Medi-Cal Handbook Applications 5. Applications · Applications 5. Applications. ... [Refer to...

Medi-Cal Handbook page 5-1Applications

5. Applications

5.1 Overview

In addition to basic application requirements, Chapter 5 includes information about the various forms and procedures that are used to determine Medi-Cal eligibility if certain criteria are met. There are specific criteria for and limitations as to when other application forms are to be used. Please review the handbook section for complete information.

Medi-Cal application forms and forms from other public assistance programs that can be used for Medi-Cal: Section:

“Application for Medi-Cal” (MC 210) 5.13

“Joint Application for Children and Pregnant Women” (MC 321 HFP) 5.14

Benefits CalWIN 5.15

“Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP” (SAWS 2) 5.18

“Use of the CalFresh Statement of Facts for Medi-Cal” (CF RECIPIENTS only) 5.19

Application forms forwarded to SSA from other programs when it appears there is eligibility for Medi-Cal:

“Healthy Families Annual Eligibility Review” (AER) Form 5.20

“Healthy Families Add New Children Form” (7/13/00 non-AER) 5.20

“Access for Infants and Mothers” (AIM) 5.21

Required Verifications when MC 321 HFP, AER and AIM Applications are Used 5.22

Children’s Health Initiative (CHI) 5.23

Applications from the Single Point of Entry (SPE) 5.24

“Express Enrollment” for Children in the National School Lunch Program (NSLP) 5.25

Update # 15-14 Revised: 05/21/15

2 Medi-Cal HandbookApplications

5.2 Who May File an Application for Medi-Cal [50143, 50146, 50145, 50147, 50147.1]

The following persons may file an application for Medi-Cal:

• Any person who wishes to receive Medi-Cal.

• If the applicant is incapable or unable to apply, or is deceased, the following persons may apply on their behalf:

• The applicant's guardian or conservator or executor. A copy of the court order must be filed in the case record.

• A person who knows of the applicant's need to apply.

• A public agency representative.

• Persons approved for CalWORKs or SSI/SSP are automatically eligible for Medi-Cal and are not required to submit a separate Medi-Cal application.

• A child may apply for Medi-Cal without parental contact in order to receive minor consent services. [Refer to “Minor Consent,” page 39-1]

• The non-custodial parent can make an application for a child who needs Medi-Cal; however, the non-custodial parent cannot complete the Statement of Facts form for his/her child except when the custodial parent is unable to complete the application.

Note:Generally, the person or agency having legal responsibility for the child completes and signs the Statement of Facts. If the custodial parent is incompetent, comatose or is suffering from amnesia, then the non-custodial parent can complete the Statement of Facts. [Refer to “Applications from Non-Custodial Parents,” page 5-24 for additional information/procedures re: who completes the MC 210 or MC 321 HFP, NOA requirements, and confidentiality rules that pertain to these situations.]

• A child not living with his/her parent(s) may apply if no person or agency accepts legal responsibility for the child. The child's application must be processed with a determination of eligibility as an adult if the child appears to be competent.

Revised: 05/21/15 Update # 15-14


• An adult who is caring for a child who is not a relative may apply for Medi-Cal for the child, if the parent is not available. There is no AFDC-MN linkage for the child, as the adult is not a “caretaker relative”. The child is a Medically Indigent Child (Aid Code 82 or 83) and in his/her own MFBU.

Note:A referral to Child Protective Services may be needed if there appears to be an inappropriate or unstable situation. In addition, a referral to Child Support Services is required for both of the child’s parents.

• If a Minor Parent applies for CalWORKS and is not eligible due to the Senior Parent’s income, only the minor’s child is approved for CalWORKs. If the Minor Parent wants Medi-Cal, the Senior Parent must apply.

Note:A new Statement of Facts form must be completed by the Senior Parent.

• A person's status as a member of a religious order (nun, priest, etc.) does not preclude eligibility for Medi-Cal.

• Persons discontinued from SSI/SSP must be contacted by the County and must be assisted in completing the Medi-Cal application in accordance with Craig v. Bontá requirements.

5.3 How to File an Application

There are many ways to file an application for Medi-Cal. Clients can choose whichever method meets their needs.

5.3.1 In-Person

Applicants are not required to go to a district office to apply for Medi-Cal, however many clients prefer to file in-person and have a face-to-face interview with an Eligibility Worker. An applicant who comes into the office will be given an intake packet and may mail it back, or may switch from a face-to-face interview to the mail-in process at any time.



5.3.2 Face-to-Face Interview

The face-to-face interview requirement for ALL Medi-Cal applications was eliminated July 1, 2000. State law mandates a simplified Medi-Cal application packet and mail-in process for adults and families. The intent is to provide easy access for both adults and families to apply for and receive Medi-Cal benefits as quickly as possible.

At the time of application, the option of scheduling a face-to-face interview with an EW must be presented in a positive way. This will ensure that applicants understand that they can get assistance in completing the forms, answers to questions and information about other programs they may be eligible for.

When an application is made, an agency staff person:

• Completes the SCD 41 and SAWS 1. If a Medi-Cal application is filed in person, the SAWS 1 must be signed by the applicant or the person acting on behalf of the applicant.

• Reviews the SAWS 1 - if there is a an immediate medical need, schedules the client for an interview as soon as possible, and explains the stand-by process.

• Provides a copy of the SAWS 1 to the applicant along with the intake packet and required informing notices.

• Provides a postage-paid return envelope to Medi-Cal applicants who wish to mail back their application, additional forms and/or verifications.

• Follows district office CHI process, if the applicant has children. [Refer to “Children’s Health Initiative (CHI), Intake Procedures,” page 5-58.]

EWs MUST NOT ROUTINELY REQUIRE MEDI-CAL APPLICANTS TO COME IN FOR A FACE-TO-FACE INTERVIEW. Applicants must always be given the choice to come in for an appointment or complete the application process by mail.

Reminder:Clients applying in person should complete and sign the MC 210 and submit it BEFORE leaving the office whenever possible, and therefore avoid any delays that may occur due to mailing of forms back and forth.

When Required

A face-to-face interview is required:



• For Minor Consent applications,

• When there is suspicion of fraud,

• At the applicant’s request, or

• When at least one of the following criteria is met:

• There is questionable information on the application form or with the verifications provided.

• The individual or family has no visible means of support and does not claim income-in-kind, or their means of support is not reported by the individual or family.

• Obvious discrepancies exist between the information reported on the application and information received from IEVS regarding the applicant’s property or income.

Note:A face-to-face interview may not be required if questions or discrepancies can be resolved by follow-up telephone and/or mail contacts.

The reason that the EW is requiring a face-to-face interview MUST be thoroughly documented in Case Comments.

Failure to Keep an Appointment

When a Medi-Cal applicant chooses to schedule an interview and fails to keep their scheduled appointment, the following procedures apply:

IF... THEN...

The applicant requests a face-to-face interview, and later does not keep his/her scheduled appointment,

NOTE: This process also applies to persons applying for both CalWORKs / GA and Medi-Cal.

The eligibility determination process automatically reverts to the mail-in application process for Medi-Cal.

MEDI-CAL APPLICANTS CANNOT BE DENIED FOR FAILURE TO KEEP THEIR SCHEDULED APPOINTMENT FOR AN INTAKE INTERVIEW.

The appointment for a face-to-face interview is not rescheduled,

The SCD 823 must be sent to the applicant allowing 10 calendar days to return the completed application form and verifications.



5.3.3 Medi-Cal Mail-In Applications

Clients may request an application by phone or in-person and/or may complete and return all necessary forms and verifications by mail. The mail-in option is available for adults and families, however an applicant can request a face-to-face interview at any time.

The EW may complete the application forms on behalf of the client through a telephone interview with the client, then mail the forms to the client to be signed, dated and returned.

Reminder:Applicants who have an immediate need for Medi-Cal should be advised to come in to the District Office.

How To Process a Mail-in Application

The application forms are not returned by the requested date, and the EW has exhausted all avenues to obtain them,

The application may be denied for failure to provide the forms/verifications necessary to complete a Medi-Cal eligibility determination.

IF... THEN...



Follow the procedures to process Mail-In applications:

If the Application is...

And, theMC 321 HFP or MC 210 is... Then the EW MUST...

Only for a pregnant woman and/or child(ren) under 19,

COMPLETE, Process for Medi-Cal,

If... Then...

Family income is at or below the FPL limit for their percent Program,

Set up the Medi-Cal case, as the application process is complete.

Family income is over the FPL limit for their percent Program, (i.e., the family will have a share-of-cost),

Send client a “Property Supplement” (MC 322), and “Additional Persons” (MC 371) form to add additional family members and request property/other verifications, and send an FPL/Property Waiver denial NOA.

NOTE: THE MC 322 AND MC371 ARE NOT REQUIRED WHEN THE MC 210 IS COMPLETED.

Forward the MC 321 HFP to SCFHP for Healthy Kids or schedule and appointment with a Certified Application Assistor (CAA) if the family is within income limits and consent has been given.

Complete the approval/denial process as regular Medi-Cal application with due dates, etc.



Only for a pregnant woman and/or child(ren) under 19,

INCOMPLETE, Contact the client by phone if possible and/or send the Verification Checklist to the client explaining what is needed to complete the application and give them a due date.

If the client... Then...

Provides what is needed, and family income is at or below the FPL limit for their percent Program,

Approve Medi-Cal as the application process is complete.

Provides what is needed and family income is over the FPL limit for their percent Program, (i.e., the case will be share-of-cost Medi-Cal)

Send the “Property Supplement” (MC 322), and “Additional Persons” (MC 371) forms to request property and/or other verifications along with an FPL/Property Waiver denial NOA.

NOTE: The MC 322 and the MC 371 are NOT required when the MC 210 is completed.

Forward the MC 321 HFP to SCFHP for Healthy Kids or schedule an appoint with a CAA if family income is within the FPL limit and consent has been given.

Does not provide what is needed,

Complete the approval/denial process as regular Medi-Cal application with due dates, etc.





[Refer to “Healthy Kids,” page 5-63 for information on referrals to Healthy Kids.]

[Refer to “Applications from the Single Point of Entry (SPE),” page 5-65.]

Requests for Cash Aid and/or CalFresh

Persons applying for cash aid and some CalFresh applicants must apply in person. The mail-in option is available to all Medi-Cal applicants and certain elderly and disabled CalFresh applicants.

Intake Packet

Both the MC 210 and the MC 321 HFP can be used with the mail-in process. A postage paid envelope, the “Medi-Cal Application Coverletter” (SCD 93 A, B, C, D), the appropriate intake packet and informing notices must be given or sent to the client. [Refer to Common-Place Handbook, “Mail-In Applications,” page 59-5.]

Reminder:The MC 219 must be sent to the applicant but does NOT have to be signed or returned by the client. It must be documented in the case that it was sent.

Not only for a pregnant woman and/ or child(ren) under 19,

(i.e., another adult in the household wants Medi-Cal)

COMPLETE OR INCOMPLETE,

Determine eligibility for the child(ren) and/or pregnant woman, if any, without delay.

Do NOT require information/verifications other than what is necessary for the child or pregnant woman’s eligibility. Pregnant women and children take priority and their eligibility is not to be held up to process other family members who may be applying.

Send the “Property Supplement” MC 322 and “Additional Persons” (MC 371) to add additional family members and request property and/or other verifications as needed. Note: The MC 322 and MC 371 are NOT required when an MC 210 is completed.

Follow up approval/denial process as regular Medi-Cal application with due dates, etc.





Additional Information/Verifications Needed

Review the application for completeness. If additional information is needed to determine eligibility, and the client/family has an open case or a case that has been closed within the last 45 days, the EW must:

• Use information/verifications in the case file when available.

• Follow SB 87 requirements when requesting information if necessary information is not in the case file. [Refer to “Ex Parte Review Process,” page 8-4.]

Minor Consent

A mail-in application may NOT be used when applying for Minor Consent Services.

Forms Not Returned

The due date for application forms to be returned by mail is 10 calendar days from the date the applicant receives the forms. When application forms are not received by the due date, the designated district office staff is to follow these procedures:

If... Then...

The application forms are returned, Assign the case to an EW for processing.

The applicant does not keep their scheduled appointment for the intake interview or return their forms by the due date,

A designated person sends the SCD 823 allowing the applicant an additional 10 calendar days to complete and return the application.

The application forms are not returned by the second due date,

A designated person initiates a phone contact with the applicant to determine if assistance is needed to complete the application process.

If the phone contact is unsuccessful, OR the applicant has not indicated a desire to complete the application process OR the application forms have still not been returned,

Assign the application to an EW for the appropriate denial.

SCD 883

An informing notice must be sent by designated clerical staff within 5 working days from the date a mail-in application is received from persons who have had no personal contact with our agency. The SCD 883 notice informs the applicant or AR that their application has been received, and includes a contact number for information and questions. This includes, but is not limited to, applications from the



Single Point of Entry (SPE) or from community-based organizations, etc. [Refer to “Applications from the Single Point of Entry (SPE),” page 5-65 for additional information about processing mail-in applications from SPE.]

5.3.4 “Application for Cash Aid, CalFresh, and/or Medi-Cal Assistance” (SAWS 1) Requirements

Medi-Cal applicants are not required to sign the SAWS 1; however, a signature is required if the application is filed in person, or by someone who is acting on behalf of the applicant.

The SAWS 1 is NOT required when using the “Application for Medi-Cal” (MC 210) or the “Joint Application for Children and Pregnant Women” (MC 321 HFP), except to preserve the beginning date of aid. A SAWS 1 and coversheet is used as follows:

IF... THEN...

The applicant picks up an application from a District Office through contact with agency staff,

The agency staff person is responsible for obtaining a SAWS 1 at the time the request for an application is made. A copy of the SAWS 1 must be given to the applicant.

The applicant requests an application by phone,

The person taking the phone request is responsible for completing and signing the SAWS 1 on behalf of the applicant. A copy of the SAWS 1 must be mailed to the applicant with the Intake packet.

The application is received without any contact with agency staff,

A SAWS 1 is NOT required. The SCD 883 must be sent by the designated clerical staff within 5 days from the date the application is received to notify the applicant that the application has been received and includes a phone number for information and questions.

Attach the copy to the application and assign to Intake. The date of application is the date the application form is received by the agency. For SPE applications, the date of application is the date it is received at SPE. This date is indicated on the Transmittal form and on the MEDS INQP screen.

Note:Document the “County Use Section” of the SAWS 1 that the coversheet was given/sent to the client.



5.3.5 When a SAWS 1 is Not Required

A new SAWS 1 is NOT required for:

• Requests for restoration of aid• Requests to add a person to a Medi-al case• Interprogram transfers• Interprogram status changes• Redeterminations• Applications from Food Stamp RECIPIENTS who complete and sign the form

“Good News for California Families” (SCD 90).• Applications received with no direct client contact with agency staff, including:

• Applications received from the Single Point of Entry (SPE)

• Access for Infants and Mothers (AIM) applications denied due to income below 200% of the FPL and are forwarded to our agency to be processed as applications for Medi-Cal for pregnancy related services only.

Exception:A newborn may be covered by the mother's full-scope card for the month of birth and the following month. If otherwise eligible, the newborn must be issued his/her own full-scope card as soon as possible. A SAWS 1 is NOT required to add a newborn; however, a SAWS 1 is required when the newborn turns one year old if there are no other family members eligible for Medi-Cal. A new MC 210 is not required if there is one on file which was completed within the last 12 months. [Refer to “Overview - Continued Eligibility for Pregnant Women and Infants,” page 22-1.]

5.4 Informing Requirements

The following information must be provided to clients:

• The rights and responsibilities form, “Information for Persons Requesting Medi-Cal” (MC 219). Document that it was given/sent to the client. The client is not required to sign and/or return it.

• The “Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives” (DHS 7068) must be completed and signed by the beneficiary representative.



• Scan the original copy in IDM, and• Give a copy to the applicant/recipient.

• The “Medi-Cal General Property Limitations for All Medi-Cal Applicants” (MC 007) must be reviewed with applicants, and applicants must be informed of:

• The appropriate property limits.

• How property is exempted, counted and valued.

• Their right to reduce nonexempt excess property within the month of application.

• Options of how excess property may be reduced, and how adequate consideration may be obtained to establish eligibility for the month Medi-Cal is requested.

• If the client declares other health, dental or vision insurance, the correct other health coverage (OHC) code must be posted on MEDS. For mail-in applications, the EW may contact the client by phone to obtain the necessary information.

• If the client declares a pending lawsuit due to accident or injury, the EW must ask the client to complete form CWC 6041. [Refer to “Third Party Liability,” page 14-1 for more information.]

• “Your Rights Under California Welfare Programs” (PUB 13) must be given to the applicant or to the authorized representative.

• “Women, Infants and Children” (WIC) information must be given to pregnant women and to families with children. (Included in CalWORKs and Medi-Cal Family Intake packets).

• The purpose, provision and availability of “Child Health and Disability Prevention” (CHDP). CHDP brochures are included in CalWORKs and Medi-Cal Family Intake packets. The brochure describes support services (scheduling and assistance with finding transportation) provided by CHDP as well as how and where services are provided. The correct information must be entered in CalWIN to ensure a referral reaches the CHDP unit.

Note:The Prenatal Care Guidance Program is available to pregnant women through CHDP. This program focuses on informing, motivating and assisting pregnant women with early and appropriate care. EWs should advise pregnant applicants and recipients about this program and refer them to CHDP for guidance. The correct information for a referral must be entered in CalWIN.



5.5 Date of Application [50151, 50181]

The application date is one of the following:

• The date the SAWS 1 is received/completed by the county taking the application.

• The date that the Single Point of Entry (SPE) received and recorded the initial application.

• The date the completed and signed form “Good News for California Families!” (SCD 90) is received by the county.

• The date of request for Medi-Cal when adding a family member to a case.

Exception:When adding a newborn,” the date of application is the date of birth.

• The date that any of the following forms are initially received by the county (when there has been no client contact with agency staff or SPE):

• “Application for Medi-Cal” (MC 210)

• “Joint Application for Children and Pregnant Women” (MC 321 HFP)

• “Access for Infants and Mothers” (AIM) Application

• “Healthy Families Annual Eligibility Review” (AER) form

• “Additional Family Members Requesting Medi-Cal (MC 371).

Note:The date of application will be the earlier of the above dates if both a SAWS 1 and any other acceptable Medi-Cal application form are received separately.



5.6 Persons Who May Represent the Client

5.6.1 Authorized Representatives

Who Can be Designated

Applicants who are competent to handle their affairs and understand their responsibilities may designate in writing an individual to accompany, assist and represent them in the Medi-Cal application, redetermination or appeals process. This person is often referred to as an “authorized representative” (AR), and may be:

• A family member,• A friend,• A representative of an organization,• A legal aid staff member, or• Any other person the client chooses.

Note:Medi-Cal regulations do not prohibit a provider or provider’s representative from serving as an AR for the applicant, although it may appear inappropriate for an employee of a provider (who has a financial stake in the eligibility of a client) to be an AR. EWs must ensure that clients understand that they have a free choice to designate any person as the AR, and that designation of a provider representative as AR is not mandatory in order to receive medical services.

The client may select an organization, law firm or group as an AR.

Client Responsibilities

Applicants who are competent to handle their affairs and understand their responsibilities must complete and sign the application for Medi-Cal. Authorized representatives may not appear for, sign the application for Medi-Cal form, or otherwise act in lieu of a competent client.



AR's Role

The authorized representative may:

• Accompany the applicant/beneficiary if a face-to-face interview is requested or required at application or redetermination.

• Assist the client in understanding and answering questions during the interview.

• Help the client obtain required verifications at application and redetermination.

• Obtain information from the EW or DDSD regarding the status of the application.

• Provide medical records and other information to the EW and DDSD for a disability evaluation.

• Review the client’s case record with or without the client being present.

• Obtain copies of non-confidential documents from the case record if requested.

• Accompany and assist the client in the appeal (fair hearing) process, and

• Receive a copy of a specific Notice of Action from the EW at the request of the client.

Note:EWs are not required to provide the AR with copies of speedletters, respond to informal requests for information, etc. However, the EW must provide an AR who is representing the client in an appeal, copies of any correspondence sent to the client regarding the appeal or request for an appeal. Send copies to the client and the AR at the same time.

AR Limitations

The authorized representative may NOT:

• Attend a face-to-face interview in lieu of the client.

• Complete the application for Medi-Cal for the client.

• Represent the client in other continuing eligibility activities when the client is competent or there is a spouse able to handle his/her affairs.



• Receive Notices of Action (NOA) other than in conjunction with a hearing unless the client has requested that a specific NOA be sent to the AR.

• Receive the client's Benefits Identification Card (BIC).

• Receive a Letter of Authorization (MC 180) if the AR is an organization, law firm or group.

The above limitations do not apply to incompetent clients in LTC facilities.

[Refer to “Who Can Complete the Statement of Facts Form,” page 5-23 for additional information.]

5.6.2 Public Guardian

The Public Guardian is a government representative who has court appointed authority. Their ability to act on behalf of a client is not limited to those activities defined under “AR’s Role”. A Public Guardian may complete and sign the application for Medi-Cal form and receive the BIC card on behalf of someone who is conserved.

5.6.3 MC 306 and Other Written Authorization

The “Appointment of Representative” (MC 306) may be used as written authorization when a client wants to designate an AR to assist in the Medi-Cal application or redetermination process. The MC 306 is not required and may be substituted with any authorization form of the authorized representative’s choice.

EW’s must accept any form of written authorization that an applicant or beneficiary signs and dates that permits another individual to assist them in the application and attainment of Medi-Cal benefits.

Written Authorization

• Is to be used only for competent applicants and recipients. (Persons determined to be “incompetent” are not able to designate another individual as their AR.)

• Is used primarily by non-family members who are interested only in the approval of Medi-Cal benefits.

• Is not necessary in order for applicants to have a family member or friend accompany and assist them at a face-to-face interview.



• Can be event-limited, such as for an application, a redetermination or an appeal. If the written authorization is event-limited then ongoing case management is not permitted.

• Is not an all-inclusive release of information form, and therefore does not allow the AR to obtain information directly from other sources.

Example:An AR may not use the written authorization to contact the client's bank regarding an account balance.

• Does not authorize the AR to receive a Letter of Authorization (MC 180) for a medical service over one year old.

• Does not authorize the AR to complete the application for Medi-Cal or request a face-to-face interview without the applicant. ARs representing competent individuals cannot act in lieu of the client. Competent individuals must sign the application for Medi-Cal and participate in a face-to-face interview if required.

• Does not have to be completed in the presence of the EW, although the EW must ensure that the client understands the purpose of the form.

• Cannot be accepted when an organization, law firm or group is named unless an individual from the organization, law firm or group is also named as a contact person.

• May be accepted via FAX or photocopy. However, the original document must be obtained within a few days. EWs may accept a photocopy of the written authorization as the original if it has an original signature and date of both the client and the AR.

• Must be completed each time the person designated to represent the client changes.

Example:John Smith from AAA Lawyers, Inc. has left the firm. He is replaced by Joe Johnson as the client's AR. Joe Johnson may represent the client only after a new written authorization is completed. Although Joe and John are employed by the same firm, the individual representative must be designated on the written authorization.



Signature and Date

The written authorization may be signed and dated by the client and the AR several days apart (The effective date is the later date).

Note:If the authorization is signed and dated by the client more than two weeks before the AR signed and dated it, the EW must:

• Contact the client to determine if he/she is aware that the AR is acting on his/her behalf and that the client has in fact designated the AR, and

• If the client is not aware of or has not designated the AR, the EW must revoke the authorization and advise the client of their right to designate an AR of choice and give them an MC 306 if they choose to use that form.

Notices of Action

EW’s are not obligated to issue NOAs on a routine basis to anyone other than the client.

Exception:The EW is required to provide copies of all NOAs to the AR in conjunction with a Fair Hearing if the EW has notification that the AR is authorized to represent the client.

In other situations the EW must use good judgement to decide if a NOA should be sent to the AR at the same time it is sent to the client. If a client does not speak or read English and the NOA is in English, the EW should send a copy of the NOA to the AR so the client is not adversely affected due to circumstances beyond his/her control.

Multiple ARs

The client may have any number of persons acting as his/her AR. However, each person must be designated on a MC 306 or other written authorization and the client and the AR must sign each form.

Expiration of Authority

The appointment of the Medi-Cal applicant’s or beneficiary’s AR is in effect until the applicant or beneficiary;



• Cancels or modifies the authorization,

• Appoints a new AR,

• AR informs the agency that he or she is no longer acting in that capacity, or

• There is a change in the legal authority on which the authority was based.

Note:These limitations do not apply to applicants or recipients who are incompetent or who are unable to handle their own affairs. [Refer to “Who Can Complete the Statement of Facts Form,” page 5-23]

5.6.4 Family Members

Some applicants or recipients want family members to assist in the eligibility determination process at application, redetermination or at any other time.

EWs must be lenient in allowing family members to provide help when requested by clients. Family members most often have an ongoing interest in the affairs of the client, whereas an AR is usually a non-family individual who has no interest in the client other than the approval of Medi-Cal benefits. This distinction is important, and one which EWs must consider when determining whether a person may assist a client beyond the application and redetermination process.

Example:Susie Smith wants her sister to help clarify for the EW questions regarding unreported earnings indicated on an IEVS report. At Susie's request, the EW must allow the sister to attend the interview scheduled with Susie to explain the IEVS information. Susie's sister is not an authorized representative and therefore is not restricted to only providing assistance during an application, redetermination or an appeal.

Example:GHA Financial Services assisted Hector Johnston in completing a Medi-Cal application. GHA Financial Services, as Hector's authorized representative, completed an MC 306 in 4/03 at the time of Hector's Medi-Cal application. In 7/03, the EW questions Hector about unreported earnings reported through IEVS. Hector has asked GHA to accompany him at the 7/20/03 interview scheduled with the EW. GHA agrees, indicating an MC 306 is on file. GHA may NOT assist the client in resolving the earnings discrepancy, as its authority to help the client expired when the Medi-Cal application was approved in 4/03.



In all situations, EWs must ensure confidentiality of client information. Client information is released to family members only with client's specific knowledge and consent. Due to its limited scope, the MC 306 is not the appropriate form to use when a family member is assisting the client.

5.6.5 Representative Payees

A Representative Payee is a person who is assigned by Social Security Administration to SSI recipients who are not capable of handling their own affairs. (Representative Payees may also be designated for beneficiaries by other governmental agencies.) The Representative Payee receives and manages the benefits for the recipient.

ARs for Medi-Cal clients are individuals designated only to assist another person in the Medi-Cal application, redetermination and appeals process. As the authority of a Representative Payee and that of an authorized representative differ, the limitations of ARs to act on behalf of clients do not apply to Representative Payees.

5.6.6 Durable Powers of Attorney

Eligibility Workers may encounter individuals who have obtained Durable Powers of Attorney (DPA) which enables them to act as Authorized Representatives (AR) for clients. These persons may present DPA documents to EWs and indicate their intent to act in lieu of the Medi-Cal client.

This section provides information regarding an AR with Durable Powers of Attorney and the Medi-Cal policies pertaining to them.

Definition

A power of attorney, as defined in Senate Bill 1907, is a written instrument that is executed by a person having the capability to enter into a contract, and that grants authority to an attorney-in-fact.

A durable power of attorney contains a clause which states that it will not be affected by the incapacity of the principal, or it may state that the DPA will become effective at the time the principal becomes incapacitated (Civil Code Section 2400).

• The principal is the person who appoints the attorney-in-fact.

• The attorney-in-fact is the person who is authorized to act on behalf of the principal.



Types of Durable Powers of Attorney

There are two types of durable powers of attorney:

• Durable Power of Attorney for Property Management (DPAP) which authorizes an attorney-in-fact to handle an individual's financial affairs; and

• Durable Power of Attorney for Health Care (DPAHC) which allows an attorney-in-fact to make health care decisions for a person who is unable to act on his or her behalf, i.e., comatose, incompetent, etc.

For purposes of obtaining Medi-Cal benefits, Durable Power of Attorney for Property Management (DPAP) is required.

Conditions of Durable Powers of Attorney

• Anyone with the ability to enter into a contract may appoint an attorney-in-fact.

• A DPAP is valid only when executed by a COMPETENT adult.

• Civil Code Section 1556 prohibits a DPA from being executed by a minor, a person of unsound mind, or a person deprived of civil rights (incarcerated or institutionalized).

• The DPAP may become effective immediately upon its execution, or it may not become effective until the principal becomes incompetent.

State Policy

Any competent adult may designate an AR, with or without a DPAP document, to assist him or her in the Medi-Cal application or redetermination process.

EWs must treat ARs with DPAP the same as an AR without DPAP. An signed letter or MC 306 must be on file for a non-family member AR with or without DPAP. The assistance of an AR with or without DPAP is limited to:

• Completing the initial application for benefits (SAWS 1),• Assisting the applicant in the interview, and• Helping the client obtain verifications.

Durable powers of attorney does not give a person any additional authority to act on behalf of a Medi-Cal client. ARs with DPAP must be allowed to assist the client wherever necessary, but are not entitled to act in lieu of the client.



Specifically, an AR with a DPAP document may not:

• Complete and sign the application for Medi-Cal for the client,• Complete the face-to-face interview (if requested or required) for the client,• Accept responsibility for the Medi-Cal client to report any changes that may

affect eligibility.

Expiration of Authority

The time period in which the AR, with a DPAP document, may act on behalf of the competent applicant or recipient ends either:

• One year from the date the AR agreement is signed, or• When the client revokes the AR at any time, either orally or in writing.

5.7 Who Can Complete the Statement of Facts Form

5.7.1 Who Must Complete

The MC 210, or any other Medi-Cal Statement of Facts form, must be completed by the applicant or spouse UNLESS:

• The applicant has a conservator, guardian or executor who should complete the form, or

• The applicant is incompetent, comatose or has amnesia and does not have a spouse, conservator or guardian. IMPORTANT: [Refer to “Persons Who May Represent the Client,” page 5-15 for complete information about who can represent the client and the requirements for persons who are representing an incompetent client, LTC, etc.]

• A child who is an applicant must complete and sign the MC 210 if either of the following applies:

• No person or agency accepts legal responsibility for the child.

• The child is applying for Minor Consent Services. [Refer to “Minor Consent,” page 39-1.]



5.7.2 Applications from Non-Custodial Parents

Non-custodial parents may file and sign a Medi-Cal application form for a child, but the non-custodial parent cannot complete the Statement of Facts form for his/her child unless the custodial parent is incompetent, comatose or suffering from amnesia. Generally, the person or agency having legal responsibility for the child is to complete and sign the Statement of Facts.

Statement of Facts Form

Medi-Cal eligibility is based on the circumstances of the custodial parent who has care and control of the child. The MC 321 HFP, MC 210 or any other Statement of Facts form serves as BOTH an application (SAWS 1) and a Statement of Facts form; therefore, the following rules apply:

Note:The MC 321 HFP is referenced below as it is the most common Statement of Facts form used for families with children; however, these rules apply to any other Statement of Facts form used.

• When the MC 321 HFP is completed and signed by the non-custodial parent, it must be used as an application (SAWS 1) only, not the Statement of Facts form.

• When a SAWS 1 or MC 321 HFP is signed by the non-custodial parent, the EW must obtain an MC 321 HFP, MC 210, SAWS 2 etc., from the custodial parent.

Note:If the non-custodial parent completed an MC 321 HFP with information about the custodial parent, it may be given or sent to the custodial parent for his/her review and signature; or, the EW may request a new Statement of Facts form from the custodial parent.

• Once the MC 321 HFP is received, the EW sends the child’s Medi-Cal benefits and any notices of action to the custodial parent.

Confidentiality

The following restrictions regarding confidentiality apply to the child’s parents:

• Information provided by the non-custodial parent that is needed to determine Medi-Cal eligibility can be shared with the custodial parent; however, information from the non-custodial parent that isn’t needed for purposes of the eligibility determination must be kept confidential.



• Information from the custodial parent cannot be shared with the non-custodial parent.

Denial NOAs

When the non-custodial parent has applied for/requested Medi-Cal on behalf of his/her child and the application is denied, the EW must determine which parent is to receive the denial notice.

• If the custodial parent fails to respond or doesn’t return the Statement of Facts form, send the denial notice to the non-custodial parent because the custodial parent did not complete the Statement of Facts.

• If the custodial parent completes and returns the Statement of Facts, but doesn’t provide requested information or verifications, send the denial notice to the custodial parent.

• If the children are already receiving Medi-Cal, send a denial notice to the custodial parent stating that an application was made on behalf of the child(ren) and that it was denied because the children are already receiving Medi-Cal.

5.8 Timeframes for Processing Applications

5.8.1 Application Processing

The determination of eligibility and share of cost, if any, must be completed within 45 days of application; except, when determination depends on establishing disability or blindness, the limit is 90 days.

If the application cannot be processed within the required time limit, there must be good cause and it must be documented. The extended time must not exceed three months from the application date.

5.8.2 Immediate Need Criteria

If the applicant has an immediate medical need, the EW must expedite the Medi-Cal eligibility determination within available resources.



Pregnant women and/or persons with a medical emergency are to be given priority appointments, it there is an available appointment. Pregnancy, in and by itself, constitutes an immediate medical need. There are no specific hours or days specified as “expedited” like CalWORKs and CalFresh regulations. CalWORKs and CalFresh applicants are scheduled ahead of regular Medi-Cal only applicants if appointments are available.

Note:These requirements apply whether or not a woman intends to terminate the pregnancy.

5.8.3 Beginning Date of Eligibility

Medi-Cal Only

The beginning date of eligibility for persons applying for Medi-Cal only is the first day of the month:

• Of application, or date of request to add a family member to an ongoing case, if all eligibility requirements of the appropriate Medi-Cal program are met within that month, OR

• Subsequent to the month of application, in which the eligibility criteria of the appropriate Medi-Cal program are met.

Note:For the purposes of this section, eligibility requirements are considered to be met for the entire month if they are met at any time during the month, except for persons detained under the penal system.

Cash Based Medi-Cal

The beginning date of Medi-Cal eligibility for persons who apply under any public assistance program is the first day of the month of application, regardless of the beginning date of the cash grant, providing the person meets the following criteria:

• Citizenship• Residency• Linkage• Financial eligibility.



For persons who do not meet these eligibility criteria during the month of application, the beginning date of eligibility for cash based Section 1931(b) Medi-Cal is the first day of the first month in which the above criteria are met.

Note:When cash based Medi-Cal is established in a month subsequent to the month of application, Medi-Cal Only eligibility requirements must be explored for the month of application.

CalWORKs Denials

The beginning date of eligibility specified above also applies to a CalWORKs applicant who meets eligibility requirements in the month of application but whose application is denied because they no longer meet eligibility requirements at the time CalWORKs eligibility is determined.

SSI/SSP Denials

The following rules apply to persons whose SSI/SSP application has been denied:

• When a person applies for Medi-Cal within 30 days of receipt of an SSI/SSP denial notice, the original SSI/SSP application date must be used.

• If more than 30 days have elapsed since receipt and the person applies for Medi-Cal, the application date is the date the SAWS 1 or other acceptable application form is received by the County.

Note:When determining Medi-Cal eligibility for SSI denials due to excess income, the original SSI/SSP application date must be used.

[Refer to “Date of Application,” page 9-18 for complete information on SSI denials]

5.8.4 Application Not Filed in the County of Residence

In the event that a county which is not the county of residence receives an application, the receiving county must date stamp the application and forward it to the correct county as soon as administratively possible. The receiving county must use the date stamp from the sending county as the date of application.



5.9 Period of Eligibility [50783]

5.9.1 Definition

The period of eligibility for:

• Cash Aid recipients (i.e., CalWORKs, SSI/SSP, RCA), continues through each successive month in which the person is determined to be eligible.

• Other PA recipients (i.e., Four Month Continuing and TMC Eligibility, In-Home Supportive Services, Title II disregard [Pickle]), is the period in which they meet all eligibility requirements of the program.

Note:[Refer to “Medi-Cal Programs [50201, 50203, 50227],” page 20-1 for general program eligibility requirements.]

• Medi-Cal Only recipients, except Minor Consent Services, is the period in which they meet all eligibility requirements of the program.

• Minor Consent Services, the period of eligibility must continue through each successive month in which they meet both of the following:

• The eligibility requirements of the program, and• They submit a completed and signed form MC 4026 to their EW, which states

the need for Minor Consent Services.

• A person in institutional status, the period of eligibility is modified for any portion of a month in which a person is ineligible due to that status as described. [Refer to “Institutional Status [50273],” page 43-1.]

• A person or family who will no longer meet all eligibility requirements as of the first of the following month, the final date of eligibility is the last day of the:

• Current month, if the discontinuance is not an adverse action (i.e. deceased, no longer a CA resident, client requests discontinuance, etc.)

• Current month, if the discontinuance is an adverse action and the ten day advance notice requirements will be met in the current month (i.e. no longer eligible for Medi-Cal, increase in share of cost, etc.)



• Following month, if the discontinuance is an adverse action and the ten day advance notice requirements will not be met in the current month.

5.9.2 Withdrawals/Requests for Discontinuance [50155]

A client may withdraw an application for or request discontinuance from Medi-Cal by any of the following:

• Completion of the MC 215 (Scan into IDM and give a copy to the applicant.)

• Submitting a signed written request specifically designating Medi-Cal. The signed request should be scanned into IDM.

Note:The client must indicate that they clearly understand the process by signing the withdrawal form. A withdrawal/request for discontinuance should be a free and willing decision based on an understanding of all available information. The client should feel satisfied that he/she made the right decision.

• Failing to respond to a Notice of Action which requests that the client contact the County to indicate a desire to continue eligibility.

5.10 Retroactive Medi-Cal [50148, 50197, 50710]

An applicant for Medi-Cal, CalWORKs, SSI/SSP, or RCA may be eligible to receive Medi-Cal for any of the three months immediately preceding the month of application. For SSI/SSP applicants, the application date is the same date as the SSA application date, even if SSI/SSP is never approved for the month of application.

Note:The application date can be obtained from the [SDX3] screen in MEDS.

5.10.1 Applications

Eligibility for retroactive Medi-Cal must always be explored at the point of intake. A person applying for retroactive Medi-Cal must:



• Submit a completed application form (SAWS 1) if the application is for retroactive coverage only. In addition, an MC 210 or any other acceptable Medi-Cal application/Statement of Facts form must be submitted for one retro month and a “Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210 A) for the two other months.

Exception:An applicant for SSI/SSP is not required to submit an MC 210.

• Submit an MC 210 A for the retro months if the request for retroactive Medi-Cal is made in conjunction with or after, an application for public assistance or Medi-Cal. An MC 210, MC 321 HFP, SAWS 2 or any other acceptable Medi-Cal application form must have been completed for the current application.

Note:For SSI/SSP applicants, EWs are to request only information and documentation that is not available through MEDS/SDX Inquiry screens and is necessary to determine eligibility.

Any written request for retroactive coverage must be considered an application. An application for retroactive Medi-Cal may be submitted at any time following an application for Medi-Cal. Medi-Cal, however, may not be approved for a month which is more than one year after the month of service.

Example:Mr. Anderson applied for Medi-Cal on 4/1/11. He had medical expenses in January, February and March of 2011, but did not apply for Retro because he thought his insurance would cover the cost. In February 2012, he discovers that his insurance did not pay and applies for Retro. In February 2012, he can be approved for Medi-Cal for February and March 2011 but it is too late for January 2011.

5.10.2 Retroactive Medi-Cal for Mail-In Applications

Anyone requesting retroactive Medi-Cal using the MC 210, MC 321 HFP or any other acceptable Medi-Cal application form must also complete the MC 210 A. The EW must send the MC 210 A when retroactive Medi-Cal is requested. The EW may assist the client by phone completing the MC 210A, then send it to the client for their signature.



Note:For children and pregnant women requesting retroactive Medi-Cal using the mail-in process, the EW must inform the client that the completion of the property questions are not required.

5.10.3 Eligibility Conditions

In order to be eligible for retroactive Medi-Cal, all of the following conditions must be met in each retroactive month:

• The applicant would have been eligible for Medi-Cal had an application been made.

• The applicant received a health care service.

• The applicant was not previously denied Medi-Cal for the month in question unless the denial was due to:

• County error, OR

• The applicant's failure to cooperate, when that failure, or the applicant's subsequent failure to reapply, was due to circumstances beyond the control of the applicant.

5.10.4 Retroactive Medi-Cal for those Age 21 or Older

A person 21 years of age or older is not retroactively eligible as a Medically Indigent person unless either of the following conditions exist:

• The person was residing in a skilled nursing or intermediate care facility during any part of both:

• The month of application.

• The month for which retroactive eligibility is requested.

• The person is a woman with a confirmed pregnancy.

5.10.5 Retroactive Medi-Cal Based on Disability

Persons applying on the basis of disability must have their disability determined prior to approval of retroactive benefits.



For SSI/SSP pending applications, a determination of Medi-Cal under any other program must be made for the retro months.

The Intake Worker must:

• Record an application for retroactive Medi-Cal to be kept pending until the State Programs - Disability Determination Service Division (SP-DDSD) determination is received.

Exception:Do not send a referral to DDSD for SSI applicants until a final disability determination has been completed by SSA. Advise the applicant to call our Agency as soon as an award or denial letter is received. EWs are to review MEDS/SDX screens periodically to obtain this information.

[Refer to Medi-Cal Update 2011-08 “Procedures,” page -2]

• Determine eligibility for the retro period.

Note:Approximately 1/3 of the persons referred are determined disabled.

• Determine eligibility for each retro month.

• Transfer the case to Continuing in “pending” status.

The Continuing Worker must:

• Issue a Medi-Cal card and approval notice when the disability determination is received.

• Revise the budget if the applicant is determined to be disabled.

5.11 Determining Medi-Cal Eligibility [50153]

Medi-Cal

Determine the program for which the applicant or family may be eligible. The client/family may choose to have the application processed under any program for which they are eligible even if the program is not the most advantageous.



Exception:Due to limitations in federal law, a 1931(b) eligible person may NOT choose to have their application processed under the AFDC-MN program.

Example:A disabled person with another linkage to Medi-Cal (e.g. deprived children), may choose to have their application processed under the AFDC-MN program instead of the ABD-MN program. (No federal limitations apply.)

Healthy Kids

If a child under age 19 is ineligible for no-cost Medi-Cal, EWs must explore eligibility for the HEALTHY KIDS Program. The net non-exempt family income must be at or below 300% of FPL, and the child CANNOT be eligible for zero share-of-cost, full-scope Medi-Cal, including TLICP. [Refer to Chart Book, Chapter 5, for current net non-exempt monthly income limits.]



SSI/SSP

Refer persons who may be eligible for SSI/SSP to the Social Security Administration for a determination of SSI/SSP eligibility with an SCD 169, unless they refuse.

• Scan the SCD 169 in IDM.• Determine if the client is eligible for any other Medi-Cal Program, pending the

SSI/SSP determination.

CalWORKs

Explore eligibility for a CalWORKs cash grant and advise the applicant if he/she is potentially eligible.

• Process the CalWORKs application, or complete an “Informal Application Refusal” (SCD 166) if they refuse.

• Scan the SCD 166 in IDM to document that the applicant was advised of potential CalWORKs cash grant eligibility.

5.12 EW Follow-Up Actions

If an applicant or their representative requests information about other programs (e.g. CHDP, In Home Supportive Services/Personal Care Services, etc.) or a referral for any services, the EW must ensure the request is met and document the action(s) taken in the case.

Eligibility requirements for the Medi-Cal program have not changed. Each case, whether the application is filed in person, by mail-in, or forwarded by SPE, must contain adequate information and supportive documentation to verify eligibility.

• Verification of identity, residence, immigration status, income and/or property are part of the eligibility determination process.

• Social Security Number(s) (SSN) must be provided as appropriate, however a copy of the Social Security card is not required, unless the SSN cannot be verified through the IEVS process.

• Income must be verified for ALL Medi-Cal applications. The EW may accept:

• One paystub as verification of income.



• If the paystub submitted accurately reflects the income reported on the application, DO NOT request additional income verification.

• If there is a discrepancy between the paystub submitted and the amount reported on the application, additional paystubs/verification may be requested.

• A copy of last year’s federal Income tax return (Divide gross income by 12) if the tax return reflects the income amount declared on the statement of facts form.

Reminder:Currently reported income is used to determine Medi-Cal eligibility. Income is no longer “anticipated” so verification and/or clarification of future income is not required.

5.13 “Application for Medi-Cal” (MC 210) [50159, 50161]

5.13.1 MC 210 and the SAWS 1

An MC 210 is a dual purpose form. It is both an “application” for Medi-Cal and the “Statement of Facts” form. The SAWS 1 is not mandatory, but is used to preserve the date of application when Medi-Cal is requested in-person at a district office, or a request for Medi-Cal is received by phone. It is not required when there has been no direct client contact, such as applications received from Single Point of Entry.

5.13.2 When Used

The MC 210 is used for ADULT-only applications to determine Medi-Cal eligibility and share of cost. It can be used for a face-to-face interview or for the mail-in process.

The MC 210 is also used for a child requesting Minor Consent Services.



5.13.3 When the MC 210 is NOT Used

The MC 210 is NOT used for the following persons or situations:

• Pregnant women and families with children under 19, use the “Joint Application for Children and Pregnant Women” (MC 321 HFP).

Note:The MC 210 may be used for pregnant women and children, however agency policy is to use the MC 321 HFP. If the MC 210 is used, do NOT require the applicant to complete the MC 321 HFP.

• Foster Care children (MC 250)

• Former Foster Care children (MC 250 A) when there has been a break-in-aid

• Food Stamp Applicants/Recipients who are applying for Medi-Cal, the DFA 285 A2 is used if it is current (less than 12 months old) and if there is sufficient information.

• When a current SAWS 2 is on file, AND

• A CalWORKS/FS application is denied and the person wishes to apply for Medi-Cal, OR

• A SAWS 2 has been completed within the last 12 months and the circumstances have not changed to such a degree as to require a new application for Medi-Cal.

• For retroactive Medi-Cal (months prior to the month of application).

Note:If the client is ONLY applying for retroactive Medi-Cal, the MC 210 or any other acceptable Medi-Cal application form must be used for one retro month and the MC 210A is completed for the second and third retro month(s), if requested.

5.13.4 Completion of MC 210 Supplements

Sometimes the EW must obtain additional and specific information beyond what is asked on the MC 210. When this occurs, supplements to the MC 210 must be used to capture all required information.



The following is a list of the supplemental forms:

• “Additional Children” (MC 371) • “Student Educational Expenses” (MC 210 S-E)• “Income In-Kind/Housing Verification” (MC 210 S-I) • “Property Supplement” (MC 210 PS) • “Work History (Earnings and Expenses)” (MC 210 S-W)

EWs must use supplemental forms when a client answers “YES” to questions on the MC 210 about residency, property/resources, income and work history.

MC 210 SUPPLEMENTAL FORMS USAGE

MC 210 S-E This form is given to the client if the MC 210 indicates any family member is attending college or a similar educational institution. Information is requested on whether the client is receiving a grant, scholarship, or loan, and any student expenses or transportation costs. This form is optional. Other school verifications may be used.

MC 210 S-I This form serves two purposes. It:

• Is a MANDATORY form when client must verify free housing or rent paid to a relative, and this is the ONLY evidence of CA residency.

• Is an OPTIONAL form which may be used to verify income-in-kind (including actual in-kind values when the client does not agree with the chart values).

MC 210 PS This form must be completed when a “YES” answer to any of the property questions requires additional information.

MC 371 The form is a mandatory form and is given to a client if he/she has indicated on the MC 210 that the family has more than three children. The information for each child must be filled in completely (except SSN, if applying for restricted benefits for the child).



When supplemental form(s) to the MC 210 are required, they are considered to be part of the MC 210. The client's signature and date is not included on all of the supplements. The certification statement on the last page of the MC 210, which is signed by the client, includes responsibility for information provided on supplemental form(s).

5.13.5 Other Required Forms/Intake Packets

In addition to the MC 210 supplemental forms, the following forms and/or verifications are required depending upon the client’s circumstances such as, but not limited to:

• “Important Information for Persons Requesting Medi-Cal” (Rights and Responsibilities - MC 219). The client’s signature is not required, however it must be documented that it was provided.

• “Statement of Citizenship, Alienage and Immigrations Status” (MC 13) (required for every non-citizen family member age 19 and over who is not pregnant, AND any adult that has not signed a declaration of citizenship.

• Child Support/Medical Support forms (CW 2.1, CW 2.1Q, SCD 95)

• Verification of income and expense deductions,

MC 210 S-W

NOTE: The SC 1707 may also be used.

This form is required to determine:

• Unemployed parent deprivation when both parents are in the home, and

• Which parent is the principal wage earner (PWE). The work histories of both parents in the home are needed to determine which parent is the PWE.

The back page of the form may be to determine who is the primary wage earner (PWE). Only one signature is required (usually the applicant).

Note: When more than one deprivation exists, the client may choose. EW must explain the advantages of each.

This form is also used when any member of the MFBU is employed or self-employed. It asks for information about the job, dependent care costs and whether child and/or spousal support is paid.

MC 210 SUPPLEMENTAL FORMS USAGE



• Immigration status verification within 30 days, and

• Evidence of residency.

Note:Applicants must provide their social security number (SSN) as appropriate, but are not required to submit copies of their social security cards, unless the EW is unable to verify the number provided.

[Refer to Common-Place Handbook, “Medi-Cal,” page 24-11 for a complete list of required forms and informing notices.]

5.14 “Joint Application for Children and Pregnant Women” (MC 321 HFP)

5.14.1 When Used

The MC 321 HFP may be used for families with children and/or a pregnant woman. However, either the MC 210 or the MC 321 HFP is acceptable as an application for Medi-Cal.

Exception:Minor Consent applications must be made in person and the minor is to be given the MC 210.

The MC 321 HFP and the MC 210 are dual purpose forms. They are used as both an “application” for Medi-Cal and the “Statement of Facts” form. The SAWS 1 is not mandatory, but it is used to preserve the date of application when Medi-Cal is requested in-person at a district office, or when a request for Medi-Cal is received by phone. It is not required when there has been no direct client contact, such as applications received from the Single Point of Entry. The MC 321 HFP is used for both walk-in and mail-in applications.

Note:If an adult applicant, without children, completes an MC 321 HFP instead of an MC 210, the EW must provide all required supplements to the applicant, including but not limited to “Real and Personal Property Supplement to



Medi-Cal Mail-In Application” (MC 322), “Statement of Citizenship, Alienage and Immigration Status” (MC 13) if the family includes non-citizens over 19 who are not pregnant, etc.

5.14.2 State Toll Free Number

The MC 321 HFP instructs applicants to call the state Toll Free number listed on the application with questions about Medi-Cal. Since the phone staff is unable to answer Medi-Cal eligibility questions, it is important to ensure that the applicant understands that the Social Services Agency District Office is responsible for answering Medi-Cal questions and/or providing assistance in completing the application forms.

5.14.3 MC 321 Supplements

The following forms are to be included with the MC 321 HFP in order to gather the necessary information for adults/parents.

• “Additional Family Members Requesting Medi-Cal” (MC 371)• “Property Supplement” (MC 322).

Note:If the Medi-Cal application is received through the Single Point of Entry (SPE), these two supplemental forms are NOT included. The EW will need to obtain these forms if adults/parents are requesting Medi-Cal.

5.14.4 Other Required Forms/Intake Packets

All other necessary supplemental forms and informing notices must be issued with the MC 321 HFP.

[Refer to Common-Place Handbook, “Medi-Cal,” page 24-3 for current requirements.]

The “Consent to Exchange/Release Information” (SCD 115) allows specific eligibility information to be shared with our CHI partners, Santa Clara Valley Health and Hospital Systems and Santa Clara Family Health Plan.

Exception:Do NOT release information about medical records or a Minor Consent case.

• The SC 115 must be included in all Medi-Cal family intake packets.



• If the applicant refuses to sign it, information cannot be shared with Health and Hospital Systems or Santa Clara Family Health Plan.

• The SCD 115 is NOT required if a Food Stamp recipient has signed the SCD 90.• The original is scanned into IDM and a copy is given to the client.• It can also be used with CalWORKs cases.

5.15 Benefits CalWIN (BCW)

BCW is a web application that provides the general public and current clients with an easier method to self-screen for potential eligibility and apply for Medi-Cal, CalFresh and CalWORKs. BCW is the web version of the paper application. My Benefits CalWIN allows clients to:

• Apply for benefits or discontinue an application

• Find out if they are eligible for other assistance programs

• Check benefit status and amount

• Submit Periodic Reports or renew benefits online

The retrieval, registering and distribution of the BCW online applications are handled by designated clerical staff. For EWs, the procedures for processing these online applications are basically the same.

[X-Ref to Common Place HB]



5.16 Procedures for Phone-In Medi-Cal Applications

WHO ACTION

Client Calls any District Office and indicates he/she would like to apply for Medi-Cal benefits.

Designated District Office Staff

• Refers the client to the applicable District Office number, or

• Completes the “Application for Cash Aid, CalFresh, and/or Medical Assistance” (SAWS 1) and SC 41.

• Performs preliminary File Clearance procedures to ensure the application is valid.

• Explains to the client that a Medi-Cal packet will be mailed to his/her address.

• Explains that the MC 210 or the MC 321 HFP must be completed and returned in the postage paid envelope provided.

• Instructs the client to mail the applicable verifications listed on the “Papers Needed for your Medi-Cal Eligibility Determination” (SC 1481).

• Date-stamps MC 210 or MC 321 HFP and mails packet to the client.

• Retains a copy of date-stamped SAWS 1.

• Submits SAWS 1 to the Centralized App/Reg Unit for processing.

• Follows established procedures to follow-up on application in 10 days.

If the application is... Then Clerical...

Received within 10 days, Assigns the application to an EW for processing.

NOT received within 10 days, Mails the “Medi-Cal Application 2nd Notice” (SCD 823) to the client with a 10 day due date.

NOTE: If the packet is not received within the 2nd 10 days, sends another notice allowing another 10 days. If no response, assigns to an EW to deny the application.

Client • Receives the packet.

• Completes the paperwork.

• Returns the forms and verifications via U.S. mail (WHERE?).



Centralized App/ Reg Unit

• Receives the completed Medi-Cal application.

• Assigns the case to an EW.

• Forwards application packet to the EW.

Eligibility Worker

• Receives the Medi-Cal application.

• Contacts the client if there are missing verifications.

• Provides the client with the case number and instructs him/her to write the case number on the documents to be provided.

If the client prefers to... Then the EW...

Provide verifications in person,

• Explains to the client to bring in the verifica-tions and have clerical photocopy them, or

• Schedules an appointment for the client to bring the verifications to the EW.

Mail/Fax the verifications, Explains to the client that when the verifications are received, the application will be processed and he/she may be contacted if further verification is needed.

Client • Gathers the necessary verifications.

• Mails or brings verifications to the District Office.

Eligibility Worker

• Receives the necessary verifications.

• Enters information into CalWIN Data Collection windows.

• Runs EDBC and approves or denies benefits.

WHO ACTION



5.17 Procedures for Walk-In Medi-Cal Applications

WHO ACTION

Client Applies for Medi-Cal at a District Office.

Clerical • Receives a request to apply for Medi-Cal.

• Performs a preliminary File Clearance to ensure the application is valid.

If the application is... Then clerical...

Not valid, Refers the client to the correct worker.

Valid, Provides the client with either an “Application for Medi-Cal” (MC 210) or the “Joint Applica-tion” (MC 321 HFP).

• Dates stamps the MC 210 or MC 321 HFP.

• Instructs the client to complete the forms in the lobby and return to the window when they are complete.

Client • Completes the application forms.

• Returns to the window and submits the application to clerical.

Clerical • Receives the Medi-Cal application forms.

• Provides the client with a Medi-Cal Intake informing packet and explains to the client that he/she will need to mail-in the applicable verifications listed on the “Papers Needed for your Medi-Cal Eligibility Determination” (SC 1481).

• Explains that the client may schedule an appointment with his/her Eligibility Worker (EW) when the EW contacts him/her, if preferred, to provide the verifications in person but that it is not required.

• Forwards the completed application to the Centralized Application Registration unit.

Centralized App Reg Unit

• Receives the completed Medi-Cal application.

• Performs the Application Registration function in CalWIN.

• Assigns the case to an EW.

• Forwards the application packet to the assigned EW for processing.



5.18 “Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP” (SAWS 2)

A current SAWS 2 can be used for Medi-Cal when:

• A CalWORKs/CalFresh application is denied and the client wishes to apply for Medi-Cal, or

• A SAWS 2 was completed within the past 12 months and circumstances have not changed that would require a new application for Medi-Cal.

Eligibility Worker

• Receives the Medi-Cal application.

• Contacts the client and requests any additional verifications needed to complete the application process.

• Provides the client with the case number and instructs him/her to write the case number on the documents to be provided.

If the client prefers to... Then the EW...

Come into the office for an appointment,

Schedules an appointment with the client to complete the application process.

Provide the verifications in person,

• Explains to the client to bring in the verifica-tions and have clerical photocopy them, or

• Schedules an appointment for the client to bring in the vivifications.

Forward the verifications via U.S. Mail,

Explains to the client that when the verifications are received, the application will be processed and the client contacted if further verification is required.

Client • Gathers necessary verifications.

• Mails or brings verifications to the District Office.

Eligibility Worker

• Receives the requested verifications.

• Enters information into CalWIN Data Collection windows.

• Runs EDBC and approves or denies benefits as appropriate.

WHO ACTION



Applicants must not be required to complete an additional application/statement of facts form if the information on file is sufficient. A SAWS 1 is used to preserve the date of application for Medi-Cal. EWs must obtain all other required forms and verifications according to the family’s circumstances and provide all mandatory informing notices to the applicant.

Note:If a Minor Parent applies for CalWORKS and is not eligible due to the Senior Parent’s income, only the minor’s child is approved for CalWORKs. If the Minor Parent wants Medi-Cal, the Senior Parent must apply. The Senior Parent must complete a new statement of facts form.

5.19 Use of the CalFresh Statement of Facts as an Application for Medi-Cal

5.19.1 Overview

CalFresh recipients who wish to apply for Medi-Cal may do so at any time. Timely action must be taken on ANY verbal, electronic or written request for Medi-Cal from a CalFresh recipient on an active CalFresh case.This applies to both Intake and Continuing cases. The date of application for Medi-Cal is the date the county is first notified by the CalFresh recipient that Medi-Cal benefits are being requested, or the date the written application is received.

All requests for Medi-Cal must be approved or denied even if there is no apparent evidence of deprivation or linkage. An approval or denial notice of action (NOA) must be sent.

The following forms may be used to determine Medi-Cal eligibility:

• “Good News for California Families” (SCD 90), AND

• CalFresh “Statement of Facts” (DFA 285 A2), OR

• “Non-Assistance CalFresh (NACF) Household Recertification Form” (FS 27).

Exception:If a request for Medi-Cal is received from someone who already has Medi-Cal benefits, a NOA is not required, however the EW must contact the client (by phone or in writing) and explain their eligibility status.



5.19.2 “Good News for California Families!” (SCD 90) Requirements

W&I Code Sections 10618.5 (AB 59) and 18925 (SB 493) require counties to provide an informing notice/application for NACF recipients who are not receiving Medi-Cal. This requirement is intended to expedite Medi-Cal enrollment for parents and their children as well as other adult CalFresh recipients.

The form “Good News for California Families!” (SCD 90) is both a Medi-Cal informing notice and an application for Medi-Cal. It is used for CalFresh RECIPIENTS who are not currently enrolled in Medi-Cal.

5.19.3 Application Process

Initial Intake Applications

Intake EWs are required to explore eligibility for all programs requested and all benefits for which the applicant may qualify. If an applicant requests CalFresh benefits, but not Medi-Cal, the EW must determine if there is potential eligibility for Medi-Cal for anyone in the household (linkage, no health insurance, etc.)

If... Then the Intake EW...

The client is requesting Medi-Cal and CalFresh at the same time,

Provides the appropriate Medi-Cal intake packet (MC 321 HFP/MC 210) and DFA 285 A1, A2 and A3.

CalFresh benefits are active and the client requests Medi-Cal while the case is still in intake,

Asks the client to read and sign the SCD 90, and uses the information on the DFA 285 A2 for the Medi-Cal application, if it is less than 12 months old and it contains sufficient information. Have the client complete any other required Medi-Cal forms, and issue all mandated informing notices.

The client is NOT interested in applying, Ask the client to complete an SCD 166. Document the reason for refusal.

Continuing (Recertifications)

As part of the CalFresh Recertification (RC) process, EWs are to check to see if all members of the CalFresh household are receiving Medi-Cal coverage and explore eligibility for Medi-Cal as follows:

Reminder:If there are children who are not receiving Medi-Cal, check MEDS for eligibility.



• If any household members are NOT receiving Medi-Cal and there is linkage (a child in the home, disabled adult, etc.), mail the SCD 90 to the client with the CalFresh RC packet.

• If Medi-Cal coverage is requested for household members, have the client sign and return the SCD 90.

5.19.4 Processing the SCD 90

• The Medi-Cal date of application is the date the signed SCD 90 is received (date stamped).

• A SAWS 1 is NOT required when the SCD 90 is on file.

• A completed and signed SCD 90 is processed as a mail-in application, unless the applicant prefers to have a face-to-face interview. [Refer to “Medi-Cal Mail-In Applications,” page 5-6 for more information.]

• The MC 219 must be given to the applicant, however a signature is not required. (Document in Maintain Case Comments that it was provided to the client.)

• The 45 (or 90) day timeframes apply to application processing.

• A signed SCD 90 is an application for Medi-Cal, therefore an approval or denial Notice of Action (NOA) is required.

Exception:If a signed SCD 90 is received from someone already on Medi-Cal, a NOA is not required, however the EW must contact the client (by phone or in writing) and explain their eligibility status.

5.19.5 When the DFA 285 A2 or FS 27 is used for Medi-Cal

CalFresh RECIPIENTS are NOT required to complete a separate or additional Medi-Cal application form when requesting Medi-Cal benefits. The “Statement of Facts for CalFresh Benefits” (DFA 285 A2) or the Non-Assistance CalFresh (NACF) Household Recertification Form” (FS 27) may be used to determine Medi-Cal eligibility for CalFresh recipients.



Note:APPLICANTS who are requesting CalFresh and Medi-Cal at the same time must complete a DFA 285 A1, A2, A3 as well as the appropriate Medi-Cal application/Statement of Facts form (MC 210 or MC 321 HFP etc.).

The DFA 285 A2 or FS 27 on file must be used instead of the MC 210 or MC 321 HFP as an application for Medi-Cal if:

• It is received within 12 months, and

• It contains sufficient information to make a Medi-Cal only determination.

• A CalFresh recipient’s request for Medi-Cal must be processed as a Medi-Cal mail-in application, unless the client prefers to come in for an appointment. All other Medi-Cal eligibility determination procedures, mandated forms and regulations remain the same.The chart below explains which application form to use in various circumstances.

IF... THEN...

A CalFresh recipient applies for Medi-Cal, The DFA 285 A2 must be used for the Medi-Cal eligibility determination if it is less than 12 months old and it contains sufficient information.

The DFA 285 A2/FS 27 does not contain sufficient information and/or verifications to determine eligibility for Medi-Cal,

Additional information/verifications must be requested from the client by phone in lieu of the SCD 50; or the client may come into the office.

The CalFresh recipient’s most recent DFA 285 A2/FS 27 is over 12 months old (i.e. aged or disabled FS household with 24 mo. certification period),

An MC 210 or MC 321 HFP is required.

A client is applying for CalFresh and Medi-Cal at the same time,

Both the DFA 285 A2 and the MC 210 or MC 321 HFP must be completed.

An applicant is approved for/active on CalFresh, then later requests Medi-Cal while the case is still with the Intake EW,

The DFA 285 A2/FS 27 must be used for Medi-Cal, as the applicant is a CalFresh “recipient.”

A CalFresh recipient requests Retroactive Medi-Cal,

An MC 210 A must be completed.



5.19.6 Aligning the Medi-Cal Redetermination (RD) with the CalFresh Recertification (RC)

Although the DFA 285 A2/FS 27 may be used to determine Medi-Cal eligibility, the Medi-Cal RD date is NOT based on the date that the form is completed.

• The Medi-Cal RD date must be 12 months from the date Medi-Cal eligibility is established.

• A “Medi-Cal Annual Redetermination” (MC 210 RV) is required at the time the annual RD is due. The DFA 285 A2/FS 27 cannot be used to complete the RD.

Note:The EW may complete the MC 210 RV for the client by phone if requested, then mail it to the client to obtain their signature. However, Medi-Cal benefits cannot be continued until the MC 210 RV is returned.

The CalFresh RC date may be aligned with the Medi-Cal RD date only if the client wishes to.

• The sole purpose of giving the client the option of completing the Medi-Cal RD during the CalFresh RC is to promote retention of Medi-Cal benefits.

• Medi-Cal must NOT be discontinued if client fails to complete the CalFresh RC.

Example:An active CalFresh household requests Medi-Cal benefits on 10/12/12. The EW uses the DFA 285 A2 on file dated 08/16/12 to establish Medi-Cal eligibility and documents that Medi-Cal eligibility is granted in October 2012. The Medi-Cal RD is due is September 2010, while the CalFresh RC is due in August 2010. The EW sends the client both the CalFresh RC packet and the Medi-Cal RD packet in hope of aligning the Medi-Cal RD with the CalFresh RC date. If the client fails to complete the RC in August 2013, CalFresh benefits are discontinued on 8/31/13. Medi-Cal benefits are continued because the Medi-Cal RD is NOT due until October 2013, or 12 months from the date Medi-Cal eligibility was established.



Follow the chart below when processing the Medi-Cal annual redetermination:

If the Medi-Cal RD is... And the client... Then...

NOT yet due, Fails to complete CalFresh RC, Continue Medi-Cal until the Medi-Cal RD due date and reissue the Medi-Cal RD packet.

NOT yet due, Completes the Medi-Cal RD during the CalFresh RC,

The Medi-Cal RD cannot be aligned with the CalFresh RC. Note: For CalFresh households with less than 12 months certification period (homeless) or a household with a 24-month certification (elderly/disabled), the Medi-Cal RD is still due 12 months from the last Medi-Cal RD date.

Due, Fails to complete the CalFresh RC and the Medi-Cal RD,

Discontinue Medi-Cal benefits with a ten-day notice of action.

Due, Fails to complete the CalFresh RC but returns an incomplete MC 210 RV,

Follow Senate Bill (SB) 87 procedures and ex-parte time frames. [Refer to “Ex Parte Review Process,” page 8-4.]

Due, Fails to complete the CalFresh RC, but completes the Medi-Cal RD (i.e., returns the MC 210 RV, and provides the necessary information/verifications),

Continue Medi-Cal and update the Medi-Cal RD due date.

5.19.7 Medi-Cal Eligibility Determination

Since CalFresh regulations differ from Medi-Cal, the DFA 285 A2 or FS 27 may not have all of the information needed to determine Medi-Cal eligibility.

Residency

CalFresh recipients already meet the Medi-Cal program residency requirement.

Citizenship/Immigration Status

Excluded members of the CalFresh household (e.g., undocumented individuals) may qualify for Medi-Cal if other eligibility requirements are met. Excluded household members must be evaluated individually based on their current citizenship/immigration status. [Refer to Common-Place Handbook, “Immigration,” page 10-1 and “Noncitizen Categories,” page 11-1 for immigration status and program eligibility.]



Income/Expenses/Budgeting

• The income/expenses information already on file must be used for Medi-Cal unless a change is reported. When income is fluctuating, the EW should average three months of income (if it is more advantageous to the client) if available, to determine the income to be budgeted for the month of application and future months. Otherwise, use the most recent pay stub provided by the client.

• There are certain expenses that are allowed in the CalFresh budget (e.g., housing cost, utilities, etc.) which are NOT allowed in the Medi-Cal budget and vice versa. Therefore, the EW must ensure that only the allowable Medi-Cal deductions are budgeted.

• For retroactive Medi-Cal, use the actual income received in each of the retroactive month(s) being requested.

5.19.8 Informing Notices and Other Required Forms

When a CalFresh recipient requests Medi-Cal benefits, a complete Medi-Cal Family or Adult Intake Packet is not required; however, a limited informing packet must be given to the client based on the case situation.

• Provide a family or adult Medi-Cal intake packet, without the Statement of Facts form, to ensure that all mandatory informing notices and other necessary forms are issued. [Refer to Common-Place Handbook, “Medi-Cal and CalFresh,” page 24-5 for current requirements.]

Reminder:The “Consent to Exchange/Release Information (CHI)” (SCD 115) must be given to families requesting Medi-Cal.

Additional Forms

The following forms may be required prior to Medi-Cal approval, depending on the case circumstances:

• Absent parent:

• “Absent Parent Questionnaire” (CW 2.1/CW 2.1Q)• “Child Support Enforcement Program Notice” (CS 196)

• Property verifications (not required for Property Waiver programs)

• “Property Supplement” (MC 210 PS)



• Disabled person:

• Disability Determination Service Division (SP-DDSD) forms (MC 223, [for applicants over age 18], or MC 223C [for applicants under age 18], MC 220s and MC 017).

5.19.9 CalFresh Ineligibility/Discontinuance

The reasons for CalFresh ineligibility or discontinuance do not always apply to Medi-Cal ineligibility or discontinuance. Follow the chart below to determine what action(s) are necessary:

If the reason for the CalFresh ineligibility/discontinuance... Then the EW must...

Affects Medi-Cal eligibility,

Example: Death of an individual

Discontinue Medi-Cal for the affected individual(s) only.

Does not affect the Medi-Cal eligibility,

Example: Failure to comply with work requirement.

Continue Medi-Cal benefits.

May or may not affect Medi-Cal eligibility,

Example: CalFresh is discontinued due to incomplete QR 7.

Determine if any of the changes reported on the QR 7 affect Medi-Cal eligibility and take appropriate action. Additional information may be requested by using the “Medi-Cal Request for Information” (MC 355) and following SB 87 time frames.

Is for failure to provide a QR 7, Continue Medi-Cal benefits. Assume that no change has occurred for Medi-Cal unless one is reported.

5.19.10 Required Documentation

EWs must clearly document ALL of the following in the case record:

• The current DFA 285 A2/FS 27 in the case record was used to complete the eligibility determination.

• All pertinent information used to determine Medi-Cal eligibility is on file (e.g., MFBU composition, deprivation/linkage, OHC, income, property, etc.)

• The date Medi-Cal eligibility is established and the Medi-Cal RD due date.



5.20 “Annual Eligibility Review” (AER) Form

The AER form is used to redetermine eligibility of the children transitioned from Healthy Families to Medi-Cal.

• Sixty days prior to the AER due date, an AER form with pre-printed information is sent to the family to request updates on household size and family income.

• If during the annual review, it is determined that the child(ren) are eligible for no cost Medi-Cal/Targeted Low Income Children’s Program (TLICP), SPE will forward the AER form along with a Transmittal form to the county.

• The Medi-Cal application date is the date that the AER form is received by SPE.

• The AER form is sent to SSA only if it has been authorized by the family.

• EWs will determine Medi-Cal eligibility using the AER form, do not return to SPE.

• The AER form must be accepted as an application for Medi-Cal in lieu of the MC 210 or MC 321 HFP.

• The following supplemental forms must be sent to the applicant upon receipt of the AER form:

• “Statement of Citizenship, Alienage and Immigration Status” (MC 13) for each Medi-Cal applicant

Note:Since the AER form does NOT contain a declaration of citizenship/immigration status and place of birth, an MC 13 is required even the client is a U.S. citizen.

• “Important Information for Persons Requesting Medi-Cal” (MC 219)• CHDP brochure• “Consent to Exchange/Release Information - CHI” (SCD 115)• Other forms and informing notices as appropriate in the family Medi-Cal

intake packet, but without the MC 321 HFP.

[Refer to Common-Place Handbook, “Medi-Cal,” page 24-3.]



Reminder:EWs must not require the applicant to submit information or verifications other than what is required with the MC 321 HFP.

If the AER form shows non-custodial parent information, request all forms and verifications from the custodial parent.

5.21 Access for Infants and Mothers (AIM) Program

The Access for Infants and Mothers (AIM) program provides health care coverage to uninsured pregnant women and their newborns who have income between 200% - 300% of the Federal Poverty Level (FPL).

5.21.1 AIM Denials Sent to SSA for Medi-Cal

AIM applications denied due to income below 200% of the FPL are forwarded to the county and are processed as applications for Medi-Cal FOR PREGNANCY RELATED SERVICES ONLY. The date of application for Medi-Cal is the date the AIM application packet is received by the county. A SAWS 1 is not required.

The AIM application is used to determine eligibility for Medi-Cal, restricted to pregnancy services only. A new Medi-Cal application/statement of facts form (MC-321 HFP or MC 210) is not required.

5.21.2 Other Required Forms

The following forms must be sent to the applicant upon receipt of the forwarded AIM application packet:

• “Notification of Receipt of AIM Application to be Processed as an Application for Medi-Cal” (SCD 1480)

• “Statement of Citizenship, Alienage and Immigration Status” (MC13)

Reminder:The AIM application does NOT include a declaration of citizenship/immigration status and place of birth. Therefore, an MC 13 is still required even if the applicant is a U.S. citizen.



• “Important Information for Persons Requesting Medi-Cal” (MC 219) is not required to be signed by the applicant, however it must be documented that it was issued.

• “Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210A), as appropriate.

[Refer to Common-Place Handbook, “Medi-Cal,” page 24-3, for a current list of necessary forms and informing notices.]

5.21.3 Processing AIM Applications

Follow the procedures below for processing AIM applications:

IF... THEN...

Income verification submitted is last year’s income tax records,

It may be used if the client states that his/her income remains the same; otherwise, request more recent information, if available.

Updated information is not available, Document in the case file, but do not take any adverse action or deny the application.

Updated information reflects an increase in the eligible pregnant woman’s income during her pregnancy or postpartum period, or a change in family status which would otherwise give the woman a SOC,

Do not take any adverse action. The applicant is protected under Continued Eligibility (CE). The information may be compared against future income information obtained as part of the redetermination.

Updated information reflects a decrease in income from that shown on the previous year’s tax return,

No immediate action needs to be taken to recompute the woman’s income eligibility, as she already has no SOC.

The AIM Application is received incomplete, Do not forward the packet back to the provider. Contact the applicant to obtain any needed information or verification that is missing from the AIM application packet.

The applicant is found ineligible for no SOC Medi-Cal due to excess income,

Note on the denial NOA that the application will be sent back to AIM.

Include a copy of the denial NOA with the reason why the applicant was determined ineligible for no SOC pregnancy-related Medi-Cal with the referral to the AIM contractor.

Continuing EWs are to follow the same procedures if any of the above forms are received on an active Medi-Cal case.

[Refer to “Access for Infants and Mothers Program (AIM),” page 17-1 for additional information about AIM.]



5.22 Required Verifications when MC 210, MC 321 HFP, AER and AIM Application Forms Are Used

It is mandatory that each case record contain adequate information with supportive documentation in the CalWIN Maintain Case Comments window to determine eligibility, including any follow-up activities needed.

The minimum information which must be documented in CalWIN and IDM is listed below:

Verification Documentation

Signed Application Original Signature on Application. Exception: Health-e-App will fax the signature page.

Identity Photo ID for family members over 18

Social Security Number Copy of Card, IEVS Report or MEDS showing SSN verified status

California Residency Driver’s License, Utility Bill, Vehicle Registration, School Enrollment, Rent Receipt or Current Check Stub

Immigration Status USCIS Documents

Income Verification Check Stub, Income Tax Return, Signed Statement from Employer, Bank Statement with Direct Deposit, Child Support Court Order REMINDER: Medi-Cal applicants are only required to provide one pay check stub for the purpose of calculating earned income.

Income Deductions Child Care Receipts, Court Ordered Child Support Paid, Health Insurance Premium Paid

Property/Assets Bank Statements, Vehicle Registrations, Life Insurance Policies, Stocks, Bonds, IRAs, 401Ks, Real Property (Not applicable for children/pregnant women under Property Waiver Programs)

Pregnancy Verification Self-verification is acceptable if requesting pregnancy-related services only; acceptable for 60 days if requesting full-scope Medi-Cal. EDC can be provided verbally if necessary.

Marital Status of Parents Clients Statement For Sneede Determination (Not required for Sneede Property Waiver)

MFBU Determination For ALL applicable persons



5.23 Children’s Health Initiative (CHI), Intake Procedures

The Santa Clara County Children’s Health Initiative (CHI) is a local effort to ensure access to no-cost or low-cost comprehensive health, dental and vision coverage to all uninsured children in Santa Clara County whose net non-exempt family income does not exceed 300% of the Federal Poverty Level (FPL). CHI was implemented in January 2001, with the goal of quickly/efficiently enrolling children into Medi-Cal, Healthy Families and Healthy Kids.

The Children’s Health Initiative was established through a collaborative partnership with SSA, Santa Clara Valley Health and Hospital Systems, Santa Clara Family Health Plan, Health Trust, Working Partnerships, PACT, Alum Rock School District, and others.

5.23.1 CHI Objectives

To ensure that our county’s CHI goal is achieved, the application process has been simplified for families in order to expedite the enrollment of children into the appropriate health insurance plan.

• Fast-Track Enrollment of Kids Intake Offices must have procedures in place to ensure that families with children who are applying for Medi-Cal only, are seen by an Eligibility Worker on the same day the application is filed.

FPL/Property Waiver Determination

SCD 1564 or MC 175-5 (optional with CalWIN)

OHC Information Information for ALL Family Members with Other Health Coverage.

Documentation Needed for Retro Applications

MC 210A Retro Medi-Cal Application (Up to 3 prior months)

Income Verification Actual Income for ALL retro months requested

Property Verification Actual amounts for ALL retro months requested (Not applicable for children/pregnant women).



Although Medi-Cal applicants are not required to have a face-to-face interview, it should be encouraged so that EWs can assist clients with the application process and answer questions, as needed.

• Single-Point-of-Service SSA District Offices are a single-point-of-service for children’s health insurance. EWs are to determine what program is in the best interest of the child(ren) on a case by case basis. Determine eligibility for all programs, in the following order:

(1) Medi-Cal (Family’s income at or below 250% of FPL) Property Waiver Program

(2) Healthy Kids (Family’s income at or below 300% of FPL and child(ren) are not eligible for NO SOC Medi-Cal.)

• Application Assistance (client friendly service) EWs are to assist the client with the application, as needed. For client convenience, postage paid envelopes and fax machines can be used to obtain verifications and other required forms.

5.23.2 How Applications are Received

Medi-Cal applications for children are received from several sources, including:

• Applications filed in-person, at District Offices

• Mail-In Applications

• Application Referrals from the CHI Toll-free Number (1-888-244-5222)

• Outreach Events

• The Single Point of Entry (SPE)

• Certified Application Assistors (CAAs)

5.23.3 Role of the Intake EW, General

Intake Eligibility Workers (and CAAs) are to assist applicants with both programs (Medi-Cal, and Healthy Kids), by:

• Screening applicants for the appropriate program based on the family’s net non-exempt income.



• Assisting applicants, as needed, with the completion of the joint “Application for Pregnant Women and Children” (MC 321 HFP) and the Healthy Kids application.

• Gathering verifications.

• Determining the health insurance premium for Medi-Cal (if applicable) and Healthy Kids.

• Assisting the family with the enrollment in a health care plan and the choice of a provider.

Note:For Medi-Cal, EWs are required to refer the client to the Health Care Options representative for assistance with choosing a Managed Care plan and/or provider.

• Reviewing the application packet for completion and signatures.

• Assembling the application packet and ensuring it is forwarded to the appropriate location for an eligibility determination:

• Medi-Cal: Processed by an EW• Healthy Kids: Santa Clara Family Health Plan

5.23.4 Application Forms and Verifications

The following forms and verifications are required to determine Medi-Cal eligibility for children under 19 and pregnant women.

EWs should provide a Family Medi-Cal Intake packet to pregnant women and children.

[Refer to Common-Place Handbook, “Medi-Cal,” page 24-3.]

CHI Release of Information Form

The “Consent to Exchange/Release Information” (SCD 115) form must be included in every family Medi-Cal intake packet. Both the EW and the client must sign it. This form enables EWs to share specific eligibility information with Santa Clara Valley Health and Hospital Systems for Medi-Cal and Santa Clara Family Health Plan regarding the Healthy Kids application. It must be completed annually.

Other Forms and Verifications



• Verification of income

• Verification of income deductions

• Verification of California residency

• Verification of Immigration Status (allow up to 30 days)

• Social Security Number (allow up to 60 days)

• Pregnancy Verification and EDC date (NOT required if applying only for the 200% Income Disregard/Property Waiver Program)

• MC 210A (if retroactive Medi-Cal is requested)

5.23.5 Adding Other Family Members

If question 36 on the MC 321 HFP “Do any of the people listed in this section, or any of the parent(s) listed in Section 2 want Medi-Cal?” is checked “Yes”, then the intake worker is responsible for determining Medi-Cal eligibility for the other persons in the household. In addition, any other verbal or written request for Medi-Cal is considered to be an application, therefore:

• Determine if there is linkage

• Obtain all required forms and verifications

• Issue all mandated informing notices

• Issue an approval or denial notice.

The following forms and verifications are needed when adding Medi-Cal for adults.

• “Additional Family Members Requesting Medi-Cal” (MC 371)

• “Real and Personal Property: Supplement to Medi-Cal Mail-In Application” (MC 322)

• CA 2.1 and CA 2.1Q (if there is an absent parent)

• Verification of Identity.

5.23.6 Property Waiver Programs

The purpose of the CHI application process is to simplify and expedite Medi-Cal enrollment for pregnant women and children. Therefore, EWs should first determine eligibility for the Property Waiver Programs and the Targeted Low Income Children’s Program (TLICP).



Eligibility Criteria

Applicants for the Property Waiver Programs must meet the following criteria:

• They are otherwise eligible for Medi-Cal.

• The applicant does not wish to verify property or spend down

• The family’s net non-exempt income is at or below the appropriate Federal Poverty Level (FPL) limit:

If the Family Member is a: Then family income must be at or below:

Pregnant woman or child under age 1 200% of the FPL

Child age 1 through 5 133% of the FPL

Child age 6 through 18 100% of the FPL

Child age 0-19 under TLICP 250% of the FPL

NOTE: Refer to Chart Book, Chapter 5, for current net non-exempt monthly income limits.

Benefits

The provisions of this program include:

• Coverage only for pregnancy related services for pregnant women. Pregnant women in this program are NOT dually eligible.

• Full or restricted services for children through age 18.

• Property information or verification is NOT required.

Property Verification NOT Required

• DO NOT ask for property information or verifications when determining Medi-Cal eligibility for a pregnant woman or child under 19 who apply for Medi-Cal through the mail-in process, and are within the Federal Poverty Level income limit.

• DO NOT require verification of property to apply the Property Waiver. The waiver is allowed without requiring any property information or verification.

• DO NOT require property verification to determine if there is income from property, unless such income is reported/indicated through another means, such as an IEVS match.



When Property Verification is Required

Property verification and the MC 322 is required when:

• INCOME from property is reported or indicated through another means (i.e. IEVS).

• Children are discontinued from the FPL programs due to an increase in family income, and there is a share-of-cost.

Reminder:Continuous Eligibility for Children (CEC) rules must be applied before a child under 19 is given a share-of-cost.

5.23.7 Healthy Kids

Healthy Kids is a public-private partnership that is locally funded. EWs must explore eligibility for Healthy Kids AFTER a child has been determined to be ineligible for Medi-Cal. Adults are not eligible for Healthy Kids.

Note:Children who only qualify for restricted Medi-Cal benefits may qualify for Healthy Kids, however children who receive full-scope Medi-Cal with a share-of-cost are ineligible.

Eligibility Criteria

Eligibility for Healthy Kids depends on the child’s age, residency status, family size and income, which must meet the following criteria:

• Resides in Santa Clara County• Is under age 19.• Net non-exempt family income is at or below 300% of the FPL. Refer to Chart

Book, Chapter 5, for current net non-exempt income limits.• Is NOT eligible for NO SOC, full-scope Medi-Cal.

Benefits

Children enrolled in Healthy Kids are members of Santa Clara Family Health Plan, and receive their health care services through the Plan’s network of doctors, clinics and hospitals.



Healthy Kids insurance provides full medical coverage including prescriptions, inpatient care, office visits, preventive services, well-baby care, dental care, vision services, mental health, and alcohol/substance abuse care.

Premiums and co-payments apply.

EW Requirements

EWs are required to:

• Screen and assess eligibility for the appropriate program(s).

• Assist the client with completion of the application process. The Healthy Kids application must NOT be mailed to applicants to complete on their own.

• Forward the MC 321 HFP to SCFHP for Healthy Kids if family income is between 250-300% FPL and consent is given.

Note:The client or EW can contact SCFHP at 877-688-7234 to schedule an appointment for the client to meet with an Certified Application Assistor to complete an application or renewal.

• Ensure that the application is complete and signed by the applicant and the EW.

• Assist the client with obtaining required documents, e.g. proof of income and residency, as needed.

Note:Verification of income-in-kind is required for the Healthy Kids Program. A written statement or the MC 210 S-C, signed by the person providing it, is acceptable verification.

• Provide information about coverage, co-payments, premium payments, incentives for paying premiums on a quarterly or annual basis, and, that premium assistance is available to some families. The family’s share of the monthly premium is $4-6 per child, with a maximum of $12-18 per family

• Assist in the selection of a provider.

• Advise the client that it is important to maintain health insurance. Address and phone number changes must be reported to Santa Clara Family Health Plan and an annual redetermination form will be required.



5.24 Applications from the Single Point of Entry (SPE)

The Single Point of Entry (SPE), in Sacramento, was established by the state to coordinate application activities for Medi-Cal. SPE receives applications from clients who have been assisted by Certified Application Assistors (CAAs) located in medical clinics. Individuals may also pick up the MC 210 or MC 321 HFP from other community organizations and mail their application directly to SPE.

As of January 1, 2004, MAXIMUS is screening and processing SPE applications.

Effective July 1, 2002, SPE began following file clearance procedures, assigning Client Index Numbers (CINs), and reporting Accelerated Enrollment (AE) eligibility and application data to the Medi-Cal Eligibility Data System (MEDS).

Effective December 31, 2012, SPE began screening children age 6-18 who are potentially eligible for the additional income disregards of the Section 1931(b) Medi-Cal program as a result of a Court Order. In addition to the 1931(b) screening processes, the Department of Health Care Services (DHCS) and the Managed Risk Medical Insurance Board (MRMIB) also implemented a new deemed infant screening process at SPE.

5.24.1 “Health-e-App”

“Health-e-App” is an automated internet-based application for Medi-Cal used in our county by the CAAs located at medical clinics that are part of Santa Clara Valley Health and Hospital Systems.

Application Process

• The CAA interviews the applicant at the clinic and enters the information directly online into Health-e-App.

• When all necessary verifications are provided, the CAA electronically forwards the application to SPE. In addition, the CAA faxes verifications and a copy of the signature page to SPE.

• When the CAA submits the completed application, the client receives the following information from SPE:

• A real-time preliminary screening



• An electronic confirmation of receipt, and• A unique application number.

SPE Actions

SPE screens the application for up to 20 days for completeness and forwards the application to SSA to determine eligibility for Medi-Cal. Hard copies of the Medi-Cal applications and all related documentation are currently delivered to the Assistance Application Center (AAC), including:

• A “Health-e-App Application Summary” printout• A Transmittal form• Copies of verifications submitted by the applicant• A signature page with a photocopy of the original signature.

The “Health-e-App Application Summary” is an official application for Medi-Cal. The same procedures apply when processing this application form.

Application Date

The date of application is the date that the “Health-e-App” is electronically submitted to SPE. The date is on the transmittal form, as well as on the MEDS INQP Screen.

Clerical Role

Follow current District Office procedures for completing file clearance procedures and registering/assigning. In addition, an INQM and INQ1 MEDS screen is needed for these applications as well as an INQP screen to verify the date of application.

5.24.2 SPE Applications and Forms

The various applications and forms received from SPE are listed below:

Document Number Action Needed

Application MC 321 HFP Process for all Medi-Cal eligibility.

Add a Person Form HF_FM_67MC Treat as an application and determine eligibility for the new child. The child may have AE.

Annual Eligibility Review (AER) Form

HF_FM_63MC Review for TLICP. If income is above/below TLICP guidelines, process for other Medi-Cal programs.



5.24.3 Application Tracking System

The application tracking system allows client information to be shared between SPE, MEDS and the individual counties. Sharing of information is accomplished through the Client Index Number (CIN). This process is intended to provide:

• Better service to clients• A more efficient data collection process, and• Fraud Prevention.

Applications are also received electronically from the MAXIMUS SPE system providing an electronic method of transferring data and images for new applications from MAXIMUS to the county through the CalWIN External Referral system.

Premium Re-evaluation HF_FM_150MC Review for potential 1931(b) eligibility and/or FPL re-calculation.

Program Review Form HF_FM_21 May include additional information than what was previously sent to HFP. Treat as an application form.

Re Enrollment Form HF_FM_58 The family has had a break in coverage and it is within 60 days of HFP termination. Children are granted AE if applicable. A copy of the most recent Application/AER form is included. Treat as a new MC application.

Review and Continued Enrollment

HF_FM_101 The family disagrees with a disenrollment decision and wants to continue while the request is reviewed. May include additional information than what was previously sent to HFP. Children are granted PE (5E) if applicable. A copy of the most recent Application/AER is included. Treat as a new application.

Transmittal Summary Cover Sheet

HF_FM_080a Recaps all applications, forms and correspondence sent for that day. Review the number of applications/forms included in the daily delivery. Indicates if:

• Other family members want Medi-Cal,• Retro Medi-Cal is requested, and• If AE is granted for any child on a case.

General correspondence is listed when SPE is forwarding additional documents AFTER an application was previously forwarded.

Transmittal Form HF_LT_016 Provides a Summary of each case forwarded.

Document Number Action Needed



5.24.4 SPE Screening Process

All applications and Healthy Families Program Annual Eligibility Review (AER) forms for children ages 6-18 years old processed at SPE are screened for potential eligibility for Medi-Cal, including 1931(b) based on the income verification provided by the family and if at least one deprivation indicator and at least one income disregard applicable to the 1931(b) program are identified. The forms include:

• MC 321 HFP• Electronic Health-e-App• HFP AER• HFP Premium Re-evaluation• HFP Add-a-Person, and• HFP Re-enrollment forms.

SPE has four (4) business days to complete it’s screening process. During the screening process, SPE:

• Completes File Clearance process to see if a child is already known to MEDS

• Assigns a Client Index Number (CIN).

• Identifies ownership of income and family relationships, deprivation factors, and income disregards (i.e., income from disability, self-employment, education, pension or retirement).

• Screens children for potential eligibility for 1931(b) and FPL programs

• Reviews for 1931(b) or CalWORKs RECIPIENT status during the prior four months

• Reviews infants under age one for Deemed Eligibility (DE)

• Contacts the applicant for missing or additional information.

• Establishes Accelerated Enrollment (AE) eligibility on MEDS for children under 19, if applicable. [Refer to Accelerated Enrollment (AE) for Children page 17-27 for more information.]

• Generates the mailing of a BIC for children enrolled in AE, if one was not previously issued.

• An Integrated Voice Response system automatically generates a call to the client when an application is forwarded for a Medi-Cal determination, or is determined to be receiving full scope, no-cost Medi-Cal benefits.



In Santa Clara County, mail-in applications from SPE are sent to the designated Office for processing.

5.24.5 CIN Assignment

SPE completes the file clearance and assigns a CIN to all individuals who are included on form submitted to SPE.

• If the client is on the Statewide Client Index (SCI), SCI and SPE will find and use the existing CIN.

Note:If the client is known to CalWIN and also has a prior MEDS record, the person completing the file clearance MUST confirm that the CIN on the Transmittal form belongs to the MEDS record associated with the county ID.

• If the application does not contain adequate information, and SPE staff are unable to obtain the information within 4 days, a CIN is not assigned to that individual.

5.24.6 Accelerated Enrollment Process (8E)

When a child appears eligible for no-cost Medi-Cal program based on the income screening performed at SPE, the child is place in Accelerated Enrollment (AE) Aid Code 8E. The Single Point of Entry (SPE) forwards the case to the residence county for a Medi-Cal determination. Medi-Cal eligibility under Aid Code 8E continues until a determination for regular Medi-Cal eligibility is completed. EW action is required to discontinue the AE eligibility.

Children in AE will appear on the monthly Exception Eligibles Report (EER) in Aid Code 8E. Once the regular Medi-Cal eligibility determination is completed and reported to MEDS, the 8E record will be cleared and MEDS will accept the Medi-Cal eligibility as long as the information entered into CalWIN EXACTLY matches MEDS. The AE program eligibility continues under Aid Code 8E until this takes place. The EER report can also be used as:

• An informational tool for determining Medi-Cal eligibility• A useful way to track missing documentation from SPE.

Note:The 8E records on the EER must be cleared as soon as possible. Staff must ensure that Aid Code 8E is terminated when processing the application/AER and Medi-Cal is approved or denied.



5.24.7 SPE Transmittal Forms

The following Transmittal forms are used with applications received from SPE:

Summary Transmittal

The “Summary Transmittal”/coversheet lists all applications and AER forms referred to the county in the batch. This listing is for inventory control and contains specific information on individual family members.

When received, designated office staff must cross-check the summary transmittal from SPE with the applications referred in the batch. If the summary transmittal contains applications not included in the batch, or, if applications included in the batch are not listed on the transmittal, the SPE Liaison must be contacted immediately by phone at (916) 673-4602 or e-mail at [email protected].

SPE Transmittal Form

Each application or Annual Eligibility Review (AER) form forwarded to SSA from SPE is attached to a Transmittal form. The transmittal is a summary of each application sent and advises the EW how each person was screened, the family composition, and income used.

The Transmittal form lists each child on the application, and indicates:

• Family Income,• What programs the children were screened for, • If Retro Medi-Cal is requested,• If additional family members are requesting Medi-Cal, and• The CIN assigned to each child.

A description of the transmittal data is provided below:

CASE LEVEL INFORMATION:

Field Description

County Name Identifies the designated county to which the application is referred. If forwarded to the wrong county, return it immediately to:

Healthy Families Attn.: SPE P.O. Box 138005 Sacramento, CA 95813-8005



Date Original Application Forwarded to CWD

If this field contains a date it is because SPE had previously sent the original application. SPE is now forwarding changes, new verifications or new information on one or more members of the application. Use this date to track when the original application was forwarded to the county.

Case Control Number (CCN)

This is the same as the Family Member Number (FMN) on the Summary Transmittal. This is the SPE case number.

Date Received This is the date SPE received the original application. Use this date as the Medi-Cal application date for new applications and for Add-A-Person applications not associated with the AER.

NOTE: This date should match the MEDS INQP screen.

Date Referred This is the date SPE determines an application should be referred to Medi-Cal. Use this as the Medi-Cal application date for AER, Add-A-Person applications associated with the AER, Premium Re-evaluation form, Re-enrollment Form and when a family opts out of Medi-Cal and then signs a reconsideration letter.

Opt-out of HF If marked “Y” the family does not want the Healthy Families Program. Process the application, request property information and determine share-of-cost Medi-Cal.

Unlisted Member Wants Medi-Cal

Y = Question #36 on the joint application, “Do any of the people listed in this section, or any of the parents listed in Section 2, want Medi-Cal” is marked yes. The EW will need to review for Medi-Cal eligibility for these individuals.

N = No other family members are requesting Medi-Cal.

Retro MC Requested

Y = Question #49 on the joint application, “Does the pregnant woman and/or child want to apply for Medi-Cal coverage for any expenses in the last three months?” (Retroactive Medi-Cal) is marked Yes. The EW will need to review for Medi-Cal eligibility for retro Medi-Cal per regulations. NOTE: The applicant must complete an MC 210A for the retro month(s).

N = Applicant is not requesting retro Medi-Cal

Any Member Disabled

Y / N

1931(b) CalWORKs Recipient

Y / N = 6 to18 years old potentially eligible for 1931(b) recipient test based on prior CalWORKs eligibility on MEDS

1931(b) Program Y / N = 6 to18 years old potentially eligible for 1931(b) Applicant or Recipient test

Deemed Eligible Y / N = Infants under age 1 screened as potentially eligible

Missing Info Y / N: The application form or the AER form was received but the missing information/verifications were not received within 20 days.



Type This designates the type of application being forwarded:

• SPE: A new case that was screened to Medi-Cal through SPE

• HF: A case that was screened to Medi-Cal by an Eligibility Enrollment Specialist (EES). This would include initial applications originally screened to HF but further verification screens them to Medi-Cal, Re-enrollment.

• AER: This case was screened to Medi-Cal during the AER

• MC AER: The packet contains a Medi-Cal Annual Redetermination

• ADD: This case was screened to Medi-Cal while an Add-a -Person form was worked on by HFP.

• PRE: This case was screened to Medi-Cal while a Premium Re-evaluation form was worked on by HFP.

INDIVIDUAL LEVEL INFORMATION:

Field Description

Member A numeric value is assigned to each member on the application, same as Person Number in CalWIN:

1 = Applicant 2 - 99 = Other family members

CIN# This is the Client Index Number (CIN) that SPE assigned to this individual. Please make sure that the CIN listed on the transmittal matches the CIN in CalWIN. Additional action may be required to link any duplicate record as appropriate. [Refer to “SPE File Clearance Procedures,” page 5-77] for instructions on handling multiple CINs]

Name Last Name; First Name; Middle Initial: Lists all the names of individuals listed on the application. The EW should review these fields for accuracy.



Relation to Applicant

Indicates the individual’s relationship to the applicant as identified by SPE.

1 Applicant’s Child G Grandparent Q Cousin

2 Second Adult’s Child H Dependent of a Minor Child

R Collateral Dependent

3 Significant Other I Mother or Father-in-Law

S Spouse

4 Ex-Stepparent J Brother or Sister

T Stepfather

A Aunt or Uncle K Grandchild U Unborn

B Stepchild L Legal Guardian V Stepmother

C Common Child M Adopted child W Ward

D Son or Daughter-in-Law

N Niece or Nephew

X Ex-Spouse

E Brother or Sister-in-Law

O Other Y Self

F Foster Child P Parent Z Unknown

Date of Birth The date of birth for each individual. The EW should review these fields for accuracy.

SSN Indicates the Social Security Number for each individual, if available. The EW should review these fields for accuracy.

Screened For Indicates what program the individual was screened for:

B = 1931(b)D = Deemed Eligible Child (less than one year old)H = Healthy FamiliesM = Medi-Cal N = Not screened to either programO = Over age 19T = Targeted Low Income Children’s Program.

Pregnant Indicator

Y = Question #34 on the Joint Application, “Are any family members who are living in he home pregnant?” is marked yes or Section 2, Questions 17-32 are answered under the last column marked, “Pregnant Woman” N = Not pregnant

REMINDER: EWs MUST EXPEDITE ELIGIBILITY DETERMINATIONS FOR ALL PREGNANT APPLICANTS.

AE Start Date Effective date of Accelerated Enrollment (AE) for this individual. Eligibility for benefits begins the first day of the month of enrollment.

AE WILL ONLY BE TERMINATED WHEN THE EW APPROVES OR DENIES MEDI-CAL USING THE EXISTING CIN.



Budget Unit The budget unit to which the individual belongs for income computation purposes per SPE screening.

Retro Medi-Cal Requested

See item #8

INCOME SECTION: These fields show the information and methodology used by Maximus in the screening process. This information should be used by the EW as a tool only.

Member The member to whom the income is associated

Frequency of Income

A = Weekly B = Bi-weekly C = Bi-monthly D = Monthly E = Yearly

Type of Income 1 Employee Pay Stubs G RSDI - Retirement Survivors Disability Insurance

2 Federal Tax Form H Veterans

3 Award Letter I Railroad Retirement

4 W2 Form Not Accepted by SPE

J SDI - State Disability Income

5 Bank Statements (Shows Direct Deposit)

K Workers Compensation

6 Employer Statement L Unemployment Benefits

7 Quarterly P/L M Pension/Retirement

8 NOA N Grants

9 Child Support O Settlements

A Alimony P Gift

B SSA Q Lottery/Bingo

C Self Employment Statement

R Other

F Affidavit

Income Type Amount

This is the gross amount of income for this family member, income type and frequency, as determined by Maximus.

Budget Unit The Budget Unit number that Maximus associates with the corresponding income and individual information. Not used by us.

Family Size The total number of family members on this case used by Maximus to determine income levels for the corresponding Budget Unit. (Same as MFBU).



5.24.8 Processing Applications Received from SPE

Missing Information

The Single Point of Entry keeps copies of all applications and verifications received and forwarded to counties for a Medi-Cal determination. If an application is received from SPE with missing information (i.e. verifications, signature page, etc.), the EW will need to request the information. The request for verifications is limited to only those that are required. For example, the EW does not need to contact SPE for property verifications, as SPE does not collect property information.

For requests for missing information or for questions regarding SPE screening, or transmittals, contact the SPE County Liaison:

• By phone at (916) 673-4602, OR• By e-mail at SPEliaisons@ maximus.com

When requesting information from SPE (by e-mail or phone), the following information must be provided:

• Case Control Number• Child’s name• Child’s Date of Birth• Child’s SSN or Pseudo #, if available• Date of Application.

Reminder:Staff must use the Secure e-mail function when communicating with SPE.

Total Gross Income

The total monthly income, before deductions as determined by Maximus.

Deductions The total amount of deductions allowed by Maximus for the corresponding Budget Unit. This includes the $90 deduction for work related expenses, when appropriate.

Total Net Income This is the Total Gross Income minus deductions.

Percent FPL This is the percentage of the Federal Poverty Level Program for the Corresponding Budget Unit. This percentage is determined by Family Size and Total Net Income, as determined by Maximus.

Members These are the members who are part of the Budget Unit. (Same as MBU)

COUNTY RESPONSE AREA:(It is no longer necessary to complete this section.)



Required Forms

The following forms are required to be provided to the family:

• CHDP Brochure• MC 003 EPSDT Brochure• MC 219 - Rights and Responsibilities• SCD 115 - CHI Release of Information Form.

Additional Forms:

• CW 2.1 and CW 2.1 Q - Medical Support Enforcement (if applicable)• MC 322 Real and Personal Property: Supplement to Medi-Cal Mail-In

Application (only if adults are requesting Medi-Cal)• MC 210 A - Request for Retroactive Medi-Cal (if Retro is requested)• MC 371 - Additional Family Members (if more than 4 children in MFBU).

Adding Adults

When adults are requesting Medi-Cal, the EW will need to contact the client for additional information. SPE only screens Medi-Cal eligibility for the children. The EW will need to obtain the “Property Supplement” (MC 322) and the MC 371 to Add a Person.

Applications originating at SPE are processed as follows:

STEP WHO ACTION

1. Clerical • Reviews Transmittal Form to ensure all applications listed are received.• Performs File Clearance and prints the INQM and INQ1 screens for

individual applications.• Checks the MEDS INQP screen for the date of application.• Registers the application in CalWIN if no active case is found.• Forwards the application with verifications to the Continuing EW if the

case is active.

2. EW If SPE indicates Retroactive Medi-Cal Only is requested, sends MC 210A to the applicant for processing.



Reminder:AE continues until an approval or denial transaction is sent to MEDS for the existing CIN. Staff MUST mirror the information on MEDS when taking action.

SPE File Clearance Procedures

Special File Clearance procedures for processing SPE applications are as follows:

Processes the Medi-Cal Application and takes the following action:

If... Then...

Medi-Cal is approved, • Completes CalWIN entries to establish eligibility on MEDS.

• Ensures that the AE record is terminated.

Child on AE is denied, Ensure that the denial is correctly reported to MEDS and the AE MEDS record is terminated.

STEP WHO ACTION

1. Clerk and EW Sup

Checks the MEDS record for the transmittal CIN and the date of application.

If... Then...

SPE erroneously linked to a MEDS record belonging to a different individual and the individual on the transmittal IS KNOWN to SCI/MEDS,

REQUEST MEDS COORDINATOR TO CALL THE ITSD HELP HOTLINE IMMEDIATELY TO RESTORE THE ERRONEOUSLY CHOSEN INDIVIDUAL’S RECORD TO WHAT IT WAS PRIOR TO THE SPE UPDATE.

Once the record is restored to its condition prior to the erroneous update, the prior BIC, if any, will be valid.

STEP WHO ACTION



5.25 “Express Enrollment” for Children in the National School Lunch Program (NSLP), AB 59

5.25.1 Overview

AB 59 (Chapter 894, Statutes of 2001) added section 14005.41 to the Welfare and Institutions (W&I) Code and section 49557.2 to the Education Code allowing children who are approved for free school lunches to apply for Medi-Cal using the information on the National School Lunch Program (NSLP) application.

A modified National School Lunch Program (NSLP) application along with a supplemental form can be used to determine eligibility for Medi-Cal. Our agency must accept and process NSLP applications from schools who wish to participate.

2. EW SPE erroneously linked to a MEDS record belonging to a different individual, and the individual on the transmittal is NOT known to SCI/MEDS,

• REQUEST MEDS COORDINATOR TO CALL THE ITSD HELP HOTLINE IMMEDIATELY TO RESTORE THE ERRONEOUSLY CHOSEN INDIVIDUAL’S RECORD TO WHAT IT WAS PRIOR TO THE SPE UPDATE. Once the record is restored to its condition prior to the erroneous update, the prior BIC, if any, will be valid.

• Submit an AP18/AP20 for the individual and check MEDS the following day to determine the CIN assigned during the MEDS batch update process.

3. EW Checks for multiple MEDS records.

If... Then...

The File Clearance identifies more than one MEDS record for the individual on the transmittal,

Completes an SC 1296 to request the MTO to complete one or more EW 11 transactions as needed to merge the MEDS records.

STEP WHO ACTION



Santa Clara County Social Services Agency has entered into an agreement with the Alum Rock School District to process the modified NSLP applications for Medi-Cal eligibility during the 2003/2004 school year, and complete Express Enrollment for qualified children.

At this time, no other school districts in Santa Clara County are participating in this program. Since Medi-Cal enrollment through the NSLP application is time-limited, EWs at the East Valley office were processing these applications.

5.25.2 Express Enrollment Definition

Express Enrollment is temporary, expedited full-scope health care coverage for children up to age 19, who qualify to receive free meals through the NSLP. Express Enrollment continues until a determination of eligibility for regular Medi-Cal is made.

5.25.3 NSLP Application Process

The NSLP provides either free or reduced price meals based on the household size and family income. Income is self-declared and no income verification is required. Alum Rock School District Child Nutrition Services (CNS) will notify the family of the child’s eligibility for the NSLP or denial within ten calendar days of receipt of the application.

Alum Rock School District (ARSD) Child Nutrition Services (CNS) mails an NSLP application to all families a few weeks before the start of the school year. Families must complete, sign and return the NSLP application for an eligibility determination. In order for children to be considered for Express Enrollment, a parent/caretaker must consent to the sharing of personal and financial information contained in the modified NSLP application by signing the optional Medi-Cal Benefits Section of the application.

• Families with household income at or below 130% of the Federal Poverty Level (FPL) qualify for free school lunches.

• Families with household income at or below 185% of the FPL qualify for reduced-priced lunches.



5.25.4 Modified NSLP Application Form

The NSLP application has been modified to include information needed for a determination of Medi-Cal eligibility:

• The child’s birth date• The child’s income• The relationship of all household members to the child for MFBU determination• The income and family size of CalFresh and Food Distribution Program on

Indian Reservation (FDPIR) recipients• A signature line for the parent/caretaker relative to provide signed consent to

sharing of information on the NSLP form for a Medi-Cal determination• A signature under penalty of perjury statement.

5.25.5 Income Verification for Express Enrollment

The modified NSLP application serves as income verification for determining Medi-Cal eligibility of a child enrolled through the Express Enrollment process. Income is self-declared and no income verification is required. However, IEVS information must be used to verify income when a Social Security Number is available.

Verification of income is required only when the EW determines there is a discrepancy in the reported income, including:

• A change is reported during or after the Medi-Cal determination• IEVS discrepancies need clarification• Retroactive Medi-Cal coverage is requested• Income was not reported on the NSLP application, or • Other family members are requesting Medi-Cal.

Reminder:Parents are not required to provide Social Security Numbers unless they are requesting Medi-Cal for themselves.

5.25.6 Express Enrollment Process

The school has sole authority to certify a child for Express Enrollment using the information provided on the modified NSLP application. Once the certification is made, the school notifies the parent/caretaker that the child is certified for temporary Medi-Cal and forwards the application to Social Services for a “regular” Medi-Cal determination.



Activation on MEDS

WITHIN 5 DAYS of receipt of the NSLP application, Social Services must:

• Complete CalWIN and MEDS file clearance procedures

• Complete an AP 18 transaction to report the application information and school determination date to MEDS, and

• Activate Aid Code 7T on MEDS.

Date of Application/Enrollment

• The Express Enrollment date is the date the school determined eligibility.

• The Application date is the date the application is received at SSA.

Ineligible Children

Children in the following categories are not eligible for Express Enrollment:

• Children who are already receiving Medi-Cal benefits through an active CalWORKs or Medi-Cal case, or through SSI.

• Children whose NSLP application lacks sufficient information for the school to make a determination for Express Enrollment.

• Children with family income exceeding the income limit.

Note:These applications are to be processed for a regular Medi-Cal eligibility determination.

Required Supplemental Forms/Notices

When a modified NSLP application is received by SSA, the following informing notices and request for information must be sent to the family:

• “Notice and Supplemental Form for Express Enrollment Applicants” (MC 368)



The MC 368 includes a check box indicating the child’s Express Enrollment status and is also a request for additional information necessary to complete the Medi-Cal eligibility determination.

• “Important Information for Medi-Cal Applicants” (MC 368 Attachment). The MC 368 A includes the applicant’s Rights, Responsibilities and Declarations, the Medi-Cal Confidentiality Notice and the Medi-Cal Privacy Notice.

• “Mental Health Services Information Notice” (MC 003)• Health Care Options Flyer• CHDP Brochure• WIC information• Other forms as applicable.

Information NOT Required

Since the goal of AB 59 is to provide health coverage for uninsured children, the request for information is limited to what is necessary to determine eligibility under the Property Waiver FPL program. The following information is NOT required under AB 59:

• “Declaration of Citizenship/Immigration Status” (MC 13)• Rights, Responsibilities and Declarations, Privacy Notice and Confidentiality

Notice (MC 219)• Medical Support Enforcement (CW 2.1)

Note:Medical Support forms are given to the parent for completion; however, no action is taken if they are not completed and returned, if only the child(ren) are active. Cooperation with medical support enforcement is required if parents want Medi-Cal.

• Proof of California Residency• Verification of Income• Verification of Allowable Income Deductions.

Note:Income deduction are not allowed unless verification is provided; therefore, income deductions may be requested to bring the family income within the FPL limit, if applicable.



Fair Hearing Rights

There are no fair hearing rights or notice of action (NOA) requirements during the Express Enrollment period. However, once an eligibility determination is made for regular Medi-Cal, the appropriate NOA must be sent to either approve or deny the application, and fair hearing rights apply. CDS NOA 590 is used for all Medi-Cal approvals and denials of the NSLP application. It contains language for transitioning children from Express Enrollment to regular Medi-Cal and for the denial of Medi-Cal benefits.

5.25.7 Medi-Cal Eligibility Determination

The Medi-Cal eligibility determination requirements (including timeframes for providing forms and verifications) have not changed. EWs must first evaluate the child for eligibility under the applicable FPL program.

Express Enrollment (7T) continues until a “regular” Medi-Cal eligibility determination is completed by the EW. Since Medi-Cal applications must be processed within 45 days, it is expected that Express Enrollment will not exceed two months.

Note:Since the Express Enrollment period is temporary and is NOT considered a Medi-Cal determination, children in Aid Code 7T must have an eligibility determination for zero SOC Medi-Cal before CEC and Bridging apply.

Other Family Members Requesting Medi-Cal

Other family members requesting Medi-Cal are NOT required to complete the MC 321 HFP. However, the form “Additional Family Members Requesting Medi-Cal” (MC 321 HFP-AP) must be used to obtain the necessary information when a request for Medi-Cal is made for other family members.

Once sufficient information is provided to assess eligibility under all Medi-Cal programs, the EW must first evaluate potential eligibility for Section 1931(b), including the NSLP applicant child(ren). All necessary verifications and requirements must be met.



Request for Retroactive Benefits

The requirement to complete a “Supplement to Statement of Facts Request for Retroactive Medi-Cal Eligibility” (MC 210 A) has not changed. Income verification is required for all requested retro months, if appropriate. Eligibility for retroactive months is based on the date the NSLP application is date-stamped as received by the District Office.

Required Actions

EWs must take the following steps upon assignment of an AB 59 application:

STEP ACTION

1. Complete one MC 368 for each child listed on the NSLP for whom Medi-Cal is requested.

2. Mail the request for information forms (MC 368, MC 368A) and applicable informing notices (MC 003, Managed Care Flyer, CHDP Brochure, WIC Brochure) to the parent/caretaker.

When the MC 368 is returned, EWs must:

1. Determine immigration status of each child to determine scope of coverage.

2. Determine eligibility for the Property Waiver Program, using the information on the NSLP application.

3. Complete the appropriate CalWIN entries to approve/deny the Property Waiver (PW) program.

4. Mail the appropriate NOAs. If the child does not qualify for full-scope, zero share-of-cost Medi-Cal, send a referral flyer to the Alum Rock School District Health Care Outreach Program Coordinator with a Joint Application (MC 321 HFP).

5. Review MEDS to ensure the appropriate Aid Codes are active.

• If approved, Property Waiver Medi-Cal is active and Aid Code 7T is terminated. • If denied, PW Medi-Cal is not active and Aid Code 7T is terminated.

6. Follow up with the family if Retro Medi-Cal is requested or if the MC 368 indicates that other family members wish to apply for Medi-Cal.

Collect the required supplemental forms and verifications and determine eligibility based on current rules and processes.

7. Document action taken in Case Comments and ensure all documents are scanned into IDM appropriately.

NOTE: Follow-up action may be required if the MC 368 is returned incomplete.



Dual Eligibility on MEDS

During the transition between Express Enrollment and Medi-Cal approval, dual eligibility under both Aid Codes will show on MEDS. Children active on MEDS under a restricted Aid Code (58, restricted) are entitled to receive medical services through the most beneficial coverage (7T, full-scope).

5.26 Public Guardian Cases

If in the course of regular intake, it is discovered that the applicant is under conservatorship, the conservator must be contacted to inform them that the client has attempted to apply.

5.26.1 General Information

The Public Administrator/Guardian/Conservator office makes applications for Medi-Cal (and possibly GA) for persons who have been “conserved” by the county court system.

The court names the Public Guardian as the “guardian” or conservator of these clients because they are unable to conduct their own legal affairs.

When the MC 368 is NOT returned, EWs must:

1. Conduct follow-up activity (i.e. phone or written contact to the family). Allow a minimum of 10 additional days for the family to submit the required information.

NOTE: As long as the family indicates that they are working to meet the requirements as requested by the EW, additional time must be allowed.

2. Send CDS 590 NOA, and send a referral flyer to the Alum Rock School District Health Care Outreach Coordinator.

3. Document action taken in Case Comments and ensure all documents are scanned into IDM appropriately prior to submitting case to EW Supervisor for transfer to closed files.

STEP ACTION



The Public Guardian's office is located at:

333 W. Julian St. - 4th Floor San Jose, CA 95110 (408) 755-7610

Mailing Address: P.O. Box 760 San Jose, CA. 95106

5.26.2 EW Procedures

1. The EW determines eligibility from the information contained in the packet and from verifications supplied by PAG/C. A face-to-face interview is not required. The application is held in pending status until all verifications are received. For redeterminations, completed forms must be returned by the end of the indicated redetermination month, or eligibility will be discontinued.

2. Completion of the “Responsibilities of Public Guardian/Conservators or Applicant/Beneficiary Representative” (DHS 7068) form is required when an applicant has a public guardian, conservator or a representative acting in his/her behalf, due to the incompetence of the client.



3. Eligibility Reminders:

a. The county of residence for application procedures is the county where conservatorship is assigned by the court.

b. Property owned by the applicant or beneficiary is treated or counted the same as for any other applicant or beneficiary.

c. Parental responsibility is not considered when a conservatorship exists.

4. All required informational notice must be sent to each Public Guardian to keep them informed of their reporting responsibilities, changes and additional information about Medi-Cal eligibility.

5. When the beneficiary is determined to be eligible, the EW completes processing, sets up the payee as “Public Guardian” for (beneficiary's name).

5.26.3 Referrals to Public Guardian

The laws governing referrals to the Public Guardian’s Office are very complex and require a number of forms to be completed. Among the required forms is a “Capacity Declaration” from a medical doctor or psychiatrist declaring the person to be in need of a conservator and a request for a court hearing to determine capacity. Due to the complexity of the referral process, the social workers at the hospitals initiate these referrals. Agency staff no longer refer individuals to the Public Guardian’s Office for conservatorship.

Note:When there is a valid reason to believe a client is being abused or neglected, then the EW must complete an “Adult Protective Services” (APS) referral.

5.26.4 Guardian and Conservator Fees

Fees paid to a court-appointed guardian or conservator are allowable deductions from unearned income when computing the share of cost of an aged, blind, or disabled medically needy individual if certain conditions are met.

[Refer to “MFBUs Which Include Aged, Blind, or Disabled MN Persons [50549],” page 57-8]



5.27 Mental Health Sub-payee Cases

These cases are processed in the same manner as Public Guardian cases with one exception. Instead of “Letter of Conservatorship”, a letter from the Mental Health Agency is required stating that they are accepting responsibility as the authorized representative for the beneficiary.

5.28 Presumptive SSI and Extended Medi-Cal

Presumptive SSI clients are able to receive zero Share-of Cost (SOC) Medi-Cal benefits for up to six months from the date PD is approved, while the Social Security Administration (SSA) makes a formal disability determination.

When an SSI/SSP applicant is approved for PD and then denied (after a formal disability determination), and a timely appeal is requested, SSI-based Medi-Cal MUST be extended throughout the entire SSA appeal process.

A presumptive SSI recipient who is found NOT to be disabled during the formal disability determination process is terminated on MEDS with a denial code, instead of a discontinuance code (N07 Cessation of Disability).

When a denial code is used, MEDS cannot automatically identify and track these individuals for extended zero SOC Medi-Cal eligibility, as it does for N07 individuals.

5.28.1 Criteria for Referrals to DHCS

Individuals meeting the criteria listed below must be referred to the Department of Health Care Services (DHCS) for potential extended zero SOC Medi-Cal eligibility:

• Self-identified as a presumptive SSI recipient who was found NOT to be disabled during the formal disability determination, OR



• A Medi-Cal applicant whose MEDS record indicates a short period of SSI eligibility (6 months or less) AND an SSI denial code (not a discontinuance code).

5.28.2 DHCS Responsibility

DHCS must manually issue extended zero SOC Medi-Cal to these clients. DHCS also sends a notice informing the clients that their SSI-based Medi-Cal eligibility has been restored.

During the period that the SSI appeal is pending with SSA, Medi-Cal eligibility will be under State control.

5.28.3 Identification of Presumptive SSI Individuals

Presumptive SSI clients are identified by the following information on MEDS:

SCREEN FIELD DESCRIPTION

INQM AID-CODE Aid Code “60” will appear (with a time period of one to six months.)

INQX DISABL-PAYMENT-CD A letter “P” will appear if the client was approved PD by SSA.

INQP APPEAL-LEVEL Should show a recent denial date and the denial reason. The appeal date for these clients should be a date that is after the date of the denial.

Example: If there is a denial code of “N32” and a denial date of 08/02/07, then if the client had requested an appeal with SSA, the appeal date should usually be within 65 days of the denial date.

5.28.4 Referral Process and Required Action

The following actions occur when an individual meeting the criteria listed above is referred to DHCS:

STEP WHO ACTION

1. EW Refers the client (name and SSN) to the Medi-Cal (MC) Liaison, noting “PD approval/denial, appeal pending with SSA.”

2. MC Liaison Forwards the information to the Medi-Cal Program Coordinator.

3. MC Program Coordinator

Forwards the information to DHCS by contacting the Medi-Cal Disability Unit.



5.29 Foster Care Program (FCP) and Adoption Assistance Program (AAP)

Refer to Foster Care Handbook, “Health Care Options for Foster Care, Adoptive and Kin-GAP Children,” page 34-1 and “Aid Code 45],” page 34-11 for Medi-Cal eligibility requirements that are associated with FC and AAP programs. All applications for Medi-Cal for FC or AAP children are completed by the Foster Care Eligibility Intake Unit.

4. DHCS Confirms with SSA that:

• The individual received presumptive SSI, and• The individual was found NOT to be disabled in the formal disability

determination process.• The disability determination is not yet “final.”

If the information is... Then DHS...

Confirmed, Activates extended zero SOC Medi-Cal, and

Tracks the client’s SSA appeal status on MEDS until the disability decision becomes “final.”

Not Confirmed, Does not activate extended zero SOC Medi-Cal or track the appeal status.

Informs the MC Program Coordinator of the action taken.

5. MC Program Coordinator

Forwards the information from DHCS to the Medi-Cal Liaison.

6. MC Liaison Forwards DHCS information to the EW.

7. EW Takes the appropriate action to approve/deny Medi-Cal.

If DHCS... Then the EW must...

Activates the extended zero SOC Medi-Cal,

Deny Medi-Cal.

Does not activate extended zero SOC Medi-Cal,

• Process the application to determine Medi-Cal eligibility.

• Approve/deny as appropriate.

Reminder: Social Security Administration disability decisions are binding for Medi-Cal. A Medi-Cal applicant who has been denied SSI within the last 12 months must be screened to determine if a DDSD referral should be completed.

STEP WHO ACTION



5.30 Medically Indigent Adult (MIA) in LTC (53-0)

Case Managers work diligently to provide the most appropriate care for their hospital in-patients. When at all possible, persons who are otherwise ineligible for Medi-Cal but are expected to remain in intermittent long term care (LTC) for more than 30 days is ready to be transferred to a Long Term Care facility. Those individuals qualify for a Medi-Cal card under the 53-0 aid-type.

Medi-Cal Handbook“Treatment of MIA Residents of Skilled Nursing/ Intermediate Care Facilities,” page 26-7 in the Medi-Cal Handbook for regulations.]

5.30.1 Intake

The following must occur when a 53-0 card is required for a new application:

Who Action

Case Manager • Contacts Information Supervisor to inquire if the client has an application pending.

Information Supervisor

• Explains that an application must be on file if one is not already pending.

• Requests SC 41 and SAWS 1 from Case Manager.• Explains the process will take a minimum of 24 hours before a

card can be issued.• Refers information to Screener.

Screener • Meets patient in hospital.• Gathers necessary paperwork.• Returns paperwork to clerical at VMC.

Clerical • Receives paperwork.• Completes application/registration function in CalWIN.• Assigns case to an EW.

EW • Receives case assignment.• Initiates intake queue in CalWIN and enters information

screen by screen.• Runs EDBC and authorizes 53-0 aid-type.• Completes SC 1296 to initiate immediate need Medi-Cal card.• Submits case to supervisor for immediate review.

EW Supervisor • Receives and reviews case• Forwards case to clerical or returns to EW for corrections, as

appropriate.



5.30.2 Continuing

When the case has already been set up in intake and is pending a DDSD decision from Oakland, the following procedures apply:

Who Action

Case Manager • Contacts Information Supervisor to inquire if a 53-0 card may be issued.

Information Supervisor

• Requests the Case Manager fax verification to 793-1875.• Forwards request to Control to determine to whom the DDSD

case is assigned.• Notifies Continuing EW a 53-0 is going to be necessary.

Case Manager • Completes necessary paperwork.• Makes arrangements with LTC facility to transport patient to

facility and reserves bed.• Faxes verification to VMC.

Clerical • Receives fax.• Assigns case.• Forwards verification to Continuing EW of record.

Continuing EW • Receives case assignment.• Verifies the client is expected to stay at least 30 days in the LTC

facility.• Receives verification.• Initiates intake queue in CalWIN and enters information screen by

screen.• Runs EDBC and authorizes 53-0 aid-type.• Completes SC 1296 to initiate immediate need Medi-Cal card.• Retains case until DDSD decision is received.

Clerical • Receives case.• Performs all clerical functions to transfer case.• Batches and scans into IDM.

Who Action



5.31 Minor Consent

The processing of Minor Consent Mental Health applications is the responsibility of the VMC bureau. The following procedures will occur with Minor Consent applications:

WHO ACTION

Department of Alcohol and Drug Services (DAD)

• Completes application packet with client.• Creates a listing of applications.• Drops off application packets along with log at VMC.

NOTE: The application packet consists of an MC 210, MC13, MC 219, MC 115, an SC 558 for each month the client is applying for Medi-Cal, and verifications.

Clerical • Receives applications.• Creates SC 41 and marks them “MC Mental Health.”• Performs app/reg function and uses drop down menu of “Outstation.”

If the client is... Then clerical...

Active on Medi-Cal and has Full Scope Medi-Cal with no SOC or OHC,

• Prints a copy of the Medi-Cal card for the client.• Submits card to the designated supervisor for that

particular month.

Not active on Medi-Cal or does NOT have Full Scope Medi-Cal and/or has a SOC or OHC,

• Performs the app/reg function to register the application.

• Assigns application to the designated EW for that month.

EW Supervisor

Batches all Medi-Cal cards and faxes to Dan LLoyd at (408) 272-6569.

Designated EW

• Receives packet.• Processes case following the immediate need criteria.• Initiates queue and enters information screen by screen to authorize/deny

Medi-Cal.• Completes SC 1296 to request an immediate need Medi-Cal card.• Writes the case number at the bottom of the Medi-Cal card.• Batches Medi-Cal cards and submits to the EW Supervisor.• Batches cases and submits to Supervisor for review (usually next day).

EW Supervisor

• Receives cards.• Faxes to Dan Lloyd at (408) 272-6569.• Reviews cases and submits to clerical for transfer placing a green sticker on trans-

fer screen, or returns to EW for correction, as appropriate.• Completes list (template) and e-mails Dan Lloyd and designated SSPM I at

MCSC.



Note:EWs at VMC will be rotated on a monthly basis to process the Minor Consent applications. Supervisors at VMC will also rotate responsibilities on a monthly basis.

Medi-Cal Handbook“Minor Consent,” page 39-1 for detailed procedures regarding the regulations for Minor Consent services.]

5.31.1 Retro Medi-Cal for Minor Consents

[Refer to Medi-Cal CalWIN Announcement #06-07 for details]

5.32 San Andreas Regional Center (SARC)

Home Community Based Services (HCBS) are referrals from San Andreas Regional Center (SARC). Nine out of ten of the applicants are disabled children. Although the children are disabled, the majority of the children are treated as MICs and set up on an 6V-0 aid type.

5.32.1 Special Treatment

SARC applications are treated differently than other Medi-Cal applications as follows:

• The income and resources of the parents are not considered.

• The adults should NOT be pended.

• IEVS should only be requested for the child, not the parents.

• Income and property verifications are only needed for the child’s income and/or property, NOT the parents’.

Clerical • Receives cases.• Processes case as a priority assignment.• Scans paperwork into IDM.• Performs necessary functions in CalWIN.• Electronically transfers case to MCSC.

WHO ACTION



Note:The parents must list their property and income on the application because a determination must be made that the client would not be eligible for a no Share of Cost Medi-Cal without deeming.

Reminder:Under no circumstances should these cases be denied. Any SARC denial must be approved by the SSPM before any action is taken.

5.32.2 MFBU/Aid Codes

Children are in their own MFBU. Aid Codes are as follows:

• 6V (DDS-HCBS Waiver) No SOC, or• 6W (DDS-HCBS Waiver SOC.

Note:If there is more than one referred child in the family, each one is in a separate case.

Medi-Cal Handbook“Model Nursing Facility (Model-NF) Waiver,” page 40-11 for more information.]

5.32.3 VMC Application Process

The “Department of Developmental Services Waiver Referral” (DHS 7096) will be attached to the appropriate CalWIN and MEDS screens, along with an informational notice that must be sent to the clients.

The following must occur with SARC applications:

Who Action

Designated Supervisor

• Receives DHS 7096. • Assigns case to designated SARC worker.• Submits to clerical staff to initiate the app/reg process.• Completes informational notice.

Clerical Staff • Completes the app/reg function in CalWIN.• Assigns case to designated EW.• Returns packet to assigned EW’s Supervisor.



Note:NOTE: All SARC cases are to be transferred to the Medi-Cal Service Center (MCSC).

Medi-Cal Handbook“Model Nursing Facility (Model-NF) Waiver,” page 40-11 for more information.]

5.33 Children’s Health Initiative (CHI)

The goal of the Children’s Health Initiative is that 100% of the children residing in Santa Clara County shall have access to quality health care through comprehensive health insurance and that no uninsured child who is a resident of Santa Clara County, and whose parents have an income at or below 300% of the Federal Poverty Level (FPL), shall be turned away from receiving health coverage.

As such, EWs must follow the following process after a Medi-Cal eligibility determination is completed (in Intake or Continuing) and a child under 19 years of age is found to be:

• Ineligible for Medi-Cal• Eligible for Medi-Cal with a share of cost• Eligible for Restricted Medi-Cal

EW Supervisor • Completes the informational notice by entering the worker’s name, worker number and telephone number on the form of the worker to whom they are assigning the case.

• Establishes a monitoring system to ensure the case is approved.

EW • Sends a copy of the informational notice to parent(s), along with the application packet, and files the other in the case folder.

• Initiates queue and enters information screen by screen to authorize Medi-Cal.

• Handwrites the 14 digit Medi-Cal number on any approval, denial and/or discontinuance notice, and

• Sends a copy to the parent(s) and a copy to SARC at: P.O. Box 50002 San Jose, CA 95150-0002.

Who Action



• Eligible for the Bridging Program.

Step Action

1. Compare the countable household income to the FPL income limits for the Healthy Families (HF) and Healthy Kids (HK) program.

2. If the child is potentially eligible for HF and/or HK based on income and age factors, then explain this to the applicant and offer application assistance. NOTE: If working with a mail-in application or a redetermination by mail, this step may occur by phone and an appointment scheduled for the application assistance.

3. Assist the applicant to:

• Complete the appropriate application from (MC/HF Joint Application or Healthy Kids Application), if not previously completed.

• Select a Health Plan/Provider.

• Understand the premium requirements and amounts (including the Healthy Kids Hardship Fund, if appropriate).

• Understand the Healthy Kids Wait List implications for children over 5 years of age.

4. Photoplay (or print from IDM) any documents/verifications what will be required by the HF/HK programs.

5. Review the application for completeness and ensure that the application is signed by both the applicant and the EW.

6. Instruct the applicant to mail the application to the appropriate program.

• Healthy Families applications should include the premium payment.

• Healthy Kids applications do not require that premium payments be included with the application due to the waitlist. Healthy Kids will bill the family for the appropriate amount.

7. Submit the CHI Statistical counts.



5.34 Tuberculosis (TB) Clinic Applications

Effective May 2006, staff is no longer outstationed at the TB clinic. The following procedures apply to TB applications:

WHO ACTION

Client • Receives TB services from the Park/Alameda Clinic.• Meets with the Financial Counselor (FC) to complete MC 274 TB, SC 41

and Medi-Cal packet.

Financial Counselor (FC)

• Meets with the client to complete the MC 274 TB, SC 41 and Adult Medi-Cal packet.

• Prepares the packet and places the paperwork in the “Pick Up” basket in the FCs office.

Clerical

• Collects packets every Tuesday.• Returns packets to VMC and places in clerical basket for processing.• Receives Medi-Cal packet, including MC 274 TB and SC 41.• IDs case and completes application/registration function.• Submits applications to TB Supervisor for worker assignment.

TB Supervisor • Receives TB applications.• Equitably assigns the TB applications between the TB workers.• Returns to clerical for CalWIN case assignment.

Clerical • Receives TB applications indicating worker of assignment.• Performs case assignment task in CalWIN.• Distributes applications to TB Workers.

Eligibility Worker (EW)

• Receives application.• Initiates Intake queue and enters information into CalWIN, screen by

screen.• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Once Medi-Cal is authorized, completes the “MEDS Request”

(SCVMC 6836-5) for FCs. NOTE: All SCVMC 6836-5 completed for the week will be placed in a designated basket in the Supervisor’s office. Clerical will deliver all the SCVMC 6836-5 forms compiled for the week every Tuesday to the FCs when new applications are picked up.

Medi-Cal Handbook“TB Program,” page 37-1 for complete details on the TB Program.]



5.35 Mental Health Applications

Mental Health applications will be handled in a similar fashion as the Tuberculosis (TB) applications, in that the Medassist Representative will gather all the paperwork and forward it to VMC for processing. The Eligibility Worker will have minimal to no contact with the client. The following process will occur with mental health applications:

WHO ACTION

Client • Receives mental health services from the mental health facilities.• Meets with the Medassist Representative to complete necessary paper-

work to initiate a Medi-Cal application (i.e., SAWS 1, MC 210).

Medassist Representative

• Meets with the client to complete the Medi-Cal packet.• Prepares packet and delivers the paperwork to the reception area at

VMC.

Clerical • Receives Medi-Cal packet, including SAWS 1 and MC 210.• Completes SC 41.• IDs case and completes application/registration function.• Performs case assignment task in CalWIN.• Assigns applications to the next available worker.


• Receives application• Initiates Intake queue and enters information into CalWIN, screen by

screen• Runs EDBC and authorizes/denies Medi-Cal, as appropriate• E-mails Medassist Representative informing them of the status of the

application NOTE: Many of these cases will be DDSD pending, and the responsibility of the Continuing Worker to process.

• Submits case to Supervisor for review.

EW Supervisor • Receives case transfer• Reviews case• Forwards case to clerical or returns to EW for corrections, as appropriate.




5.36 Barbara Aaron Pavilion (BAP) Applications

Barbara Aaron Pavilion (BAP) is a treatment facility that provides emergency psychiatric services. The following procedures apply to Barbara Aaron Pavilion (BAP) applications:

Who Action

Client • Receives mental health services at BAP.• Meets with Medical Admitting Clerk to determine financial status.

Medical Admitting Clerk

• Meets with patient to determine financial status.• Contacts clerk at VMC to properly identify client and determine Medi-Cal

status.

Clerical • Receives call from BAP.• ID’s case in CalWIN and MEDS.

If the case is... Then Clerical

Open, Provides the EW’s name and phone number, and instructs the client to contact the worker of record.

Closed (or no case), • Requests Medical Clerk to provide the client with an SC 41 and SAWS 1.

• Instructs Medical Clerk to have the client complete the forms in the lobby.

Open and the individual needs to be added,

• Requests Medical Clerk to provide the client with an SC 41 and SAWS 1 to initiate the SC 1230 process.

• Instructs Medical Clerk to have the client complete the forms in the lobby.

Medical Admitting Clerk

• Completes SC 41 and SAWS 1.• Provides client with Medi-Cal packet.• Explains how to complete forms and that an appointment will be made

shortly to interview the client.• Hand carries application packet to VMC for processing.

Patient • Signs SAWS 1.• Receives Medi-Cal packet.

Clerical • Receives paperwork.• Enters information on SC 41.• Completes application/registration task in CalWIN.• Assigns case to an EW ASAP.• Enters EW number on BAP sheet.



5.37 Medassist (Argent)

Medassist, previously referred to as Argent, serves as a Collection Agency for Health and Hospital Systems (HHS). When HHS is unsuccessful at obtaining payment for services rendered, or accounts under Ability to Pay that are potentially Medi-Cal eligible, after a certain amount of time those accounts are placed in a closed file. On a monthly basis, Medassist reviews those closed accounts and works with Social Services Agency (SSA) in an attempt to activate the client’s Medi-Cal. Medassist receives approximately 10% of the amount collected for the hospital.

5.37.1 Procedures

The following procedures apply to Medassist applications:

Eligibility Worker • Receives application.• Makes appointment with client or family member ASAP.• Conducts face to face interview.• Initializes intake queue and enters information into CalWIN, screen by

screen.• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Submits case to EW Supervisor for transfer.

EW Supervisor • Receives case transfer.• Reviews case.• Forwards case to clerical or returns to EW for corrections, as appropriate.


Who Action

Medassist • Reviews closed accounts.• Selects those accounts that appear to have Medi-Cal eligibility.• Attempts to obtain authorization from the client to act as the

representative on behalf of the client. NOTE: If the release is not obtained, SSA is not allowed to speak with Medassist staff regarding the case status.

• Completes a SAWS 1 for those cases.• Logs applications on log sheet.• Forwards applications to VMC for processing.

Who Action



EW Supervisor or Designated EW

• Receives initial applications.• Reviews log to ensure all applications logged are enclosed.• Signs off log indicating applications are received.• Submits to clerical.

Clerical Staff • Receives applications.• Prints pertinent MEDS and CalWIN screens.

Designated EW • Receives packet.• Reviews screens to determine validity of application.

If the application is... Then the EW...

NOT valid, E-mails the list of invalid applications to the Argent Manager at HHS.

Valid, Submits to clerical for app/reg purposes.

Clerical • Receives returned packets.• Completes SC 41s for the valid applications.• Logs case name and number into log.• Completes app/reg function.• Places packet in basket for EW to pick up.

Designated EW • Receives applications.• Initializes intake queue and enters information into CalWIN,

screen by screen.• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Follows-up with client and/or Medassist Representative, as

appropriate.• Submits case to EW Supervisor for transfer.

EW Supervisor • Receives and reviews case.• Forwards case to clerical or returns to EW for corrections, as

appropriate.


Who Action



5.38 Planned Parenthood

The following procedures apply to applications received from Planned Parenthood:

Who Action

Client • Receives pregnancy related services at Planned Parenthood.• Meets with Financial Counselor to determine financial status.

Financial Counselor

• Meets with patient to determine financial status.• Contacts clerk at Tully Road Clinic to properly identify client and

determine Medi-Cal status.

Clerical • Receives call from Planned Parenthood.• ID’s case in CalWIN and MEDS.

If the case is... Then Clerical

Open, Provides the EW’s name and phone number, and instructs the client to contact the worker of record.

Closed (or no case), • Requests Financial Counselor to provide the client with an SC 41 and SAWS 1.

• Instructs Financial Counselor to have the client complete the forms in the lobby.

• Schedules an appointment for either Tuesday or Thursday.

Open and the individual needs to be added,

• Requests Financial Counselor to provide the client with an SC 41 and SAWS 1 to initiate the SC 1230 process.

• Instructs Financial Counselor to have the client complete the forms in the lobby.

Financial Counselor

• Completes SC 41 and SAWS 1.• Provides client with Medi-Cal packet.• Explains how to complete forms and provides date of interview.• Hand carries application packet to Tully Road Clinic for processing.

Patient • Signs SAWS 1.• Receives Medi-Cal packet.



5.39 Therapeutic Abortions (TABs)

These applications are considered Priority #1 emergency applications and are processed as follows:

Clerical • Receives paperwork.• Enters information on SC 41.• Completes application/registration task in CalWIN.• Assigns case to an EW.

Eligibility Worker • Receives application.• Conducts face to face interview.• Initializes intake queue and enters information into CalWIN, screen by

screen.• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Submits case to EW Supervisor for transfer.

EW Supervisor • Receives case transfer.• Reviews case.• Forwards case to clerical or returns to EW for corrections, as appropri-

ate.


WHO ACTION

Client • Applies for Medi-Cal and indicates an abortion is needed.

Clerical • Provides client with an SC 41 and SAWS 1.• Explains client must complete paperwork in office.

Client • Receives paperwork.• Completes forms indicating that an abortion is needed.• Submits paperwork to clerical.

Clerical • Receives SC 41 and SAWS 1.• Performs app/reg task in CalWIN.• Performs case assignment task in CalWIN.• Provides assigned worker with necessary paperwork and screens.

Who Action



5.40 Partners in AIDS Care and Education (PACE)

SSA has made special arrangements with the Partners in AIDS/HIV Care and Education (PACE) Clinic. When patients are seen at PACE and the patient is diagnosed with AIDS/HIV, the Medical Admitting Clerk will:

• Complete an SC 41 and SAWS 1.

• Pages the Screener and coordinates the appointment with the Screener to ensure the client is seen immediately.

• The Screener will meet the patient at the clinic and follow regular procedures to get the application processed.


• Receives application.• Processes application as immediate need.• Initiates Intake queue and enters information into CalWIN, screen by

screen.• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Arranges case for IDM scanning.• Submits to Supervisor for review.

EW Supervisor • Receives case.• Reviews case.• Submits to clerical for transfer or returns to EW for corrections, as appro-

priate.

Clerical • Receives case.• Scans into IDM.• Makes necessary entries in CalWIN to transfer case.

WHO ACTION



5.41 Homeless

The following procedures must be followed for clients who have no address:

WHO ACTION

Client • Applies for Medi-Cal and indicates he/she is homeless and has no address.

Clerical • Provides client with an SC 41 and SAWS 1.• Explains client must complete paperwork in office.

Client • Receives paperwork.• Completes forms indicating client is homeless.• Submits paperwork to clerical.

Clerical • Receives SC 41 and SAWS 1.• Performs app/reg task in CalWIN.• Performs case assignment task in CalWIN.• Provides assigned worker with necessary paperwork and screens.


• Receives application.• Processes application as immediate need.• Initiates Intake queue and enters information into CalWIN, screen by

screen.• Uses district office address most convenient to client.

NOTE: DO NOT USE MCSC’s ADDRESS!• Makes every attempt to secure all needed verifications at the first con-

tact. If unable to do so, makes arrangements to have client return, stress-ing importance of return appointment.

• Runs EDBC and authorizes/denies Medi-Cal, as appropriate.• Arranges case for IDM scanning.• Submits to Supervisor for review.

EW Supervisor • Receives case.• Reviews case.• Submits to clerical for transfer or returns to EW for corrections, as appro-

priate.

Clerical • Receives case.• Scans into IDM.• Makes necessary entries in CalWIN to transfer case.



5.42 SC 1230 Process

When a patient acquires a bill at the hospital and/or clinic, the Financial Counselor contacts clerical staff at VMC or the clinic to identify the patient and determine his/her Medi-Cal status. If the client should be activated/added to a case that is already in an active status, then a different process is followed.

5.42.1 SC 1230 Process for the Hospital

The following procedures apply to persons needing to be added to a case where a bill from the hospital was acquired:

WHO ACTION

Client • Receives in-patient services from the hospital.• Meets with the Financial Counselor (FC) to determine the pay status.


• Meets with the client to determine the pay status.• Calls clerical staff at VMC to determine the client’s Medi-Cal Status.



Clerical • Receives call from the FC.• IDs client in CalWIN and MEDS to make the most accurate determination

possible.

If the client has... Then clerical...

An application pending in an intake office other than the VMC Bureau,

• Informs the FC that the case is pending in another district office and hasn’t been assigned to an EW yet; and that VMC will be pulling the application back.

• Informs the FC to follow normal procedures as if client had no application and refer it to a screener.

• Contacts Intake Office and requests that the application be forwarded to VMC, that we would like to take over the application.

• Documents case log that application was requested.

NOTE: If the case is in a pending status and is assigned to an EW in another district office, the Financial Counselor will make note of it and fol-low-up periodically with the SSA Management Analyst to inquire on the status of the case.

A case that has been dis-continued over 30 days and is not pending in another District Office,

Informs the FC to follow normal procedures.

A case that has been dis-continued less than 30 days,

Informs the FC to complete the SAWS 1 and SC 41 and to place in the Screener’s basket for centralized SC 1230 process.

A case open in another district office but the indi-vidual receiving the ser-vices is not active,

Informs the FC to complete the SAWS 1 and SC 41 and to place in the Screener’s basket for centralized SC 1230 process.

A case open and the indi-vidual is active on MEDS,

• Stops the process.• Notifies FC the client is active and provides

MEDS information.


• Completes SC 41, SAWS 1 and admit sheet.• Maintains log of cases.• Places paperwork, including log, in the envelope marked “Attention: SC

1230 EW.”• Places packet in Screener’s basket.

Screening EW • Picks up the packet from the basket.• Hands-off packet to clerical basket marked “SC 1230s” upon returning to

VMC.

WHO ACTION



5.42.2 SC 1230 Process for Clinics

The following procedures apply to persons needing to be added to a case where a bill from a clinic was acquired:

Clerical • Receives packet.• Date stamps paper work.• IDs cases in CalWIN and MEDS.• Attaches pertinent screens to packet (e.g., Inquiry Case Info, Case Detail

Summary, Case Members, MEDS Screens, etc.)• Returns packet to SC 1230 EW.

SC 1230 VMC Worker

• Receives packet.• Reviews screens and CalWIN documentation for accuracy to ensure the

SC 1230 request if valid.• Completes the “VMC Medi-Cal Status Request” (SC 1230).• Prepares paper work so original documents can be scanned into the IDM

System. NOTE: Clerical does the actual scanning into IDM.

• Every Friday afternoon, forwards the SC 1230 and original documents to the EW of record.

• Forwards 2nd copy of SC 1230 to EW Supervisor. NOTE: For cases at MCSC, forwards to SSPM I.

• Logs SC 1230 into “Outstanding VMC Status Request” log book.• Files copy of SC 1230 in the file folder according to the corresponding

due date.• Forwards copy of log to VMC Management Analyst weekly.• Provides listing to SSPM the first Monday of every month.

District Office EW

• Receives the SC 1230.• Processes request, approving or denying the Medi-Cal.• Completes SC 1230 and submits it to the EW Supervisor.

District Office EW Supervisor

• Receives the SC 1230.• Follows up on the SC 1230 processing.• Returns the completed copy of the SC 1230 to the VMC Worker with the

appropriate MEDS screen.

SC 1230 VMC Worker

• Receives SC 1230 packet back.• Notifies Diana Steward via e-mail status of case.

NOTE: If the packet is not returned timely, the EW will send an SC 1230A to the EW, EW Supervisor and SSPM of that District Office.

WHO ACTION

Client • Receives out-patient services from clinics.• Meets with the Financial Counselor (FC) and/or Certified Application Assistant

(CAA) for appropriate screening.

WHO ACTION



FC / CAA • Meets with the client for appropriate screening.• Calls clerical staff at the designated clinic to determine the client’s Medi-Cal Sta-

tus. NOTE: The question on the SC 41, “Is aid being requested” must be marked “no” for those children who are already in receipt of Medi-Cal.

Clerical • Receives call from the FC/CAA.• IDs client in CalWIN and MEDS to make the most accurate determination possi-

ble.

If the client has... Then clerical...

An application pending in an intake office other than VMC Bureau,

• Informs the FC/CAA that the case is pending in another district office and hasn’t been assigned to an EW yet; and the clinic will be pulling the application back.

• Informs the FC to follow normal procedures as if client had no application.

• Contacts Intake Office and requests that the application be forwarded to that clinic, that we would like to take over the application.

• Documents case log that application was requested.

A case that has been discon-tinued over 30 days and is not pending in another District Office,

Informs the FC/CAA to follow normal procedures.

A case that has been discon-tinued less than 30 days,

Informs the FC/CAA to complete the SAWS 1 and SC 41 (indicating the date of service) and to forward the paperwork to VMC for the centralized SC 1230 process.

A case open in another dis-trict office but the individual receiving the services is not active,

Informs the FC/CAA to complete the SAWS 1 and SC 41 (indicating the date of service) and to forward the paperwork to VMC for the centralized SC 1230 process.

A case open and the individ-ual is active on MEDS,

• Stops the process.• Notifies FC/CAA the client is active and provides

MEDS information.

FC / CAA • Completes an SC 41 and SAWS 1.• Documents “ADD” at the top of the SC 41 (this will flag the application as an “add

on”)• Places in envelope marked “VMC: Attention SC 1230 EW.”• Places packet in the “Pony Box” located in the clerical area.

NOTE: Only request aid for family members who are not currently receiving Medi-Cal coverage and wish to be added to the case.

WHO ACTION



Clerical at VMC

• Receives packet.• Date stamps paper work.• IDs cases in CalWIN and MEDS.• Attaches pertinent screens to packet (e.g., Inquiry Case Info, Case Detail Sum-

mary, Case Members, MEDS Screens, etc.)• Returns packet to SC 1230 EW.

SC 1230 VMC Worker

• Receives packet.• Reviews screens and CalWIN documentation for accuracy to ensure the SC 1230

request if valid.• Completes the “VMC Medi-Cal Status Request” (SC 1230).• Prepares paper work so original documents can be scanned into the IDM System.

NOTE: Clerical does the actual scanning into IDM.• Every Friday afternoon, forwards the SC 1230 and original documents to the EW

of record.• Forwards 2nd copy of SC 1230 to EW Supervisor.

NOTE: For cases at MCSC, forwards to SSPM I. • Logs SC 1230 into “Outstanding VMC Status Request” log book.• Files copy of SC 1230 in the file folder according to the corresponding due date.• Forwards copy of log to VMC Management Analyst weekly.• Provides listing to SSPM the first Monday of every month.

District Office EW

• Receives the SC 1230.• Processes request, approving or denying the Medi-Cal.• Completes SC 1230 and submits it to the EW Supervisor.

District Office EW Supervisor

• Receives the SC 1230.• Follows up on the SC 1230 processing.• Returns the completed copy of the SC 1230 to the VMC Worker with the appropri-

ate MEDS screen.

SC 1230 VMC Worker

• Receives SC 1230 packet back.• Notifies Nuvia Hernandez via e-mail status of case.

NOTE: If the packet is not returned timely, the EW will send an SC 1230A to the EW, EW Supervisor and SSPM of that District Office.

WHO ACTION



5.42.3 EW Process

The following are tasks the EW must follow when processing SC 1230s:

NEW REFERRALS

• Receives referral from clerical.• Reviews referral to determine validity.

The the referral is...

Then the EW...

Invalid, • Logs the application.• Returns to clerical with an explanation as to why

it is invalid.

Valid, • Reviews CalWIN case comments for information.

• Reviews MEDS.• Completes “VMC Medi-Cal Status Request”

(SC 1230).• Logs the case in the SC 1230 Log.• Prepares packet for IDM purposes (SAWS 1,

Admit Sheet, SC 1230 and Case Management Screen.) Once paperwork is scanned:

• Ponies original SC 1230 with forms to EW.• Ponies a copy of the SC 1230 to the EW

Supervisor of record.

IF SC 1230 IS RETURNED BEFORE THE DUE DATE

The response time from the original referral is 30 days.

If the individual was...

Then the EW...

Approved, • Checks MEDS to ensure the month in question correctly activated.

• Documents case as received if activated correctly, and files the SC 1230.

Denied Reviews EW’s reason for denial in CalWIN

If Medi-Cal was... Then the EW...

• Denied correctly, • Enters case in log with denial reason.

• Files original SC 1230.

• Denied incorrectly,

• Sends an SC 1230 A to EW and EWS.

• Documents reason in CalWIN case comments.

• Updates log.



Note:When a 3rd request is required, the SSPM sends a notice to the District Office SSPM.

5.43 Renal Dialysis

Patients receiving Renal Dialysis need immediate attention, as their lives depend on renal dialysis for survival. Renal Dialysis applications are to be treated as priority #1 applications. When patients are seen for Renal Dialysis, the Social Worker will:

• Complete an SC 41 and SAWS 1.

• Fax the paperwork to VMC.

• The paperwork is processed by clerical staff and handed off to the Screener.

SC 1230 NOT RECEIVED BY DUE DATE

• Reviews referrals due.• Checks MEDS and CalWIN (case comments and wrap-up).

If action has... Then the EW...

Been taken, Completes steps as noted previously.

NOT been taken, Initiates the SC 1230 A process as noted previously.

(SC 1230 A) NOT RETURNED

• Reviews referrals due.• Checks MEDS and CalWIN (case comments and wrap-up).

If action has... Then the EW...

Been taken, Completes steps as noted previously.

NOT been taken, • Initiates a second SC 1230 A request and follows procedures as noted previously.

• Forwards a copy to District Office SSPM and SSPM at VMC.

SC 1230 LOG • EW provides a copy of log every Friday to the Management Analyst. NOTE: If no changes from the previous week and e-mail will be sent to notify the MA.

• Provides copy of logs separated by District Office to the VMC SSPM the first Monday of every month.

• Updates log monthly, removing those updated and documenting those that required follow-up.

• E-Mails the monthly log on a monthly basis.



The Screener will make arrangements with the Social Worker to meet the patient at the clinic. Regular procedures will be followed to get the application processed.


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