Update : Medi-Cal Healthy Families Program Transition to Medi-Cal and Targeted Low-Income Children s Program (TLICP)

Transcription

1 Santa Clara County Social Services Agency page 1 Date: 12/31/12 References: ACWDL 12-29, ACWDL 12-30, ACWDL 12-33, ACWDL Cross-References: Clerical: Handbook Revision: Yes Yes Healthy Families Program Transition to Medi-Cal and Targeted Low-Income Children s Program (TLICP) Background The enactment of the 2012 Trailer Bill, Assembly Bill (AB) 1494 requires that the Healthy Families Program (HFP) stop enrolling new children by December 31, 2012 and begin moving all HFP children into the Medi-Cal program no sooner than January 1, In addition, AB 1494 expanded the Medi-Cal program for children zero to 19 years of age to include the Medically Needy Program for Targeted Low-Income Children s Program (TLICP). With this expansion of the Medi-Cal program, the Healthy Families Program (HFP) ends on December 31, Changes The last HFP eligibility decision will be used to give temporary Medi-Cal eligibility to the transitioned children in order to allow for a smooth transfer to Medi-Cal without the need to re-apply. After the transition, occurring in four phases and beginning no sooner than January 1, 2013, the HFP will stop enrolling new children. All transitioned children will be subsequently covered under the Medi-Cal program. Transition Phases Statewide about 875,000 children currently enrolled in HFP will be transitioned to Medi-Cal during Approximately 32,000 children currently in HFP in Santa Clara County will be transitioned to Medi-Cal. in two phases. [Refer to Effective Dates, page 17-18]

2 page 2 Phase 1 includes 22,000 children enrolled in HFP plans that are also a Medi-Cal managed care plans. (Children enrolled in Anthem Blue Cross or Santa Clara Family Health Plan) These children will start transitioning no sooner than January 1, Phase 2 includes 10,000 children enrolled in HFP plan that is a subcontractor of a Medi-Cal managed health care plan (Children enrolled in Kaiser). These children will start transitioning no sooner than April 1, Transition Aid Codes HFP children will remain in HFP aid code 9H (0C for AIM-linked infants) until their transition phase. Children due to be transitioned will be placed into one of two temporary aid codes in MEDS-5C or 5D. Aid code 5C provides full scope Medi-Cal coverage without premium payment to children with family income at or below 150% FPL. Aid code 5D provides full scope Medi-Cal coverage with a premium payment to children with family income above 150% FPL and up to 250% FPL. Example: Phase 1 transition starts on 01/01/2013. ONLY children in Phase 1 will receive aid code 5C or 5D. The remaining HFP children retain the HFP aid code until their transition phase. Transitioned children remain in the applicable transition aid code until the date of the child s HFP Annual Eligibility Review (AER), there is a change in circumstance that warrants a Medi-Cal review of eligibility, or if the child is in an existing Medi-Cal case and the family s Medi-Cal Redetermination (RD) occurs sooner than the child s HFP AER. Transition Process The timing of the Medi-Cal determination depends upon the individual circumstances of the child transitioning from the HFP. Some HFP children may already be in a Medi-Cal case with other family members. Others may not have any association with a Medi-Cal case. Child in an Open Medi-Cal Case When a child in transitional aid code 5C or 5D is also in an open Medi-Cal case with other family members and that case has a Medi-Cal RD date that occurs prior to the child s HFP AER date, the EW will include the HFP child at the Medi-Cal RD date and not wait until the child s HFP AER date.

3 page 3 When a child in aid code 5C or 5D is also in an open Medi-Cal case with other family members and the child s HFP AER is before the Medi-Cal family s RD date, the EW will add the child and evaluate the Medi-Cal case with the child without having to wait for the Medi-Cal RD date. Note: This does not mean that the EW moves the Medi-Cal RD date. The case keeps its Medi-Cal RD date and the EW does a redetermination for Medi-Cal at that time. Continuous Eligibility for Children (CEC) If the family Medi-Cal RD, or adding the child to the Medi-Cal case as an add a child, results in a change that would move the HFP child to a Medi-Cal share-of-cost (SOC), premium payment, or program ineligibility, the child is eligible for CEC and continues with no SOC Medi-Cal until his/her AER. Continuous eligibility also protects the child from non financial reasons for discontinuance, even if those changes adversely affect other family members, except for: Death Child reaches the age limit Child loses California residency or The child/guardian or representative of the child requests disenrollment Reminder: Non-payment of premium is not a reason for CEC. If child is eligible for CEC, EW must suppress transaction to MEDS for that child. Child must be left in the transitional aid code until his/her AER date. Child s last completed AER date can be found on MEDS INQ2 screen.

4 page 4 When the child reaches age 19 or the end of their AER, EW must run EDBC to place the child in the appropriate aid code and send transaction to MEDS. Child With a Closed or No Medi-Cal Case If a child in aid code 5C, 5D does not have a Medi-Cal case, the EW is not required to take an action until the HFP AER date. At the HFP AER date, the EW will open a Medi-Cal case and determine if the child is Medi-Cal eligible. Note: If other family members request Medi-Cal the EW follows the current procedures for adding family members to the case. HFP AERs Due in January, February and March 2013 MAXIMUS will initiate the renewal process for children who have AERs due in January, February, and March of MAXIMUS has sent renewal packages during the months of October, November, and December 2012 to these families. If HFP AER packets are returned MAXIMUS will complete the AER process and based on the updated eligibility information place these children in the appropriate transition aid code. The next redetermination for these children is in the corresponding month of 2014 (January, February or March) when the county will have responsibility to complete the redetermination unless there is a change in circumstances before the RD date. Renewals Due April 2013 Through December 2013 For HFP AERs due in April through December 2013, MAXIMUS will send out renewal packages using a modified pre-populated form specific to the Medi-Cal program. The time frame for mailing these Medi-Cal renewal packages will be consistent with the current Medi-Cal processes. Within 10 business days, MAXIMUS will review the forms returned by the beneficiary for completeness. If AER is incomplete MAXIMUS will make five attempts to contact the family within the 10 day time frame. After 10 days MAXIMUS will forward the forms to the county. Upon receipt of the documentation from MAXIMUS, the county will have 3 business days to determine that the application received was complete and that begins the annual renewal process. In addition, MAXIMUS will provide to the county information related to the number of renewal packages mailed but not returned as confirmation of non-receipt for the county for audit and appeal purposes MAXIMUS will also send to the county any additional information if received from the beneficiary after original documents were sent.

5 page 5 The EW will use the submitted documents and any additional information required to make the Medi-Cal eligibility determination and place the child into the appropriate Medi-Cal aid code (which now includes TLICP) or discontinue the case. Notices Prior to each phase of the transition, the State will mail notifications to the affected families. Those transitioning in Phase 1 were mailed a 60-day notification in November 2012, and a reminder notification in December Welcome Packet The State will send a Medi-Cal welcome packet to transitioning HFP families prior to the effective date of their transition. The welcome packet includes: PUB 68, Medi-Cal What It Means To You MC 003 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program information MC 219, Important Information for Persons Requesting Medi-Cal Multilingual notice request for assistance. Important Information about dental benefits A list of counties with telephone office contact information for Medi-Cal inquires. BIC The State will be sending Beneficiary Identification Cards (BICs) only to children who received a BIC prior to Children who received a BIC in 2011 or 2012 will not get a new one. Procedure Below is the procedure for processing transitioning HFP children to Medi-Cal. Who Program Action Receives a report from CalWIN identifying children with and without an active Medi-Cal case no later than the 15th of the month prior to the month child's HFP Annual Eligibility Review (AER) packet is due. If... There is an active Medi-Cal case, There is NO active Medi-Cal case, Then... s the report to the assigned Office to complete an Add a Person/Add a Program process. s the list to the AS staff in the designated Office.

6 page 6 Unit AS Unit EWS Receives HFP list. Performs full file clearance and Application Registration. Assigns to the Unit case load # in CalWIN. Sends the copy of the report to the Unit EWS. Receives the HFP list. Equitably assigns work among the EWs in the Unit. Updates the HFP report with the assigned EW's names and EW #. Sends the updated list back to the AS. When HFP AER Packet is Received Unit AS Receives and date-stamps HFP AER packet. Documents in CalWIN's Maintain Case Comment window when the HFP AER packet was received. If Case is assigned To any other District Office, Then... Forwards the HFP AER packet to the assigned Office To Unit, Forwards the HFP AER packet to the assigned EW utilizing the HFP list Updates the HFP report with the date HFP AER is forwarded to the EW Sends completed list to the Unit EWS on the last working day of the month Unit EW Receives the HFP AER packet. Reviews for completeness within 3 days of the date HFP AER packet is received. Makes appropriate CalWIN entries. If the HFP AER is Then Complete Dispositions the application accordingly. [Refer to CalWIN, page -20] if processing prior to February 18, 2013 Informs the EWS that HFP AER is completed.

7 page 7 Unit EW Incomplete Approves Medi-Cal for children, if Medi-Cal is requested for parent(s) and children, AND verification not provided is necessary only to establish eligibility for the parent(s) (i.e. assets). Follows existing SB 87 procedures to obtain information and complete the eligibility review. Reminder: Before initiating any discontinuance action, EWs must: - Conduct an ex parte review - Attempt telephone contact, and - Mail the MC 355 to the client Documents in the Maintain Case Comments window. If the client... Submits the missing verifications, Does not submit verifications by the due date, Then... Processes the MC application and approves benefits. Informs EWS that HFP AER is completed. Sends the appropriate discontinuance NOA(s) if by the 20-day due date the client has still not submitted the missing verifications. Note: CalWIN generated denial NOAs must be deleted and manual discontinuance NOAs sent. Informs EWS that HFP AER is completed. Documents in the Maintain Case Comments window. Submits all HFP AER documents and MEDS screens in the designated basket for the EWS review. Reminder: Even though these cases are processed as applications they must be treated as redeterminations. If the client fails to return the HFP AER form by the requested due date, EW must send a timely 10 day NOA to discontinue the Medi-Cal benefits for failure to cooperate with the annual RD requirements. The discontinuance action is effective on the last day of the month the RD is due provided a timely NOA can be issued to the beneficiary. The SB 87 process does not apply in this situation.

8 page 8 Unit EWS Selects/reviews HFP AERs for accuracy/completeness as per policy. If the HFP AER Processing is Accurate and complete, Not accurate or complete, Then... Places the HFP AER form and verifications in the designated basket labeled HFP AER. Returns case to EW for corrections. Office AS Retrieves HFP AER form and verifications from the designated basket Transfers case to appropriate caseload at BSC in CalWIN. IDMs the form and verifications. Reminder If the client Returns a complete signed annual HFP AER form with all necessary verifications within 30 days of the Medi-Cal discontinuance. Then... Case must be rescinded and eligibility determined as though the form was submitted in a timely manner. New application IS NOT required. Program Receives a report from SPE identifying clients that failed to return the HFP AER forms by the requested due date. IDs clients in CalWIN and sorts by Office. s the report to the assigned Office. Office AS Compares report received from SPE with the one generated in the Office. Reconciles any discrepancies. s report back to Program. Note: If the request to add another family member to Medi-Cal (i.e. parent) is made after the application is dispositioned but before it is transferred to Continuing, it is a responsibility of the Unit EW to initiate an Add a Person process. Targeted Low-Income Children s Program The Targeted Low-Income Children s Program (TLICP) expands income eligibility for children zero to 19 years of age to 250% of the FPL. To be eligible for the TLICP a child must meet the following criteria: Children up to their 19th birthday. Net family income must be at or below 250% of the FPL. Child must be a U.S. citizen or qualified alien. Child must be a California resident.

9 page 9 Note: There is no property limit for the TLICP. Property is not considered, nor verified. Beginning January 1, 2013, the TLICP must be evaluated when applicable at any Medi-Cal eligibility determination. Reminder: Eligibility determinations include but are not limited to applications, annual redeterminations, midyear status reports, or reported changes. Aid Codes Five new aid codes were created for the TLICP: H1, H2, H3, H4, and H5. These aid codes are in addition to the existing FPL aid codes. The side-by-side table below displays current Medi-Cal FPL Children s Programs aid codes with descriptions and the new Medi-Cal TLICP aid codes with descriptions of the population that each serve. Current Medi-Cal FPL Children s Programs New Medi-Cal TLIPC Program Aid Code Description Aid Code Description % FPL Infant 0C Provides full Medi-Cal benefits to eligible infants up to 1 year old or continues beyond one year when in an inpatient status that began before the first birthday and family income is at or below 200% of the FPL. AIM Infants enrolled in HFP Infants from a family with an income up to and including 300% of the FPL, born to a mother enrolled in AIM. H1 TLICP - infants Not Subject to Premium Provides full scope, no-cost Medi-Cal for infants who are U.S. citizens, have satisfactory immigration status, or awaiting citizenship verification. Coverage is up to the month of their first birthday or continues beyond one year when in an inpatient status that began before the first birthday. Family income is above 200% and up to and including 250% of the FPL. Includes AIM infants up to the month of their first birthday from a family with an income above 200% up to and including 250% of the FPL.

10 page 10 Current Medi-Cal FPL Children s Programs New Medi-Cal TLIPC Program Aid Code Description Aid Code Description % Program 8P Provides full Medi-Cal benefits to eligible children ages 1 through the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday and family income is at or below 133% of the FPL. 133% Property Waiver Provides full-scope Medi-Cal benefits to eligible children ages 1 through the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday, and family income is at or below 133% of the FPL. H2 TLICP - Children 1-6 Not Subject to Premium Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; ages 1 through the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday and family income is above133%of FPL and up to and including 150% of FPL. 7A 8R 100% Program Provides full benefits to otherwise eligible children, ages 6 through the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday and family income is at or below 100% of the FPL. 100% Property Waiver Provides full-scope benefits to otherwise eligible children, ages 6 through the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday, and family income is at or below 100% of the FPL. H4 TLCIP - Children 6-19 Not Subject to Premium Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; ages 6 through the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday for family income above 100% up to and including 150% of the FPL.

11 page 11 Aid Code Targeted Low-Income Children s Program - Premium Payment Aid Codes with Description H3 TLCIP - Children 1-6 Subject to Premium Provides full-scope coverage based on a premium payment to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; from age 1 to the month of their 6th birthday or continues when in an inpatient status which began before the 6th birthday, with family income above 150% up to and including 250% of the FPL. Includes infants age 1 up to the month of their 2nd birthday from a family with an income above 200% up to and including 250% of the FPL, born to a mother enrolled in AIM. H5 TLCIP - Children 6-19 Subject to Premium Provides full-scope coverage based on a premium payment to children with U.S. citizenship, satisfactory immigration status, or awaiting citizenship verification; from age 6 to the month of their 19th birthday or continues when in an inpatient status which began before the 19th birthday, with family income above 150% up to and including 250% of the FPL. Retroactive Coverage Retroactive eligibility is not available for TLICP aid codes H1, H2, H3, H4, and H5 to cover medical expenses in the three months prior to the implementation date of the program - for the months of October, November, and December Therefore, between January and March 2013, when a family with children in these aid codes requests Medi-Cal retroactive coverage, EW need to assess eligibility for other Medi-Cal programs in existence in October, November, or December Example: Family applies in February 2013 and requests 3-month retroactive Medi-Cal. TLICP can only be granted for January Eligibility for November and December 2012 must be evaluated for other Medi-Cal programs not for TLICP. Reminder: Eligibility for other Medi-Cal programs will involve the need to assess for resources thus additional information will be needed from families if retroactive eligibility is requested. Retroactive eligibility will phase in for the TLICP aid codes of H1, H2, H3, H4, and H5 over the first three months as follows:

12 page 12 Individuals eligible for H1, H2, H3, H4 or H5 in: Retro coverage for H1, H2, H3, H4 or H5 January 2013 No coverage prior to January 2013 February 2013 January 2013 March 2013 January and February 2013 April 2013 January, February, and March 2013 Bridging for AIM-Linked Infants AIM-linked infants with family incomes up to 250% FPL will enroll in TLICP. If at their annual Medi-Cal redetermination, the EW determines an AIM-linked child is above 250% FPL, the EW will need to forward the child s case information back to MAXIMUS for reenrollment to the HF AIM program. After the Annual RD is processed, all forms must be forwarded to the HF AIM program along with all necessary verifications when ALL the following conditions are met: A child is an AIM linked infant A child is under age two A child becomes ineligible for Medi-Cal in the month following the RD Family income exceeds 250% of the FPL Note: To determine if a child is an AIM-linked infant, the EW will need to check in MEDS for the aid code 0C prior to the transition aid code of 5C or 5D. If the child has 0C prior to the transition aid code, then this child is an AIM-linked infant. The EW will use the current HFP referral process and use aid code 7X to bridge the infant to HFP for the continuation of benefits under the HFP program. Bridging program functionality in EDBC will be removed in CalWIN. However aid code 7X will continue to be available for selection on the aid code drop down menu. The EW must perform the BLO and select aid code 7X for the first month AIM-linked infant is discontinued from TLICP and placed in any SOC Medi-Cal aid code. For more information on AIM Program refer to [ Access for Infants and Mothers Program (AIM), page 17-1]

13 page 13 Processing New Applications With the exception of the AIM-linked babies there will be no new enrollments into HFP upon the implementation of transitioning the HFP children to Medi-Cal. The Single Point of Entry (SPE) will remain in existence and will continue to accept mail-in applications and applications submitted through the Health-e-App system. The Single Point of Entry will: Conduct a MEDS clearance to determine if the child already has an open Medi-Cal case which would make them ineligible for accelerated enrollment (AE). Review for completeness, and if an application is not complete, request any missing information from the family. Screen for likely Medi-Cal eligibility and grant AE to children who screen as eligible and whose family incomes are below 250% FPL. Forward all applications to the county for eligibility determination. Note: MAXIMUS has 20 calendar days to contact the family to complete the application and/or provide the missing information before submitting the application to the county. After 20 days MAXIMUS will forward the incomplete application to the county. Reminder: Application date is the date that SPE receives the application and not the date that the county receives the application. Accelerated Enrollment (AE) SPE grants AE, a temporary full-scope, no cost Medi-Cal to all applications received for children zero up to the month of their 19th birthday, which appear eligible for full scope Medi-Cal and whose family incomes are below 250% FPL. SPE will continue to use the 8E aid code for AE. During the time period that the child is granted AE, he/she will not be subject to premiums until the EW has completed the eligibility determination process. AE at CHDP DHCS has redefined the AE aid code, 8X for the Child Health and Disability Prevention (CHDP) Gateway Program. 8X was previously used to grant AE to the HFP to children through CHDP Gateway. This redefined aid code will now be used by CHDP Gateway to screen children to Medi-Cal under TLICP effective January 1, Children

14 page 14 who meet the requirements to be pre-enrolled through the Gateway are automatically given full-scope, zero SOC Medi-Cal for the month of screening and the following month in one of the Aid Codes below. Aid Code 8W 8X Description CHDP Gateway Medi-Cal up to 150% FPL CHDP Gateway Medi-Cal above 150% up to and including 250% FPL Note: During the time period that the child is granted AE via CHDP, he/she will not be subject to premiums until the county has completed the eligibility determination process. Procedure Below is the procedure for processing applications received from SPE. Who Unit AS Action Receives Medi-Cal applications from SPE along with the transmittal sheet. Applications NOT granted AE will be identified as such. IDs the client to determine if there is an active Medi-Cal case If... There is an active Medi-Cal case Then... Forwards the application to the assigned Office. There is NO active Medi-Cal case If AE is... Then Granted, Performs full file clearance and Application Registration Selects SPE as Application Source in CalWIN Selects SPE-AE as Application Type in CalWIN Assigns to the Unit case load # in CalWIN.

15 page 15 Unit AS Not Granted, Performs full file clearance and Application Registration. Selects SPE as Application Source in CalWIN Selects SPE-Non AE as Application Type in CalWIN Assigns to the Unit case load # in CalWIN. Forwards all applications to the Unit EWS. Unit EWS Unit EW Receives transmittal sheet and applications. Equitably assigns work among the EWs in the Unit. Monitors SPE-Non AE applications are dispositioned within 10 days. Receives an application. Reviews the application and verifications provided. Prioritizes applications identified as SPE-Non AE Makes appropriate CalWIN entries If the application is... Then... Complete, Dispositions the application accordingly. [Refer to CalWIN, page -20] if processing prior to February 18, Informs EWS that application is completed if application is identified as SPE-Non AE. Incomplete, Approves Medi-Cal for children, if Medi-Cal is requested for parent(s) and children, AND verification not provided is necessary only to establish eligibility for the parent(s) (i.e. assets) Mails an SCD 1121 and any applicable supplemental forms with a 10-day due date. Informs the EWS that application is received incomplete if application is identified as SPE-Non AE. Documents in the Maintain Case Comments window. If the client... Submits the missing verifications, Then... Processes the MC application and approves benefits.

16 page 16 Unit EW Does not submit verifications by the due date Sends the 2nd copy of the SCD 1121 with another 10-day due date. Sends the appropriate denial NOA(s) if by the 10-day due date the client has still not submitted the missing verifications or forms. Submits all application documents and MEDS screens in the designated basket for the EWS review. Unit EWS Selects/reviews applications for accuracy/completeness as per policy. If the Application Processing is Accurate and complete, Then... Places the application and verifications in the designated basket labeled SPE. Not accurate or complete, Returns case to EW for corrections. Monitors that application is still dispositioned within 10 days of receipt if identified as SPE-Non AE. Unit AS Note: Retrieves Application form and verifications from the designated basket Transfers case to appropriate caseload at BSC in CalWIN. IDMs the form and verifications If the request to add another family member to Medi-Cal (i.e. parent) is made after the application is dispositioned but before it is transferred to Continuing, it is a responsibility of the Unit EW to initiate an Add a Person process. Premiums AB 1494 also implements a premium payment program for children with income above 150% FPL up to 250% FPL. Monthly premiums amounts are set up at thirteen dollars ($13) per child with a maximum family contribution of thirty-nine dollars ($39) per month (i.e. $13 per month/one child,$26 per month/two children, and $39 per month/for three or more children). Note: These premiums are not allowed as a deduction against income for members of the Medi-Cal family budget unit. The chart below represents the current Medi-Cal FPL, the Medi-Cal FPL for TLICP, and those FPL incomes subject to premium payments.

17 page 17 Age of Child a Current FPL limits TLICP FPL limits Subject to Premiums 0-1 Up to 200% Above 200% and up to and including 250% 1-6 Up to 133% Above 133% and up to and including 250% 6-19 Up to 100% Above 100% and up to and including 250% N/A Incomes above 150% and up to and including 250% Incomes above 150% and up to and including 250% a. Eligible up to the month of the 1st, 6th, or 19th birthday; or continues beyond the 1st, 6th, or 19th birthday when in an inpatient status which began prior to the 1st, 6th, or 19th birthday. Premium Collection Effective January 1, 2013, when the EW processes an application, or completes an annual redetermination and determines the family income is above 150% of the FPL, a notification will be made to MAXIMUS for collection of the premium. Premium payment aid codes (H3 and H5) reported to MEDS will be then reported to MAXIMUS. Cases with family income up to 150% of the FPL will not be subject to premiums and information for these children will not be sent to MAXIMUS. Name MAXIMUS will not be used on any materials going to beneficiaries. If a beneficiary has a question about the premium payment, the beneficiary is to be directed to contact the Medi-Cal Premium Payment Section at This contact information will be noted on their premium informing materials and billing statements. Missed Payments When a beneficiary misses a premium payment for thirty (30) calendar days, the Medi-Cal Premium Payment Section will send an overdue reminder notice to the family regarding payment due (monthly billing statement). The notice and billing statement specifies the amount past due, payment date, and potential discontinuance language for non-payment of premiums. If the beneficiary does not make a payment on the past due amount within an additional fifteen (15) calendar days, the Medi-Cal Premium Payment Section sends an additional reminder notice. Any collected past due premiums will first be applied to the outstanding balance owed.

18 page 18 Example: If a family pays $26 dollars per month in premiums, has a balance due of $78 to cover three months in arrears, and they pay $52, the $52 will be applied to the two most outstanding months. The Medi-Cal Premium Payment Section will also contact the beneficiary by telephone to remind the beneficiary of the imminent disenrollment. SB 87 Process The Medi-Cal Premium Payment Section will notify the county when the beneficiary has not paid premiums for 60 days and there was no response to the nonpayment notices from the beneficiary. When this information is received, the EW initiates the SB 87 process to determine if there is eligibility for another Medi-Cal program. If the EW determines there is no other eligibility for Medi-Cal other than paying a premium, the EW will discontinue the case with a timely notice. [ Refer to Senate Bill (SB) 87 Process, page 8-1] Note: AIM-linked infants, because of existing program rules, have a 90 days grace period instead of 60 days. This will continue after the transition to Medi-Cal. Reporting Requirements AB 1494 requires the counties to report to DHCS data on applications submitted directly to the county and from the SPE that were not granted AE. The data for those cases that the SPE granted AE (8E is the only AE aid code that the SPE grants) will be reported as part of the ongoing County Performance Standards for Medi-Cal Applications. The county is required to report the following: The number of applications approved for aid codes H1, H2, H3, H4, or H5 in the data month. A breakout of the applications based on the number of children approved for each of the aid codes: H1, H2, H3, H4, or H5 The average number of days it took to process applications submitted directly to the county and from SPE. The processing period begins with the date the county received the application. For the applications received from SPE that were not granted AE, the total number of applications denied during the data month. Data reports will be submitted on a monthly basis beginning in March 2013 and continue through February The data month will be the month that is two months prior to the report month.

19 page 19 Example: The report due in March 2013 will be for activity in January Reports will be due by the 15th of the report month. Performance Standards A new bi-annual (due every six months) performance standard report will be required for the following performance standards during the first year of the HFP to Medi-Cal transition: Applications received from SPE 90% of applications received from SPE that are complete and without client errors for children that WERE NOT granted AE and ARE NOT active on a Medi-Cal program will be processed within 10 working days of receipt from SPE. The processing period for the 10 working days period begins with the date the county receives the application. Note: Complete and Without Client Error means that all questions on the application were answered and that no further action is required from the client. The EW has the information necessary to make a disposition of initial eligibility or ineligibility. 90% of applications received from SPE that are complete and without client errors for children that WERE granted AE or ARE active on a Medi-Cal program will be processed within 45 days of receipt from SPE. This standard will be reported as part of the regular performance standard reporting requirements already in place. Applications submitted directly to the county Social Services Applications submitted directly to the county will be processed within 45 days of the date the county receives the application. This standard will be reported as part of the regular performance standard reporting requirements already in place. Implementation The effective date for implementation of the new TLICP, aid codes H1, H2, H3, H4, and H5, will be upon implementation of the transition but no sooner than January 1, Additional information and instructions to staff will be provided as soon as they are received from the State.

20 page 20 Documentation All actions must be documented in the Maintain Case Comments window in CalWIN. Data Systems CalWIN New aid codes (H1-H5) will be available in CalWIN for manual use on January 1, Associated functionality for these new aid codes will be programmed into the systems no later than end of February New Approval, Denial, Discontinuance and Change NOA's for the TLICP will also be available in CalWIN for manual use on January 1, [Refer to Forms, page -21] All references to HFP will be removed from existing Medi-Cal Correspondence in CalWIN by January 1, Starting January 1, 2013, this process must be followed when processing Medi-Cal application or RD for child 0 to 19 years of age. Who Action EW Runs EDBC. Reviews Display Eligibility Summary window. If the child... Fails for any FPL program or has SOC, Then... Completes the HFP scratch budget to determine if the child is eligible for any TLICP aid code (H1-H5). [Refer to Medi-Cal TLICP Scratch Budget] If the child is... Eligible, Not eligible, Then... Submits request to EWS to perform BLO. Sends a manually generated denial NOA in CalWIN Passes with NO SOC Authorizes the benefits EWS Receives BLO request. Performs BLO. Authorizes benefits. Informs EW that BLO has been completed. EW Reviews NOAs in print queue Deletes all incorrect NOAs Selects and prints appropriate NOAs manually Enters a Medi-Cal Batch AU with the effective end date of 02/28/12 Submits SCD 1296 if necessary. MTO Forces appropriate aid code into MEDS.

21 page 21 EW Verifies that correct aid code is in MEDS. Documents in Maintain Case Comments window that the child is approved for the TLICP aid Code, based on a manual TLICP budget computation. Submits appropriate MEDS screens to IDM. MEDS Eligibility Transactions (HF20) to update the pending eligibility for January 2013 to either 5C or 5D for children transitioning in Phase 1 was processed in MEDS on December 20, 2012 and is viewable on MEDS Inquiry screens INQ2 since December 21. The transitioned record will remain in the interim aid code 5C or 5D, and will continue to roll-over with each MEDS Renewal, until the EW reports a new eligibility or report a denied Medi-Cal application to MEDS. EW Supervisors Eligibility Work Supervisors (EWS) must review the information provided in this Update with their units at their next unit meeting. Clerical Office Management Coordinators (OMCs) must review the information provided in this Update with their respective staff at their next meeting Forms The following Notices of Action (NOAs) will be available in CalWIN effective 01/01/2013: TLICP Approval Reason Code NM Child(ren) is approved for the TLC program with no premium payment required. Reason Code NM Child(ren) is approved for the TLC program with a premium payment required. TLICP Discontinuance Reason Code NM Child(ren) is discontinued because family's income is over the limit for the TLC program Reason Code NM Child is discontinued from the TLC program because they have reached the age of 19. Reason Code NM Child(ren) is discontinued from TLC program for failure to make premium payments TLICP Denial Reason Code NM Child is denied for TLC program because family is over income limits

22 page 22 Other Programs These changes only apply to the Medi-Cal program. Chart Book The Chart Book is updated to reflect the new FPL levels applicable to the Targeted Low-Income Children s Program (TLIPC). [Refer to Common-Place Handbook, Targeted Low-Income Children s Program (TLICP) and 250% Working Disabled Program (WDP), page 5-11] JAN PICOLORICH, INTERIM DIRECTOR Department of Employment and Benefit Services Contact Person(s): Margareta Hodzic, Medi-Cal Program Coordinator, (408)