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1 USER INFORMATION You can look up Medi-Cal Policy by finding the section you want under the Bookmarks tab to the left of the screen. To expand the section, just click on the + symbol for more topics. When you see the topic in Bookmarks, just click and it will link you directly to the section of the Medi-Cal Policy that you need. DPSS DISCLAIMER STATEMENT DPSS may provide information about links on this website. At this time; however, the links are not available to other sections. Links to any LEADER procedures referenced are for internal use only and is not intended to be available to the viewing public. Tips for Using Adobe PDF Files The Medi-Cal Policy on this site is available only in Portable Document Format (PDF.) IN addition to preserving the appearance of the original file, PDF allows any one to view the file using Adobe s free Acrobat Reader software. To Download the free Adobe Acrobat Reader, click here : Problems with PDF Files? Click here: Tips for Using Adobe PDF Files.

2 Medi-Cal Policy Table of Contents MC Definitions, Abbreviations and Program Terms MC Meaning of Words MC Medi-Cal Program Administration MC Medi-Cal Regulations MC Fiscal Intermediary MC Medi-Cal Consultant MC Medi-Cal Review MC Medi-Cal Review Team MC Health Care Services MC Abbreviations MC Adequate Consideration MC Adult MC Aid to Families with Dependant Children MC Applicant MC Application MC Approval of Eligibility MC Beneficiary MC Board and Care MC Burial Insurance MC MC MC Cash Grant Certification Date for Claims Clearance Certification Effective Date MC Certification for Medi-Cal MC Certified Long-Term Care Insurance Policies or Certificate MC MC MC MC MC Child Child Health and disability Prevention Program (CHDP) Gateway Competent Contiguous Property Conversion of Property MC County Agency MC County Cash-Based Medi-Cal Eligibility MC County Department MC County Case Error Rate MC Eligibility and Assistanc3e Standards Manual (EAS) MC Eligibility Quality Control MC Eligibility Services

3 MC Emergency Assistance MC Encumbrances of record MC Family Member MC Federal Poverty Level MC Heirloom MC Home MC Immigration and Naturalization Services (INS) MC Impairment Related Work Experience (IRWE) MC Income and Eligibility Verification System (IEVS) MC In-Home Supportive Services (IHSS) MC Inmate MC Institution MC Institution 0 Medical MC Institution Mental Diseases MC Institution Non-medical MC Institution Private MC Institution Public MC Institution Tuberculosis MC Intraprogram Status Change MC Interprogram Transfer MC Life Insurance MC Limited Service Status MC Linked MC Long-Term Care (LTC) MC Marriage MC Medi-Cal MC Medi-Cal Card aka Benefits Identification Card (BIC) MC State Dollar Error Rate MC Federal Standard MC State Caused Errors MC Medi-Cal Family Budget Unit (MFBU) MC Medi-Cal Only Eligibility MC Medical Support MC MC Medically Indigent (MI) Person or Family Medically Needy (MN) Person or Family MC Minimum Basic Standard of Adequate Care (MBSAC) MC Minor Consent Services MC Multiple Dwelling Unit MC Nonrecurring Lump Sum Payment

4 MC MC MC Obligate Other Public Assistance (Other PA) Recipient Overpayment MC Parent MC Parent Minor MC MC MC MC MC MC MC MC MC MC Parents Unmarried Patient Persons Living in the Home Property - Community Property Personal Property Real Property Separate Property Share of Community Public Agency Public Assistance (PA) Recipient MC Public Funds MC Publicly Operated Community Residence MC Qualified Disabled and Working Individual MC Qualified Medicare Beneficiary MC MC MC MC MC MC MC MC MC Reapplication Redetermination Relative Relative Caretaker Repayment Residence Responsible Relative Restoration Share of Cost MC Share of Encumbrances MC Specified Low-Income Medicare Beneficiary (SLMB) MC State Date Exchange (SDX) MC Stepparent MC Supplemental Security Income/State Supplemental Program (SSI/SSP) MC Therapeutic Wages MC Title II Disregard Person MC MC Transfer of Property Verification MC Article 2 Administration MC County Department Responsibilities

5 MC Article 3 County of Responsibility MC County of Responsibility MC Inter-County Transfer Procedure Overview MC Inter-County Transfer Effective Date of Discontinuance MC Article 4 Application Process MC Application Process General Clarification MC Verification/Documentation Policy Documentation MC Client Representatives Eligibility Process MC Address MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC MC Persons Who May File an Application for Medi-Cal Child Applying for Minor Consent Medi-Cal Services Application Form Date of Application Medi-Cal Application Process for All Programs Withdrawal of Application Request for Discontinuance Face-To-Face Interview Statement of Facts Persons Who May Complete and Sign the Statement of Facts Filing the Statement of Facts Verification Prior to Approval Clarification of Statement of Facts Verification by Signature Discontinuance Due to Death Promptness Requirement Notice of Action Medi-Cal Only Determinations or Redeterminations Corrective Action on Denied Applications Referral for Social Services Applicant and Beneficiaries General Reporting Responsibilities Unconditionally Available Income Redeterminations Frequency and Process Status Reports MC Article 5 Medi-Cal Programs MC Medi-Cal Programs General MC Medically Needy Program MC Linkage to AFDC MC Deprivation Deceased Parent MC Deprivation Physical or Mental Incapacity of a Parent MC Deprivation Absent Parent MC Deprivation Unemployed Parent MC Blindness MC Age MC Disability MC Public Assistance Cash Grant Programs

6 MC Other Public Assistance Program MC In-Home Supportive Services (IHSS) MC Medically Indigent Program MC Repatriate Program MC Qualified Disabled and Working Individual Program MC Refugee Medical Assistance (RMA) and Entrant Medical Assistance (EMA) MC Qualified Medicare Beneficiary Program (QMB) MC Specified Low Income Medicare Beneficiary Program (SLMB) MC Day Postpartum Services Program MC Special Zero Share of Cost Program for Pregnant Women and Infants Income Disregard Program (200% Program) MC Continued Eligibility Program for Pregnant/Postpartum Women and Infants MC Special Zero Share of Cost Program for Children Age One to Age Six (133% Program) MC Special Zero Share of Cost Program for Children Age Six to Nineteen (100% Program) MC Dialysis, Tuberculosis (TB), and Total Parental Nutrition (TPN) Program ACWDL ACWDL ACWDL ACWDL (b) Medi-Cal Only 1931(b) Medi-Cal Only Sneede Transitional Medi-Cal (TMC) Continuous Eligibility for Children (CEC) MC Article 6 Institutional Status MC Institutional Status MC Medi-Cal Ineligibility Due to Institutional Status MC Article 7 Alienage, Citizenship and Residence MC Citizenship or Immigration Requirements for Full Medi-Cal Benefits MC Documentation Requirements for Citizenship or Naturalization MC Immigration and Naturalization (USCIS) Documentation, Alien Status and Medi-Cal Program Eligibility MC Permanently Residing Under Color of Law (PRUCOL), the United States Citizenship and Immigration Services (USCIS) MC Amnesty Alien MC Opportunity to Document Satisfactory Immigration Status MC Verification of Satisfactory Immigration Status MC MC MC Restricted Medi-Cal Benefits for Certain Aliens Written Declaration of Status as a Citizen of the United States, a National of the United States, or an Alien California Residence General

7 MC California Residence Evidence MC MC MC MC MC MC MC MC Temporary Absence from the State Death during Absence from the State Persons Living on Land Leased or Owned by the United States Persons on Parole from Correctional or Other Institutions Foster Children and Institutionalized Persons Placed Out-of-State Out-of-State Foster Children and Institutionalized Persons Placed in California Other Persons In Out-of-State Institutions Other Persons in California Institutions MC Article 8 Responsible Relatives and Unit Determination MC Responsible Relatives MC Medi-Cal Family Budget Unit MC Medi-Cal Family Budget Unit Determination, No Family Member in LTC or Board and Care MC MFBU Determination Child Stays Alternately with Each Parent MC MC MC Medi-Cal Family Budget Unit (MFBU Determination, Family Member in Long Term Care or Board and Care Ineligible Members of the Medi-Cal Family Budget Unit Persons Excluded from the Medi-Cal Family Budget Unit MC Article 9 Property MC Property Evaluation MC Availability of Property MC Treatment of Property Separate and Community Property MC Owner of Property MC conversion or Transfer of Property MC Conversion of Property Treatment MC Transfer of Property with Retention of a Life Estate MC Period of Ineligibility Due to Transfer of Property MC Encumbrances MC Share of Encumbrances Determination MC Utilization Requirements MC Exemption of Property MC Property Reserve MC Property Limit MC Separation of Community Property Spouse in Long Term Care Facility MC Limits and Methods of Property Determination for the Qualified Medicare Beneficiary (QMB) or the Specified Low Income Medicare Beneficiary (SLMB)

8 MC Article 10 Income MC Income General MC Income Gross Earned Income MC Income Net Profit from Self-Employment MC Income Gross Unearned Income MC Income Net Income from Property MC Income - Income In-Kind MC Income Value of Income In-Kind MC Income Ownership of Income MC Income Availability of Income MC Income Unavailable Income MC Income Apportionment of Income Over Time MC Income Apportionment of Income Exemptions and Deductions Over Time MC Income Fluctuating Income MC Income Income Exemptions and Deductions General MC Income Payments Exempt from Consideration as Income MC Income Property Tax Refunds MC Income California Franchise Tax Board Payments MC MC MC MC MC MC MC MC MC Income Public Assistance and General Relief Grants Income Work Incentive Program (WIN) Income Social Services Income Assistance Based on Need Income Federal Housing Assistance Income Training Expenses Income Foster Care Payments Income Exempt Loans, Grants, Scholarships and Fellowships Income Payments to Victims of Crimes MC Income Relocation Assistance Benefits MC Income Disaster and Emergency Assistance Benefits MC Income Payments to Victims of the National Socialist Persecution MC Income Federal Payments to Indians and Alaskan Natives MC Income Vista Payments MC Income Job Training Partnership Act (JTPA) replaced by Workforce Investment Act (WIA) Payments MC Income Executive Volunteer Programs MC Income Senior Citizen Volunteer Programs MC Income Irregular or Infrequent Income MC Income Student Exemption MC Income Earned Tax Credit MC Income Earnings of Children Under Age 14 MC Income Deductions from Income

9 MC Income Educational Expenses MC Income 0 Deductions from Income MFBU Which Include Aged, Blind or Disabled MN Persons MC Income Support Payment from an Absent Parent MC Income 0 Any Income Deduction Unearned Income MC Income Guardian and Conservator Fees MC Income Student Deduction MC Income Thirty Dollars Plus One-Third MFBUs Which Include Aged, Blind or Disable MN Persons MC Income Any Income Deduction Earned Income MC Income - Sixty-Five Plus One-Half MC Income Income Work Expenses of the Blind MC Income Income Necessary to Achieve Self-Support ACWDL No Income 2MC 50 Percent Working Disabled Program MC Income Cost of In-Home Supportive Services ABD/MN and SGA Disabled MC Income Deductions from Earned Income AFDC/MN, MI or Ineligible Members of the MFBU MC Income Deduction for Work Expenses MC Income Thirty Dollars Plus One-Third MC Income Deduction for Dependent Care MC Income Court Ordered Alimony or Child Support MC Income Child/Spousal Support Received by AFDC/MN MC Income Deductions from Any Income All MN or MI Programs MC Income Income of an MN or MI Person Used to determine Public Assistance Eligibility of Another Family Member MC Income Health Insurance Premiums MC Income Treatment of Income MC Income Income of Persons Excluded form the MFBU MC Income Income Deemed Available from the Stepparent MC Income Treatment Stepparent Cases MC Income Treatment of Income Persons in LTC MC Income Treatment of Income Persons No Longer Receiving Title XVI Due to a Cost of Living Increase in OASDI Benefits Under Title II (Title II Disregard) PICKLE MC Income Income Determination and Limit for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual-1 (QI-1) ACWDL No Income Aged & Disabled Federal Poverty Level (A&D FPL) Program

10 MC Income Income Determination and Limit for Qualified Disable and Working Disabled Individual (QDWI) ACWDL No Income 1931(b) Program Income - Sneede Income 1931(b) Sneede MC Article 11 Maintenance Need MC Maintenance Need Family Members Maintaining Separate Residences with Eligibility Determined as a Single MFBU MC Maintenance Need Persons in Long-Term Care MC Article 12 Share of Cost MC Share of Cost General MC Determination of share of Cost MC Processing Cases When a Share of Cost Has Been Reduced Retroactively MC Changes Which Decrease the Share of Cost MC Changes Which Increase the Share of Cost MC Changes in Share of Cost Determination Due to Administrative Error MC MFBUs Which Includes a Title II Disregard Person MC Article 13 Period of Eligibility MC Beginning Date of Eligibility MC Period of Eligibility MC Retroactive Activity MC Certification Card for Medi-Cal MC Article 14 Med-Cal Card Use and Issuance MC Medi-Cal Card Use MC Medi-Cal Signature Requirements MC Medi-Cal Card Authorization for Services MC Locations Where Medi-Cal Card May Be Used MC Format of Medi-Cal Card MC Medi-Cal Cards for Restricted Medi-Cal Benefits to Certain Aliens MC Medi-Cal Card Issuances by the Department MC Limitations on Eligibility Reports and Card Issuance Requests Submitted by the County Department MC Medi-Cal Card Issuance by the County Department No Share of Cost MC Medi-Cal Card Issuance by the County Department Share of Cost MC Limitation on Medi-Cal Card Issuances

11 MC Article 15 Other Health Case Coverage and Medicare Buy-in Coverage MC Other Health Care Coverage General MC Beneficiary Responsibility Other Health Care Coverage MC County Department Responsibility Other Health Care Coverage MC Department Responsibility Other Health Care Coverage MC Recovery of Third Party Payments MC Determination of Good Cause for Refusal to Cooperate MC Veterans Aid and Attendance Payments MC Medicare Buy-In MC Medicare Coverage MC Requirements to Apply for Medicare MC Other Health Care Coverage Premium Payment MC Article 16 Overpayment, Fraud and Improper Utilization MC Potential Overpayments MC Potential Overpayments Unreported Other Health Coverage MC Fraud MC County Action on Potential Overpayment MC Medi-Cal Overpayments Fraud CalWORKs Cash Grant MC Utilization Restrictions MC Article 17 Dialysis Medi-Cal Program and Special Treatment Program (STP) MC Medi-Cal Special Treatment Programs General MC Medi-Cal Special Treatment Programs Beneficiary MC Real Property Medi-Cal Special Treatment Programs MC Personal Property Medi-Cal Special Treatment Programs MC Gross Income Medi-Cal Special Treatment Programs MC Annual Net Worth MC Percentage Obligation MC Application Process Medi-Cal Special Treatment Programs MC Eligibility Requirements Medi-Cal Special Treatment Programs MC Verification Requirements Medi-Cal Special Treatment Programs MC Eligibility Determination Medi-Cal Special Treatment Programs MC Beginning Date of Eligibility Medi-Cal Special Treatment Programs MC Determination of Annual Net Worth Mc Determination and Application of Percentage Obligation Medi-Cal Special Treatment Program MC Share of Cost Medi-Cal Special Treatment Programs Supplement Beneficiary MC Article 18 Fair Hearings MC Right to State Hearing MC State Hearing MC Fair Hearing

12 MC Article 19 Estate Recoveries, Waivers & Estate Hearings MC Definitions MC Estate Claims MC Notification MC Undue Hardship Criteria MC Estate Hearing

13 MC Definitions, Abbreviations and Program Terms MC MEANING OF WORDS - Words have their usual meaning unless the context or a definition clearly indicates a different meaning. SHALL means mandatory MAY means permissive SHOULD means suggested or recommended. MC Medi-Cal Program Administration What is the Department? The Department is the State (California) agency that is approved by the Department of Health and Human Services to administer the Medi-Cal program. The county welfare department is responsible for local (county level) administration of the Medi-Cal Program under the direction of the Department. MC Medi-Cal Regulations What are Medi-Cal regulations? They are the rules, principals, and systems that are put into effect for the purposes of administering the Medi-Cal Program. MC Fiscal Intermediary MC Medi-Cal Consultant MC Medi-Cal Review Any individual, partnership or association, corporation or institution contracted with the Department for the performance of fiscal services related to the program. A professional individual employed by the Department to provide advice in matters related to services provided under Medi-Cal. A periodic, but not less than annual, evaluation of the health needs of each beneficiary in each: mental hospital, skilled nursing facility, and intermediate care facility

14 Medi-Cal Review Team A team comprised of a physician and other appropriate health and social service personnel that conduct a medical review. MC Health Care Services The medical services, social services, supplies, devices, drugs and any other medical that an eligible person is entitled to receive in accordance with Medi-Cal regulations.

15 MC Abbreviations ABD - Aged, Blind or Disabled ABD MN - Aged, Blind or Disabled- - Medically Needy. AFDC - Aid to Families with Dependant Children (obsolete) see CalWORKs AFDC- - MN - Aid to Families with Dependant Children- - Medically Needy Identification BIC Benefits Issuance Card BRU- Benefits Review Unit CalWORKs- California Work Opportunity and Responsibility to Kids Program CETA- Comprehensive Employment and Training Act CHDP- Child Health and Disability Prevention Program EAS- Eligibility and Assistance Standards Manual ETS- Employment Training Service HIC- Social Security Health Insurance Claim Number INS- Immigration and Naturalization Service LTC- Long-Term Care MBSAC- Minimum Basic Standard of Adequate Care MEDS- Medi-Cal Eligibility Data System MBU- Mini Budget Unit MFBU- Medi-Cal Family Budget Unit MI- Medically Indigent MN- Medically Needy OASDI- Old Age Survivors and Disability Insurance Other PA- Other Public Assistance PA- Public Assistance PCCM- Primary Care Management POE- Proof of Eligibility SDX- State Data Exchange SSN- Social Security Number SSI/SSP- Supplemental Security Income/State Supplement Program

16 MC Adequate Consideration The receipt of cash or property which is fair and reasonable under the circumstances considering the net market value of property that is sold, converted or transferred. MC Adult 1931(b) Program An adult is: For the 1931(b) Program: A Person 18 years of age or older, if he/she is not enrolled as a full-time student (as defined by the school) in high school or he/she has completed high school, and is not in a vocational or technical training program. For the Medically Needy Only Program: A person who is 21 years of age or older. A person who is 21 years of age or older. A blind or disabled medically needy (MN) person who is 18 to 21 years of age who is living in the home of a parent and not currently enrolled in school, college university, or course of vocational/technical training to prepare for gainful employment. Any person who is 18 to 21 years of age who is: 1. not living in the home of a parent or caretaker relative 2. not claimed as a tax dependant of his/her parent(s) 3. not receiving out-of-home care from a public agency. A person 14 to 18 years of age who is not living in the home of a parent or caretaker relative and who does not have a parent, caretaker relative or legal guardian handling any of his/her financial affairs.

17 MC Aid to Families with Dependant Children MC Applicant C Application The public assistance program that provided a cash grant and Medi-Cal to children deprived of parental support or care and their eligible relatives prior to CalWORKs. The individual or family making an application, request for restoration of aid, or reapplication A written request for aid. MC Approval of Eligibility MC Beneficiary The determination made by the county department that a person or family is eligible for Medi-Cal. A person who has been determined eligible for Medi-Cal. MC Board and Care MC Burial Insurance MC Cash Grant MC Certification Date for Claims Clearance MC Certification - Effective Date MC Certification for Medi-Cal Receipt of board, room, personal care and supplemental services related to individual needs in a non-medical protective living environment. Insurance that can only be used to pay the burial expenses of the insured. The money payment made to a person eligible for CalWORKs, SSI/SSP, General Relief, or CAPI. The date of the most recent service listed on the MEDS SOC screen. The date the person is certified to receive Medi-Cal benefits. The determination by the Department that a person is eligible for Medi-Cal and; has no share of cost has met the share of cost or is in long-term care and; has a share of cost that is less than the cost of long-term care at the Medi-Cal rate.

18 MC Certified Long-Term Care Insurance Policy or Certificate Any long-term care insurance policy/certificate certified and approved by the Department of Health Services. MC Child For 1931(b) a child is: For the 1931(b) Program: A person up to their eighteenth birthday. A person 18 years of age or older, if he/she is enrolled as a full-time student (as defined by the school) in high school or has not completed high school, is in a vocational or technical training program which cannot result in a college degree, provided he/she can reasonably be expected to complete either program before reaching age 19. For the Medically Needy Only Program: A person under the age of 21 except for persons who are specified as adults in MEM section MC For Medi-Cal Program purposes: An unborn is considered a child. MC Child Health and Disability Prevention Program (CHDP)Gateway A community based program for early identification and referral for treatment of persons under 21 years of age. MC Competent MC Contiguous Property MC Conversion of Property MC County Agency Being able to act on one s own behalf in business and personal matters. Adjacent or adjoining property that is not separated by a road, street, right of way or in any other manner. Changing property from one form to another without changing ownership. An administrative division of a county government or a non-county organization that has a contract with the county to act on the County s behalf.

19 MC County Cash-Based Medi-Cal Eligibility Eligibility for Medi-Cal benefits that is based on the Department s determination of eligibility for a cash grant or IHSS. MC County Department MC County Case Error Rate MC Eligibility and Assistance Standards Manual (EAS) The department authorized by the county Board of Supervisors to administer aid programs, including Medi- Cal. The number of quality control case reviews found in error. Regulations pertaining to AFDC, APSB, SSP and EVH programs. MC Eligibility Quality Control MC Eligibility Services MC Emergency Assistance MC Encumbrances of Record MC Family Member The Federal and/or State mandated review of Medi-Cal cases to ensure proper determination of eligibility. Services provided relating to the initial and continuing determination of a person s or family s Medi-Cal eligibility. Public assistance programs that provide assistance for 30 days to: Families not meeting the qualifications for the federal CalWORKs program. Those children who are being, or in immediate danger of being abused, neglected or exploited and to families of such children. Obligations for which property is security. Evidenced by a written document A family member is described as: A child or sibling children. The parents married/unmarried of the sibling children. The stepparents of the sibling children. The separate children of either unmarried parent or of the stepparent. If no children, family member means a single person or a married couple.

20 MC Federal Poverty Level The income level based on the official poverty line defined by the Federal Office of Management and Budget. MC Heirloom MC Home MC Immigration and Naturalization Services (INS) Any item of personal property, other than cash and securities, which has substantially sentimental value, has been owned by a family for a least two generations and is intended to be retained by the family in succeeding generations. Real or personal property, fixed or mobile, located on land or water, in which a person or family lives. The branch of the United States Government that administers regulations regarding aliens in the United States. NAME HAS BEEN CHANGED TO: Bureau of Citizenship and Immigration Services MC Impairment Related Work Experience (IRWE) MC Income and Eligibility Verification System (IEVS) MC In-Home Supportive Services (IHSS) MC Inmate The expenses of a working disabled Qualified Medicare Beneficiary (QMB), or Specified Low-Income Medicare Beneficiary (SLMB) program applicant/beneficiary which are necessary to become or remain employed. The federally mandated system established to obtain, use, and verify information relevant to eligibility and share of cost. The program which provides necessary personal and domestic care so that aged, blind, and disabled persons may remain in their own homes. A person living or being cared for in an institution. Exclusions: Persons residing at a facility for vocational training or educational purposes, Person temporarily in an institution pending more suitable arrangements, i.e.: Children pending foster care placement.

21 MC Institution MC Institution -- Medica MC Institution -- Mental Diseases An establishment which provides food and shelter, and some service or treatment to four or more persons unrelated to the proprietor. Any of the following types of public or private hospitals/medical facilities licensed by an official State standard setting authority: Acute care hospital Acute Psychiatric hospital Intermediate care facility Skilled nursing facility An institution primarily engaged in providing diagnosis, treatment or care for persons with mental illness. MC 500MC 50-Institution -- Nonmedical MC Institution -- Private MC Institution -- Public Any institution providing non-medical residential care, custodial care, custody or restraint. This includes penal institutions. A privately owned or nonprofit facility managed and controlled by an individual, private association or corporation. An Institution that is the responsibility of a governmental unit or which a governmental unit exercises administrative control. Exclusions: Medical facilities and publicly operated community residences serving no more than 16 persons. MC Institution - - Tuberculosis MC Intraprogram Status Change MC Interprogram Transfer An institution primarily engaged in providing diagnosis, treatment or care for persons with tuberculosis. A change in a person s or family s eligibility from one aid category to another category, in which the first digit of the aid code remains the same. A transfer of eligibility from one aid category to another aid category in which the first digit of the aid code changes.

22 MC Life Insurance MC Limited Service Status A contract for which premiums are paid during the lifetime of the insured, and on which the insuring company pays the face amount of the policy to the beneficiary upon the death of the insured. The beneficiary has limited use of the Medi-Cal card because of: 1. improper utilization of service, 2. application as a child, or, 3. participation in a pilot project conducted by the Department. MC Linked MC Long-Term Care (LTC) MC Marriage MC Medi-Cal MC Medi-Cal Card AKA Benefits Identification Card (BIC) MC State Dollar Error Rate MC Federal Standard Meeting the following requirements: SSI/SSP requirements of age, blindness or disability (1931(b) (former AFDC rules) requirements for deprivation of parental support or care Reference: CalWORKs Deprivation Section Inpatient medical care which lasts for more than the month of admission and is expected to last for at least 1 (one) full calendar month after the month of admission. The state of being married. Includes a legal common-law marriage. California s medical assistance program and the benefits available under the program. A computer identification card issued to a person certified to receive Medi-Cal in order to identify the cardholder and to authorize the receipt of Medi-Cal covered services. The Medicaid dollar error rate reported to the Department by the United States Dept. of Health and Human Services, less any portion that is attributed to the State caused errors. The Medicaid dollar error rate standard that the State is held accountable for by the Federal Government.

23 MC State Caused Errors MC Medi-Cal Family Budget Unit (MFBU) MC Medi-Cal Only Eligibility MC Medical Support MC Medically Indigent (MI) Person or Family Errors in a county that the State assumes responsibility for. The persons who are included in the Medi-Cal eligibility and share of cost determination. A person s or family s eligibility for Medi-Cal benefits that has been determined separately from any other aid or benefit program. Any liability or payment for the purpose of medical care under a court or administrative order. A person or family eligible under the Medically Indigent program. Reference: Article 5 - Medi-Cal Programs; MEM Section MC MC Medically Needy (MN) Person or Family MC Minimum Basic Standard of Adequate Care (MBSAC) MC Minor Consent Services MC Multiple Dwelling Unit A person or family eligible under the Medically Needy program. The amount necessary to provide a CalWORKs family with the basic needs. Restricted services related to: Sexual assault Drug or alcohol abuse for children 12 years of age or older Pregnancy Family planning Venereal disease for children 12 years of age or older. Mental health care for children 12 years of age or older. Any dwelling with more than one separate living unit. NOTE: As a minimum a unit would include a bathroom and a kitchen.

24 MC Nonrecurring Lump Sum Payment MC Obligate MC Other Public Assistance (Other PA) Recipient MC Overpayment MC Parent MC Parent-Minor MC Parents Unmarried MC Patient MC Persons Living in the Home MC Property Community A payment accrued over more than one calendar month and not expected to be received again in the future. To incur a cost for health care services. A person eligible for Medi-Cal under one of the categories in the Other Public Assistance program, which consists of/includes: Four Month Continuing Eligibility (Section MC 50243) Nine Month Continuing Eligibility (Section MC 50244) In-Home Supportive Services (Section MC 50245) Twenty Percent Social Security Increase (Section MC 50247) The receipt of Medi-Cal benefits when there is no entitlement to all or a portion of the benefits received. The natural or adoptive parent of a child. A person who meets the definition of a medically needy child and has his/her own child or children living in the home. Parent who are living together with their common child and the parents are not married to each other. A person receiving individual professional services by a licensed practitioner of the healing arts towards maintenance, improvement, or protection of health, or the alleviation of disability or pain. All of the following: Persons physically present in the home Persons temporarily absent from the home because of hospitalization, visiting, vacation, trips in connection with work, or because of similar reasons Reference: MEM Section MC Property acquired by either spouse during marriage.

25 MC Property Personal MC Property Real MC Property - Separate MC Property Share of Community MC Public Agency MC Public Assistance (PA) Recipient MC Public Funds MC Publicly Operated Community Residence Possessions or interest, exclusive of real property (see MC 50074), title that may easily transported or stored; including but not limited to: Cash on Hand Bank accounts Notes Mortgages, Deeds of trust, Cash surrender value of life insurance motor vehicles uncollected judgments, and interest in a firm in receivership, a lawsuit, patents and copyrights. Land and improvements which generally includes any immovable property attached to the and any oil, minerals, timber or other rights related to the land. Any item that is considered separate property under California Property Law. Property that is acquired by an individual by any method prior to marriage, after obtaining an interlocutory or final judgment of dissolution, or while voluntarily separated; or at any time by gift or inheritance, or purchases made with funds that are separate property or with funds from the sale of separate property. Is to be treated as if each spouse owns one-half of the community property. An administrative division of local, state or federal government, or an organization that has a contract to act in behalf of the local, state or federal government. A person or family receiving assistance under the CalWORKs, SSI/SSP, refugee program. Monies provided by local, state or federal government. See Section MC for more information A facility designed and planned to serve no more than 16 residents which is actually serving 16 or fewer residence.

26 MC Qualified Disabled and Working Individual MC Qualified Medicare Beneficiary An individual who meets the eligibility requirements for the Qualified Disabled and Working Individual program. An individual who meets the eligibility requirements for the Qualified Medicare Beneficiary program. Reference: MEM MC MC Reapplication An application for Medi-Cal only eligibility made in the same county as a previous under the following circumstances: the previous application was denied or withdrawn, or Medi-Cal only eligibility based on the previous application has been discontinued for more than 12 months. MC Redetermination MC Relative MC Relative Caretaker MC Repayment MC Residence MC Responsible relative The review of a person s or family s Medi-Cal eligibility. Any of the following persons: Mother, father, grandfather, grandmother, son, daughter, brother, sister, stepfather, stepbrother, stepsister, uncle, aunt, first cousin, nephew, niece, half-brother, half-sister, or any such person of denoted by a prefix of gran, great or great-great; or the suffix in-law. A relative who provides care and supervision to a child, if there is no natural or adoptive parent in the home. The liquidation of an overpayment in response to issuance of demands and recovery by the Department of Benefit Payments. The place in which a person or family lives or is physically present. A relative who is responsible to contribute to the cost of health care services received by a Medi-Cal beneficiary.

27 MC Restoration MC Share of Cost MC Share of Encumbrances MC Specified Low-Income Medicare Beneficiary (SLMB) The approval of Medi-Cal only eligibility for a person or family in the same county as that in which they were previously eligible for Medi-Cal only, if the effective date of the approval occurs within 12 months of the end of the previous period of eligibility. A person s or family s net income in excess of their maintenance need that must be paid or obligated toward the cost of health care services before the person/family may be certified and receive medical services. That portion of the encumbrances (liens, charges, or claims) attributed to each portion of jointly owned property. An individual who meets the eligibility criteria for the SLMB program. Reference: MEM Section MC MC State Data Exchange (SDX) MC Stepparent MC Supplemental Security Income/State Supplemental Program (SSI/SSP) MC Theraputic Wages MC Title II Disregard Person MC Transfer of Property The data system by which the Federal Government provides information to the State regarding the eligibility of SSI/SSP applicants and recipients. A person who is married to a parent of a child and is not the other parent of the child. The federal and state payments that are paid to aged, blind, or disabled persons. Wages that are earned by an individual who has been prescribed work as therapy by a physician who does not have a financial interest in the long-term care facility in which the individual resides. A person who meets all the conditions in section MC Reference: MEM Section MC A change of ownership whereby a person no longer hold title to or beneficial interest in, property.

28 MC Verification The process of obtaining acceptable evidence which substantiates statements made by an applicant/beneficiary.

29 MC Article 2 Administration MC County Department Responsibilities What are the requirements for follow-up/control on anticipated changes? Eligibility staff are responsible for ensuring Medi-Cal benefits are paid only on behalf of eligible beneficiaries and to ensure that the share of cost (SOC) amounts are correct on a continuing basis. There are situations where an EW can reasonably anticipate changes in circumstances and thereby establish a Future Action Control (FAC)on LEADER to control for follow-up contact to see if the change has occurred and if so, to get updated information and take appropriate action. NOTE: If client is in receipt of UIB. Control for 90 days to question the client about his employment status and possible increased income from employment. See FUTURE ACTION CONTROLS - USER INITIATED for LEADER procedures What do I do if I take a new application and one of the family members meets the definition of LTC, or is in a medical facility and is expected to meet the LTC definition? If the SAWS 1 application has not been completed and you know that a member of the family meets the LTC definition you must refer the applicant, or the person making the request to the LTC District. If the SAWS 1 is completed and it is discovered that a member of the family meets the definition of LTC, you must do the following: Inform the applicant or representative that eligibility will be determined and if approved, the case will be transferred to the LTC District and determine eligibility and share of cost as expeditiously as possible and if Medi-Cal is approved, transfer case to the LTC District within 3 days per LEADER instructions with a miscellaneous transmittal. See LTC for LEADER procedures

30 Responsibilities of district staff for processing Long-Term Care cases What do I do if I have an approved case and there is a change in circumstance where one of the family members now meets the definition of LTC? If the person that may now be eligible for LTC does not have an at-home spouse or dependent family member(s) then fully document the LEADER case comments to reflect all of the pertinent information received. You must inform the beneficiary/representative that the change may result in an increase in the SOC and that the case will be transferred to the LTC district. You must also determine whether the LTC person will be allowed to retain income for upkeep of the home. (see MC maintenance Need - Persons in LTC) If there is an at-home spouse or dependent family member(s) you must follow the same procedures as mentioned before and immediately prepare the case for transfer to the LTC District within 3 working days. The transfer transmittal should indicate that this is an LTC case with an at-home spouse or dependent family member. See CASE TRANSFERS for LEADER procedures

31 MC Article 3 County of Responsibility MC County of Responsibility General Policy Can a Los Angeles County resident apply for Medi-Cal in another County? If so, which county is responsible for processing the case? Yes. A California resident or his/her representative, spouse or responsible relative may apply for Medi-Cal in any County within the state. Normally, the County of Responsibility for determining the initial and continuing MC eligibility is the county where the applicant resides. Types of Applications Are there situations where applications can be taken and sometimes processed in a county other than the county of residence? Yes. Regular - If applicant applies for MC in a different county from where he/she lives, the County of Responsibility is the county that takes the application, for the purposes of making the initial determination of eligibility, issuing benefits and filing the application. Courtesy - Rare situations and should be determined on a case by case basis. Hardship must exist for the client and the action must be mutually agreed upon by the two counties. If all the information required to determine eligibility is available, the receiving county shall issue benefits before the case is transferred to the applicant s County of Residence for processing. If information is not available the receiving county shall forward the application to the County of Residence within 15 days from the date of application for follow up and completion. Competent Applicant - LTC - Would be processed the same as the Regular application. Incompetent Applicant - LTC - Would be processed the same as the Regular application with the exception being that the case is transferred to the County of Residence of the incompetent persons spouse, responsible relative, or other representative for ongoing maintenance

32 See APPLICATION for LEADER procedures MC Inter-county Transfer Procedure Overview What is a Medi-Cal Only (MAO) intercounty transfer? By definition, a Medi-Cal Only (MAO) inter-county transfer (ICT) is the transfer of responsibility of Medi-Cal eligibility from one county to another, within the state of California, when a beneficiary changes his/her county of residence. See ICT for LEADER procedures Responsibility Who is responsible for processing a ICT case? To facilitate the ICT process and the completion of required reports the district may have an ICT unit. Intake Workers: Approved Workers: If the applicant changes his county of residence while the case is pending, the application must be approved before the case is transferred to the ICT unit. Upon receipt of information that the applicant has changed his county of residence, on the same day you are to hand carry the case to the ICT Eligibility Supervisor. When do I initiate an inter-county transfer? When a permanent change in county address or a change for an indefinite period is reported, the EW must assist the beneficiary with the transition of Medi-Cal benefits to the Receiving County. Counties are responsible for transferring case record information from the beneficiary s old county of residence (Sending County) to the new county of residence (Receiving County) so that Medi-Cal benefits can continue without interruption. What do I do if the change of address is temporary? If a beneficiary reports a temporary change in county address due to seasonal employment, medical care, or other personal reasons and the beneficiary continues to maintain a primary residence in Los Angeles County an ICT shall not be initiated. The EW must ensure that the Medi-Cal Eligibility Data System (MEDS) record for the beneficiary is updated to show the temporary residence county address and county code to facilitate continued access to medical care in the temporary

33 residence county. Comments must be documented with the person s temporary address, as well as, the reason for absence and the beneficiary reminded of his/her reporting responsibilities for changes that can affect Medi-Cal eligibility. The EW manually initiates an EW 12 MEDS transaction through the district MEDS liaison. See ADDRESS - CHANGE/CORRECTION for LEADER procedures What are the sending EW s responsibilities? The Sending County EW s responsibilities are: Initiate to the Receiving County within seven calendar days of the report that a beneficiary is living in another county Confirm the change of address by telephone if a telephone number is provided to the county Send an ICT Informing Notice (MC 358-S) to the beneficiary regarding the county address change and the initiation of the case transfer to the Receiving County; Complete a change of address to LEADER and ensure that MEDS has been properly updated either by LEADER to MEDS interface or by an on-line MEDS transaction as necessary; Continue Medi-Cal on-line on MEDS during the ICT process pending changes in LEADER programming, until Receiving/Sending EW s agree upon discontinuance/approval dates; Initiate a change of residence address and residence county code on MEDS manually using an EW 12 MEDS transaction (questions regarding the EW 12 process should be directed to the district MEDS Liaisons); Notify the Receiving County of the initiation of a case transfer in writing with a MC 360; Send an ICT packet to the Receiving County with copies of available documents supporting the beneficiary s eligibility through the ICT transfer period (30 day transfer period has been eliminated); Annotate the missing documentation or verification on the MC 360 for the Receiving County to follow-up with the beneficiary at the next redetermination if sending

34 EW is unable to locate documents/verification. What forms does the sending EW use to initiate an ICT? The ICT forms/notices are the following: MC 358S (12/02) Medi-Cal Informing Notice Intercounty Transfer - Sending County MC 358S (SP) (12/02) Medi-Cal Information Notice Intercounty transfer - Sending County MC 359R (12/02) Medi-Cal Notice of Action Intercounty Transfer - Receiving County MC 359R (SP) (12/02) Medi-Cal Notice of Action Intercounty Transfer - Receiving County MC 360 (7/02) Notification of Medi-Cal Intercounty Transfer These forms are not yet available through Materials Management. Photocopies must be used until supplies are available. What documents must the Sending County EW include in the ICT packet? The Sending County must provide information necessary for the Receiving County to initiate an active Medi-Cal case for the beneficiary and must ensure any documentation supporting the beneficiary s eligibility is promptly sent. The following is a list of photocopied documents the Sending County EW must include in the ICT packet: Current Medi-Cal application and appropriate supplements including MC 210S-W for Primary Wage Earner or the last annual redetermination form (MC 210 RV Pilot) Identification and/or social security numbers Computer generated case documents, budget worksheets for Medi-Cal Family Budget Unit (MFBU)/Mini Budget Units (MBU) or standard state forms Description of MFBU/MBU Last Notice(s) of Action for eligibility or share-of-cost Case Narrative/Summary Copy of ICT information Notice (MC 358-S) sent to beneficiary

35 If the case situation applies, the following documents may also be required: Income or property verification (MC 176P or case narrative on how income or property was verified for current eligibility. Pregnancy verification for full-scope benefits. Medi-Cal Statement of Citizenship, Alienate, and Immigration Status (MC 13) Other Health Coverage Information (DHS 6155) Child, Spousal and Medical Support Information, CA 2.1s, including any court orders for child/spousal support. Veterans Referral, CA-5 Copy of Disability and Adult Programs decision or verification of incapacity Authorized Representative form or letter, What if the beneficiary reports changes in circumstances related with the move? If the beneficiary reports changes, such as a change in employment or household composition, which would require the Receiving County to follow-up or complete an eligibility review once the transfer is completed, the Sending County must annotate the information on the MC 360, Notification of Medi-Cal Intercounty Transfer, and in the case documents provided to the Receiving County. What are the Receiving EW responsibilities? Complete the ICT no later than the first of the month after the 30-day ICT notification from the Sending County; The beneficiary shall not be required to complete a new application; A full eligibility review shall not be conducted until the next annual redetermination unless there is a change in circumstances which might affect Medi-Cal eligibility; Review the ICT packet for completeness upon receipt of the ICT notification; Verify the beneficiary s current address and active Medi-