County shall set reasonable deadline for returning the Statement of Facts, inform applicant of the deadline, and attempt to contact applicant if Statement is not submitted by deadline (50165)

414-4A Requirements for two contacts, then specific NOA, if county is to deny applications for failure to provide information; discontinuance actions governed by SB 87 (ACWDL 90-07, 97-48, 02-59)

414-5 Legislative intent to process nursing facility applications timely, and to encourage nursing facility participation (SB 635)

414-5A County may not deny application of LTC person due to non-cooperation of representative, but must do diligent search (ACWDL 94-62)

414-6 Nursing facility applicants shall be assisted in applying and have applications processed timely (W&IC 14110.05)

414-7 Requirement to outstation EWs at Disproportionate Share Hospitals and Federally Qualified Health Centers (ACWDL 98-13)

414-8 Two contacts mandated, and must be documented, when county is proposing to discontinue on redetermination and beneficiary fails to provide information/verification (ACWDL 97-48)

414-8A Implementation of two contact requirement applies to mail-in applications (ACWDL 08-07)

414-8B Clarification on what constitutes contact (ACWDL 08-07)

414-8C Application process reminders (ACWDL 08-07)

414-8D Two contact requirement applies to applicants; SB87 process applies to beneficiaries (ACWDL 08-07)

414-10 Income maintenance responsibility to make and record eligibility and grant determinations for PA cases, and for MN SHARE OF COST cases (MPP 11-501.1, .2)

414-11 State law eliminated the requirement that pregnant women and children complete a face-to-face interview (W&IC 14011.1; ACWDL 98-42)

414-11A Elimination of face-to-face interview except when good cause or fraud exist (ACWDL 00-31)

414-12 County must send informing brochures and forms with redetermination notice, and provide such information to beneficiaries on request (ACWDL 99-36)

414-13 Application defined; county duty to complete SAWS I when applicant calls in to apply for Medi-Cal (50022; ACWDL 00-31)

414-13A Protecting the date of application in mail-in or walk-in situations; county duty to assist; when applicant need not sign application for Medi-Cal, but must still sign for CalWORKs and FS (ACWDL 01-06)

414-13B Information which must be included when an application is mailed to, or handed to, an applicant (ACWDL 01-06)

414-14 Counties must provide DHCS 0001 form to applicants and DHCS 0002 form to beneficiaries (ACWDL 07-12)

415-1 Denial of application for failure to cooperate (50175(a))

415-1B Denial/discontinuance for noncooperation applies only to individual who fails to cooperate and those for whom he/she is responsible (ACWDL 92-09)

415-1C Annual Medi-Cal redetermination required by state and federal law (ACWDL 06-16)

415-1D Informing beneficiary of annual redetermination requirements (ACWDL 06-16)

415-1E Counties must mail only MC 210 RV form along with mandated program information; no need for ex parte review prior to sending redetermination packet (ACWDL 06-16)

415-1F County must allow beneficiary at least 20 days to complete and return required forms; may not require face-to-face interview unless SB 87 process will not resolve all issues (ACWDL 06-16)

415-1G If good cause for failing to return forms within 30 days after Medi-Cal termination, Medi-Cal is reinstated without break in benefits; if no good cause, beneficiary must reapply (ACWDL 06-16)

415-1H If annual form returned complete with verification within 30 days of termination, county must determine eligibility as though submitted timely (ACWDL 06-16)

415-2 General duty of applicant or beneficiary to cooperate (50185(a))

415-2A DA decides whether person has cooperated in identifying the absent parent, securing medical support, and determining paternity, but the county makes the good cause determination (ACWDL 97-64; MEPM 23E-1)

415-2B Good cause claim for cooperation re paternity, medical support results in eligibility for Medi-Cal if other conditions are met, and once granted, shall continue until or unless the county decides at redetermination that circumstances have changed (MEPM 23E-1)

415-2C Criteria for establishing if good cause for noncooperation with the FSD/DA exists, and evidence which can support claim; good cause determination made by county (MEPM 23E-2, 3)

415-2D FSD/DA makes determination of noncooperation in establishing paternity, medical support; necessity to have staff persons readily available; cooperation requirements and factors to consider as to whether cooperation exists (MEPM 23E-1)

415-3 Denial or discontinuance due to noncooperation can be rescinded if good cause established (50175(b)(2))

415-4 Good cause for failure to cooperate (50175(c))

415-5 Duty to report changes within 10 days (50185(a)(4))

415-6 Applicant or recipient must take action to accept unconditionally available income as a condition of eligibility (50186)

415-7 Applicant must attempt to obtain Share of costial Security Number (50187)

415-8 Parent, not child, disqualified for parent's failure to cooperate with medical support or identifying an absent parent or determining paternity (ACWDL 93-56, 97-64; 50175(a)(7); MEPM 23E-1, 2; W&IC 14008.7)

415-8A Good cause requirements for failure to cooperate in paternity, medical, or child support, or third-party payments (50771.5(a)-(c))

415-9 Serious physical or emotional harm defined; burden on applicant (50771.5(d)-(f))

415-10 Claims for good cause for medical support required only once per situation (ACWDL 93-56)

415-11 Documentation of U.S. citizenship and identity required (ACWDL 07-04)

415-11A Federal law requires CDHS to implement federal citizenship/identity documentation requirements with as much flexibility as allowed (ACWDL 07-04)

416-3 Midyear status report requirement and exemptions from that requirement (W&IC 14011.16; ACWDL 03-41)

416-3A Midyear status report filed six months after later of application date or annual redetermination (W&IC 14011.16; ACWDL 03-41)

416-3B County must provide MSR to beneficiary in fifth or “mail”month; MSR must be returned by the fifth day of the sixth or “due” month (W&IC 14011.16; ACWDL 03-41)

416-3C If MSR reflects change in circumstances effecting eligibility, county must do an SB 87 determination (W&IC 14011.16; ACWDL 03-41)

416-3D If MSR is signed, but incomplete, county must do an SB 87 determination (W&IC 14011.16; ACWDL 03-41)

416-3E Recipient failure to return an MSR results in discontinuance of benefits (W&IC 14011.16; ACWDL 03-41)

416-3F If recipient submits an MSR within 30 days of discontinuance, county must evaluate and rescind discontinuance if eligibility exists (W&IC 14011.16; ACWDL 03-41)

417-1 Edwards v. Myers relating to continuing Medi-Cal following the discontinuance of AFDC-related Medi-Cal; re-evaluation for all programs required as of 7/1/01 (MEPM 40; W&IC 14005.31, .32, .37)

417-1A Refugees entitled to evaluation for evaluation of Medi-Cal eligibility under SB 87 (ACWDL 97-57, 01-36, 01-39; MEPM 24B-11; W&IC 14005.31, .32, and .37)

417-2A When recipient of Medi-Cal benefits is no longer eligible for benefits, re-evaluation of eligibility must occur (W&IC 14005.31(a))

417-2B Notice to be sent when re-evaluation of Medi-Cal eligibility occurs (W&IC 14005.31(b))

417-2C What happens when Medi-Cal benefits are transferred from one program to another, and required notice (W&IC 14005.32(a))

417-2D When re-evaluation shall not re-occur after loss of Medi-Cal eligibility; continuation of benefits when evaluation is occurring; required notices (W&IC 14005.37)

417-2E If county is sure that there is no need to transfer eligibility to another Medi-Cal program, no redetermination necessary but documentation must occur and notice must be sent (W&IC 14005.39)

417-2F Required SB 87 procedures for counties evaluating Medi-Cal eligibility (ACWDL 02-59)

417-3 Four-month continuing Medi-Cal benefits for AFDC families terminated because of increased child/spousal support (50243; ACWDL 90-32, 90-33, 90-66)

417-6 TMC eligibility (MEPM 5B-3, 4)

417-6A CalWORKs, 1931(b) and Edwards benefits count towards TMC eligibility period (MEPM 5B-11)

417-6B Receipt of CalWORKs plus 1931(b) in 3 of last 6 months meets TMC eligibility test (MEPM 5B-12)

417-6C TMC requirements (ACWDL 90-66, 90-77, 95-85, 98-43)

417-6E What constitutes “because of” hours of employment or earnings for purposes of potential TMC eligibility (MEPM 5B-6, 7)

417-6D Persons who are not eligible for TMC, even if the family lost CalWORKs or 1931(b) benefits due to increased hours of employment or earned income (MEPM 5B-6)

417-6F Persons receiving TMC are ineligible members of the MFBU of those persons who ar