Medi-Cal Handbook Transitional Medi-Cal (TMC) 37 ... · the family proves that the discontinuance...

Medi-Cal Handbook page 37-1Transitional Medi-Cal (TMC)

37. Transitional Medi-Cal (TMC)

37.1 Overview [50244]

The Family Support Act of 1988 expanded or replaced certain provisions of the AFDC program with some comprehensive program changes including:

• An increased emphasis on the collection of child support.

• Opportunities for employment training.

• Transitional Child Care (TCC) assistance available to pay part of an employed person's child care costs after federal cash payments have stopped.

• Up to 12 months of zero share of cost Medi-Cal for recipients discontinued from AFDC (now CalWORKs) due to:

• An increase in the earnings or hours from employment of the caretaker relative or the principal wage earner, or

• The loss of the $30 and 1/3 earned income disregard by anyone in the family.

The TMC Program is effective 4/1/90 for eligible persons who became ineligible for CalWORKs/Section 1931(b) on or after 3/31/90. Effective January 1, 1998, reference to AFDC has been changed to mean CalWORKs or the Section 1931(b) program. Neither CalWORKs nor Section 1931(b) has time limits on earned income disregard.

Effective 10/1/95, TMC was expanded to include families who were discontinued from AFDC (and now CalWORKs) due to the marriage or reuniting of spouses, which caused assets and/or income to exceed the AFDC limits, or who no longer met the deprivation requirements. Effective June 1, 1999, Wedfare was eliminated as an eligibility factor for TMC, however, families receiving TMC under this federal waiver provision could continue to receive benefits until their maximum of one year federal TMC benefits was complete.

Due to welfare reform (PRWORA), the AFDC program ended on 12/31/97 and California replaced it with the CalWORKs program. Effective 1/1/98, Section 1931(b) Medi-Cal was established to provide Medi-Cal coverage for CalWORKs families and families who meet the income, property and deprivation requirements

Update # 13-08 Revised: 06/28/13

2 Medi-Cal HandbookTransitional Medi-Cal (TMC)

of the AFDC program as it existed on 7/16/96. TMC eligibility became linked to the receipt of either component of the Section 1931(b) Medi-Cal Program. This provided that recipients of cash-based or non cash-based Section 1931(b) Medi-Cal who are discontinued for increased earnings are eligible for the TMC Program for up to twelve months. Because the rules developed for Section 1931(b) are in some cases less restrictive than CalWORKs rules it is possible that families leaving cash aid may continue to be eligible for Section 1931(b) Medi-Cal. If not, and if they were discontinued from CalWORKs due to increased earnings, they may be eligible for TMC.

Assembly Bill 2780 signed into law by the Governor in 1998, provided a second year of TMC with state-only funding for persons 19 years and older in addition to the existing federal program. Effective October 1, 2003, Assembly Bill 1762 eliminated the second year of TMC. No new persons were added to this program after September 30, 2003.

Because otherwise eligible aliens who do not have Satisfactory Immigration Status may be eligible under Section 1931(b) for restricted benefits, TMC was also expanded to include persons with restricted benefits.

37.1.1 Who Qualifies for TMC

Persons terminated from CalWORKs must first be evaluated for Section 1931(b) prior to determining eligibility for TMC.

If the family is... And... Then the family...

Eligible for Section 1931(b),

Remain on Section 1931(b) until determined ineligible for that program.

Not eligible for Section 1931(b) after CalWORKs discontinuance,

The CalWORKs or Section 1931(b) discontinuance reason is due to increased earnings/hours from employment,

Must be evaluated for TMC.

Note:Persons who received Section 1931(b)-ONLY for three of the last six calendar months and are terminated for increased hours/earnings from employment are also eligible for TMC even if they were never a recipient of CalWORKs.

Revised: 06/28/13 Update # 13-08


Qualifying Criteria for Discontinued CalWORKs/Section 1931(b)

Families are eligible to receive Initial TMC (Aid Code 39) benefits for a period of up to six months following the month in which they became ineligible for CalWORKs/Section 1931(b) if:

• They were eligible for and received a federal cash grant or non cash-based Section 1931(b) Medi-Cal in at least three of the six calendar months immediately preceding the month that ineligibility was determined.

Note:Federal cash aid includes Aid Codes 30, 33, 35, 40, 42, 4C, 4F, 4G, 3E, 3G, 3H, 3L, 3M, 3P, 3R, and 3U.

AND

• They were discontinued from a federal cash grant or non cash-based Section 1931(b) Medi-Cal because of increased income from the employment of the PWE or caretaker relative of a child who is in or added to the CalWORKs filing unit, including parents of an SSI child.

Note:In the case of a two-parent household, TMC eligibility may be due to the earnings of either parent.

Reminder:WEDFARE: The marriage or the reuniting of spouses which caused assets and/or income to increase above the CalWORKs limit or resulted in the family no longer meeting the deprivation requirements was eliminated as an eligibility factor for TMC effective June 1, 1999. TMC is NOT available to married (or unmarried parents) who reunite after 6/1/99.

If the EW becomes aware within 30 days of the CalWORKs discontinuance that the family could have been determined ineligible for cash aid for the above reason, TMC must be established effective the 1st of the month following the date of CalWORKs ineligibility. This applies to any reason for discontinuance, as long as the family proves that the discontinuance could have been based on the qualifying reason for TMC.

Example:A CalWORKs family fails to return a QR 7. The case is discontinued and automatically converts to Aid Code 38. The EW determines that the parent returned to work and the family would have been eligible for TMC as there is no eligibility for Section 1931(b). Establish TMC and reduce the Initial TMC



period by the number of months the family received Aid Code 38 Medi-Cal. Since Aid Code 38 is a zero share-of-cost Medi-Cal program, there is no need to retroactively changed it to a TMC Aid Code 39 on MEDS.

Discontinuance from CalWORKs/Section 1931(b) solely due to the receipt of State Disability Insurance (SDI) does not make persons eligible for TMC. The TMC regulations do not consider receipt of SDI as an “increase in hours or earnings from employment,” therefore, there is no eligibility for TMC.

Non-Qualifying CalWORKs/Section 1931(b) Discontinuance Reasons

TMC is not available to persons who are discontinued from CalWORKs/Section 1931(b) for the following reasons. This includes, but is NOT LIMITED to:

• The reuniting of spouses.• The increased earnings of a child in the AU.• An increase in a stepparent contribution.• The return of an unmarried absent parent to the home, thus ending deprivation.• The stepparent's ability to meet the needs of the parent.• The increased earnings of a parent who was:

• Receiving SSI, or• A caretaker stepparent.



Definitions/ Who Qualifies for TMC

The following CalWORKs/Section 1931(b) definitions apply when determining who is eligible for TMC:

Terminology Definition

Recipient A person is considered to be a CalWORKs/Section 1931(b) recipient if he/she:

• Received CalWORKs/Section 1931(b) (including zero basic grant, under $10).

• Is eligible for but not receiving CalWORKs/Section 1931(b) because of an administrative reason, such as:

a. A determination is pending of the amount of the cash grant, or

b. An overpayment is being adjusted, or

c. A change of the recipient's representative payee.

Note: Persons sanctioned by CalWORKs for failure to participate in CalWORKs Employment Services (CWES) activities or failure to pursue child/spousal support are eligible for TMC, and if otherwise eligible, considered recipients of CalWORKs.

Family “Family” for purposes of establishing TMC means:

• All the members of a family unit in which the caretaker relative was eligible for and received CalWORKs/Section 1931(b) in 3 of the last 6 months, OR

• Individuals who were members of the CalWORKs/Section 1931(b) family unit during the month the family was determined to be ineligible.

• Family members who enter the home during the Initial or Additional six-month TMC period.

Caretaker Relative

For TMC purposes, a caretaker relative is the person in the home responsible for the care and control of a dependent child, and must be one of the following:

• The father, mother, brother, sister, half-brother, half-sister, uncle, aunt, first cousin, nephew, niece or any such person of a preceding generation denoted by the prefixes grand, great, great-great.

• The stepfather, stepmother, stepbrother or stepsister.

• The spouse of a person specified above, even after the marriage has been terminated by death or dissolution.



37.1.2 Ineligible Persons

The following persons are not eligible for TMC:

• A Supplemental Security Income (SSI) recipient.

• An In Home Supportive Services (IHSS) recipient

• Parents or mutual children with no linkage or the father of an unborn with no other children

• Persons who were discontinued from CalWORKs/Section 1931(b) due to loss of deprivation when a parent/spouse with earnings returns home

• Persons discontinued from CalWORKs or Section 1931(b) due to the change in the treatment of state disability insurance payments from unearned to earned income because this is not considered actual earnings from employment

• Persons who were convicted of fraud at any time during the last six months in which the family received Section 1931(b)-ONLY

• Persons who do not meet the CalWORKs definition of a child (over 18 and not enrolled in school and expected to graduate by age 19) unless they are a child prior to entering TMC. Then they remain eligible unless they are the youngest child in the home. In that case, the entire TMC family must be discontinued

• Persons who were not eligible for CalWORKs or Section 1931(b) and whose income and resources were not counted when determining family members who were receiving CalWORKs or Section 1931(b) such as non-needy caretaker relative

Child A child, for purposes of establishing TMC is under age 18, or is an 18-year-old who meets the CalWORKs age requirements and is in school or a vocational program and expected to graduate before age 19.

• Persons who do not meet the CalWORKs definition of a child are not eligible for TMC unless they met the definition of a child when Initial TMC was approved.

• If a child should become an adult during the TMC period, he/she may remain on TMC unless he/she is the youngest child in the home. In that case, the entire family is discontinued from TMC, and must be evaluated for other Medi-Cal Programs.

Terminology Definition



• Persons who remain eligible for Section 1931(b) because they are a Sneede class member and they are in a separate MBU. [Refer to “MFBU Composition,” page 37-8.]

Ineligible Aid CodesIndividuals who receive assistance under RCA/ECA Aid Codes 01 or 08 are NOT eligible for TMC.

37.1.3 Adding a Person to Existing TMC

In addition to the individuals who were included in the CalWORKs or Section 1931(b) family unit at the time the family lost eligibility, family members who enter the home during the initial 6-month period, additional 6-month period may be eligible for TMC. These persons include:

• Newborn or adopted children

• Persons who would have been eligible for CalWORKs or Section 1931(b) if they had been in the home in the month the family was determined to be ineligible

• Persons under CalWORKs sanction for failure to cooperate with work requirements or child/spousal support, whose income but not needs were included in the CalWORKs unit

• Other CalWORKs sanctioned or ineligible persons such as undocumented, fleeing felons, or whose 60-month time limit has expired, whose income but not needs were included the CalWORKs unit

• Persons in the family who were terminated from Supplemental Security Income (SSI) due to increased earnings from other family members on CalWORKs or Section 1931(b).

Reminder:Any earned income of the above added persons must be counted when computing the family’s earned income if he/she wishes to receive TMC. Persons added to the TMC case only receive TMC for the remainder of the family’s TMC period. Adding a new person with earnings during the TMC period may cause the family to have earned income over 185% of the Federal Poverty level which may cause the family to be ineligible for Additional TMC.

Note:TMC recipients are included as “ineligible persons” of the MFBU when determining the share of cost for other family members.



37.1.4 Persons Leaving the Home

TMC continues for families even if the parents or spouses separate or divorce or children leave the home in either the initial or additional TMC period; however, the remaining TMC family must continue to reside in California and must include a child.

Reminder:The family size is reduced when determining the average earned income during the additional six-month TMC period since the person who left is no longer included in the MFBU. The family’s earned income may also be reduced to the extent the person who left had earned income. If the family size changed during the preceding three-month period, use the current family size.

37.1.5 MFBU Composition

Persons receiving TMC are ineligible members of the MFBU of those persons who are not eligible for TMC when determining Medi-Cal eligibility for other family members and may use their non-covered Medi-Cal health care costs to reduce other family members’ or responsible relatives’ share of cost.

It is possible that some persons will be eligible for Section 1931(b) and some will not after Sneede rules are applied.

Example:A mother and her separate child are eligible for Section 1931(b) and her spouse and his separate child are not even though they have linkage. The husband and his separate child are eligible for AFDC-MN. If the Section 1931(b) mother’s earnings from employment cause her and her child to lose Section 1931(b) eligibility, they are eligible for TMC. However the other family members may remain in the MN program. If the family income decreases, those persons in the MN program should be re-evaluated to determine if they would be eligible for Section 1931(b)

Due to Sneede rules, some persons may continue to be eligible for Section 1931(b) even if some of the other family members are over the income or property limits and eligible for TMC. Section 1931(b) persons may continue to receive Medi-Cal until they are no longer eligible. If they have received Medi-Cal under Section 1931(b) for three of the last six months, and have been terminated for increased earnings from employment, they are then entitled to TMC for the entire TMC period if they remain eligible even though other family members have already been receiving TMC in prior months. They may have status reporting due dates different from the other members of the family who began receiving TMC in prior months.



Optional Members

A person who is not receiving any Medi-Cal benefits and does not wish to be added to the TMC case (e.g., absent parent returns home during the TMC period of his family) is NOT required to be included, and his/her income is NOT counted, and is NOT considered in the family size for the 185% FPL determination. However, if optional members choose to be included during the TMC period, he/she cannot be excluded until the family becomes ineligible for TMC.

37.1.6 Return to CalWORKs or Section 1931(b)

If a family returns to CalWORKs or Section 1931(b) during any of the TMC periods and is then terminated due to another reason which does not meet the TMC criteria (e.g., is not related to employment or does not meet the three out of preceding six-month requirement), the family is:

• Eligible for the remainder of the original TMC period if they are otherwise eligible.

• The months of zero Share of Cost Medi-Cal which they received when they returned to CalWORKs or Section 1931(b) are counted as if TMC were received in those months for purposes of determining the remaining months of the original TMC period.

• If they meet the requirements of TMC when terminated, they are evaluated for a new Initial TMC period.

Example:A family was discontinued from CalWORKs due to increased earnings of the caretaker relative.They received TMC for four months. The caretaker relative became unemployed and the family was again eligible for CalWORKs. After two months, they found another job and were again discontinued from CalWORKs.

• The two months of cash-based Section 1931(b) Medi-Cal counts as if TMC were received and completes the Initial TMC period.

• The family is not eligible for Initial TMC under a new TMC program because they did not receive CalWORKs or Section 1931(b) Medi-Cal in three out of the preceding six months, however they are eligible to receive an additional six months of the original TMC period if all other eligibility criteria are met.



Note:Persons who were terminated from CalWORKs or Section 1931(b) must meet deprivation rules when they lose eligibility for TMC and return to those programs.

37.1.7 EW Procedures/Responsibility

EWs must follow these procedures when determining eligibility for TMC:

Step Action

1 Determine if the discontinuance of CalWORKs/Section 1931(b) is due to increased hours of employment or increased employment related earnings of the parent/caretaker relative.

REMINDER: TMC is not available due to marriage or the reuniting of separated spouses/unmarried parents.

2 Review the case information to determine if the family was eligible for and received CalWORKs or Section 1931(b) in three out of the last six months. The three months do not have to be consecutive.

3 Set up the initial six months of Transitional Medi-Cal on Aid Code 39/3T if both conditions (1 & 2) above apply.

4 The TMC Approval NOA will be automatically generated by CalWIN when TMC is approved.

5 The case may be transferred no earlier than the first working day of the second month following the month of CalWORKs/Section 1931(b) discontinuance.

EXAMPLE: CalWORKs is discontinued timely on 7/31. Transfer to the MCSC (if no Food Stamps) no earlier than the 1st working day in September.

• This is to allow for the possibility of a restoration of CalWORKs benefits, should there be an erroneous CalWORKs discontinuance, e.g., the client reports an expected increase in hours, yet remains working less than 100 hours per month.

• If CalWORKs was erroneously received prior to the actual discontinuance, the TMC case may be transferred within the first month following the CalWORKs discontinuance. Complete any appropriate overpayment referrals.

• If only one month of Initial TMC (Aid Code 39/3T) eligibility remains, the EW must determine eligibility or ineligibility for Additional TMC (Aid Code 59/5T) prior to transferring the case.



37.1.8 TMC Informing Flyer

The “Request for Transitional Medi-Cal (TMC) or Four Month Continuing Medi-Cal” (MC 325) contains information about the TMC program and a section for clients to provide information on increased earnings or child support and request TMC benefits. The MC 325 must be provided to:

• CalWORKs and Section 1931(b) applicants when Medi-Cal eligibility is approved,

• CalWORKs recipients discontinued for failure to complete an annual redetermination or submit a complete QR 7,

• Section 1931(b) recipients discontinued for failure to complete an annual Redetermination or submit a complete MSR.

37.2 Initial Six Months of TMC (39/3T)

Persons who are eligible for Initial TMC will receive zero share-of-cost Medi-Cal for up to six months immediately following the last month of CalWORKs/Section 1931(b) discontinuance. The first six-month period has NO eligibility requirements other than that the family must continue to have a child living in the home and the family must reside in California.

• No application is required

• There must be no break in aid

• Property is not considered as a condition of eligibility

• No 185% FPL test when setting up Initial TMC. The 185% test is for determining eligibility for Additional TMC.

• Redeterminations are not required during this period (unless there is a requirement for another aid category, e.g., Food Stamps).

Note:Adults on TMC (whether Initial or Additional) are not required to complete a Midyear Status Report. The MC 176 TMC is sufficient.



Reduction in Initial TMC Months

The period of time for which individuals are set up for Initial TMC (Aid Code 39/3T) must be decreased by the number of months they erroneously received zero share-of-cost Medi-Cal under Aid Code 38 or a CalWORKs overpayment after the date the family became technically ineligible for CalWORKs.

Example:The family has failed to report that a parent/caretaker relative became employed in April. The EW would have discontinued the cash grant effective April 30th had the information been reported timely; instead, the grant was discontinued June 30th. The Initial TMC period should have been May to October. Because of the fact that a CalWORKs grant was erroneously received in May and June, the Initial TMC period for the family begins in July and ends in October.

37.3 Additional Six Months of TMC (59/5T)

Persons who are eligible for the entire six month Initial TMC period may be eligible for up to another six additional months of zero share of cost Medi-Cal immediately following Initial TMC if:

• There is an eligible child residing in the home.

• The family meets the TMC reporting requirements.

• The parent/caretaker relative has earnings in one or more of the last three months of Initial TMC, unless the unemployment results from:

• Involuntary loss of employment

• Illness

• Other good cause.

• The family's average net nonexempt earned income does not exceed 185% of the federal poverty level according to family size.

Note:There is no separate Approval NOA required for Additional TMC (59/5T).



Reminder:There is no property limit for Initial/Additional TMC.

Eligibility for Additional TMC must be discontinued as soon as a timely discontinuance NOA can be issued if none of the above criteria is met.

If the family did not receive the Initial TMC for the entire six-month period, then the family is not eligible for Additional TMC.

Example:The only child left the home in the third month of the Initial TMC period. The family was terminated from TMC. In the fifth month, the child returned to the home. The family is eligible to received the remaining two months (fifth and sixth month) of the Initial TMC. However, the family is not eligible for Additional TMC because they did not receive the entire six months (i.e., no eligibility in the fourth month) of Initial TMC.

Exception:The family moved to another state in the first month of the Initial TMC period. Although the family continues to meet all the Initial TMC eligibility requirements, TMC must be discontinued because they are no longer California residents. The family returned to California in the third month of the Initial TMC period. They may receive the remainder of the Initial TMC six-month period and Additional TMC (if otherwise eligible) since the family continued to be eligible for TMC even though they did not actually receive the entire six months of Initial TMC.

Persons who are found to be ineligible for Additional TMC must have their eligibility determined for other Medi-Cal programs.

Note:Adults on TMC (whether Initial or Additional) are not required to complete a Midyear Status Report. The MC 176 TMC is sufficient.



37.4 TMC Status Report

This section covers status report requirements for both Initial TMC (39/3T) and Additional TMC (59/5T).

TMC Program

Initial TMC (Aid Code 39/3T)

Persons receiving Initial TMC (Aid Code 39/3T) must submit a quarterly status report (MC 176 TMC) by the 21st day of the 4th month.

The status report covers the preceding 3-month period, including any month(s) that the family erroneously received CalWORKs.

Example 1: (CalWORKs discontinued timely) CalWORKs is discontinued timely on 7/31 and Aid Code 39/3T is established 8/1. The first quarterly status report will be generated in the October transmittal process and is due by no later than 11/21. The report months are August, September and October.

Example 2: (Initial TMC period reduced) The EW learns from the QR 7 submitted 8/10 that the parent became fully employed 7/9. The family is ineligible for CalWORKs in July and August. Initial TMC (Aid Code 39/3T) is approved for four months beginning 9/1. The first status report will be sent at the end of September and is due 10/21. The report months are July, August and September.

The MC 176 TMC status report does not meet Food Stamp reporting requirements.

The MC 176 TMC submitted in Month 4 of Initial TMC is used to determine eligibility for Additional TMC (59/5T).

Additional TMC can be established if a complete and correct status report is received prior to the last day of Initial TMC eligibility, and the family’s net nonexempt earned income does not exceed 185% of the federal poverty level.



37.4.1 Good Cause Determinations

A beneficiary may have good cause for not meeting the reporting requirements during either the Initial or Additional six month TMC period. Good cause exists only when the beneficiary cannot reasonably be expected to fulfill his/her reporting responsibilities due to factors beyond his/her control. The burden of proof is on the client.

The following criteria must be met when determining if good cause exists.

• A good cause determination must only be granted if the request is made by the parent, caretaker relative, or an authorized representative.

• The beneficiary must make a clear written or verbal request for an opportunity to give an explanation for not meeting the reporting requirements.

• Or, in lieu of a request, the EW must determine that one of the following reasons for good cause exists:

• The client has a mental or physical condition which prevents or interferes with timely and/or complete reporting.

• The delay in reporting or failure to report is due to county error.

Additional TMC (Aid Code 59/5T)

Once Additional TMC eligibility has been established, status reports (MC 176 TMC) are due by the 21st day of:

• The first month of Additional TMC (month 7 of ongoing TMC eligibility), and

• The fourth month of Additional TMC (Month 10 of ongoing TMC eligibility).

Additional TMC can be continued if:

• A complete and correct status report is received prior to the effective date of discontinuance, and

• The family is otherwise eligible (e.g., income is at or below 185% of the federal poverty level), and

• The EW determines that the family had good cause for failure to meet the reporting requirements, and

• The Additional TMC period has not expired. (Aid Code 59/5T can only be received for a maximum of six months.

TMC Program



• The EW establishes that there are other extenuating circumstances.

Reminder:The good cause determination must be documented on the Maintain Case Comments window.

37.4.2 Incomplete TMC Status Reports

When a TMC status report is incomplete:

• Contact the client by phone or send an MC 355 when a status report is incomplete and additional information is needed to determine ongoing TMC eligibility.

• Follow the specific TMC program reporting requirements.

• The Initial TMC (39/3T) status report is due by the 21st day of the 4th month, but TMC benefits cannot be stopped until the end of month 6, even when the status report is not received or not correct.

• The Additional TMC (59/5T) status reports are due by the 21st day of the 1st and 4th months. If the TMC status report is not received, the EW will not be able to terminate benefits until the following month in order to provide a timely and adequate discontinuance NOA.

Example:A family receiving Additional TMC has an MC 176 TMC due on 9/21 which is not received. There is not enough time to send a 10 day notice of discontinuance for September. Therefore, a redetermination packet must be sent immediately (MC 210RV, MC 219, etc.), and Aid Code 59/5T discontinued 10/31. [Refer to “Redetermination Due to Loss of TMC Eligibility,” page 37-21]

37.4.3 Status Report Verification Requirements

Status reports must include all information and the following verifications for EACH of the three months included in the report period.

• Gross income of all family members, including:

• The earned income of all family members living in the home who were members of the AU during the month the family became ineligible for CalWORKs/Section 1931(b), and



• Earnings of family members who are not eligible for TMC and are receiving Medi-Cal under another program such as Section 1931(b), Medically Needy, Medically Indigent, and

• Any parent(s) who return to the home and added during the TMC period,

• Any nonexempt earnings of children.

• The actual, unreimbursed child care expenses paid by the parent/caretaker relative in order to remain employed.

• The other health coverage premium, in order to be allowed as an earnings deduction.

• Send an MC 355 if an incomplete status report is received.

Reminder:Unlike CalWORKs, Medi-Cal status report information can be clarified by a telephone call to the client and documented by the EW whenever possible.

37.4.4 Nonexempt Earned Income

The family's average nonexempt earned income is used to determine eligibility for Additional TMC (Aid Code 59/5T).

• Exempt earned income is not counted when computing the family's earnings.

• Exempt student income (50543)• Earnings of a child under age 14 (50544)• The Earned Income Tax Credit• Irregular/Infrequent income (50542)• Earnings of an optional TMC member (per Section 5.1.5).

[Refer to “Exempt Earned Income,” page 56-4 if more information is needed.]

• Unearned income is not counted in determining eligibility for TMC.

• Earnings disregards are not allowed when computing net-nonexempt earnings for TMC (e.g., the $90 work related expense deduction).

• Deduct the actual, unreimbursed child care expenses paid by the parent/caretaker relative in order to remain employed



Reminder:There is no property limit for TMC.

37.4.5 Determining Average Net-Nonexempt Earned Income

Family earnings must remain at or below 185% of the FPL to be eligible for additional TMC. The family's average net-nonexempt earned income is determined as follows:

• The average monthly gross earnings for the preceding 3 month period after deduction of any monthly child care expenses necessary for employment are compared to 185% of FPL for the current family size, even if some family members are not eligible for TMC and are receiving Medi-Cal under Section 1931(b), MN or MI (except PA or Other PA).

• Family earnings include those of a child as well as the parent(s) or parent and stepparent. Sneede rules apply.

• Child care expenses that are reimbursed by the state are not allowable nor are any other deductions.

• A person who is not receiving Medi-Cal benefits and does not wish to be added to the TMC case, such as an absent parent returning home during the TMC period of his family is not required to be included and his/her income is not counted, nor is he/she considered in the family size.

TMC Status Report Worksheet

The “TMC Status Report Worksheet: (SC 1638) may be used for a manual calculation. The following illustrates the process used for manual calculations:

Complete header information

• The “Report Period” includes the 3 months covered by the status report.• The “Month Affected” is either:

• The 1st month of Additional TMC (Aid Code 59/5T), or

• The month following the month that the status report is due.

• The number in the family includes:

• Persons receiving TMC, and• Ineligible members of the MFBU.



• Enter 185% of the federal poverty level (FPL) used for Medi-Cal Programs. [Refer to Chart Book, “Federal Poverty Level (FPL) Programs Monthly Income Comparison Chart”, page 5-9.]

Does this family include at least one eligible child?

• If yes, continue.• If no, discontinue TMC(A 10-day NOA is required).

Was the parent/caretaker relative unemployed during one or more months of the report period?

• If yes, determine if there was good cause. Good cause exists if the unemployment results from:

• Involuntary loss of employment• Illness• Other good cause, as determined by the EW.

• If no, continue.

Compute the family's earned income:

To determine the family's average net-nonexempt earned income:

• Include the nonexempt earnings of adults and child(ren) in the MFBU.

• Include the gross earnings of any other family members who are now in the home and who are not receiving TMC.

• Subtract any health insurance premiums which are actually being paid by the family.

• Verify the premium amount.• Obtain a “Health Insurance Questionnaire” (DHS 6155) if one is not currently

on file.

• Subtract from the gross earnings, the actual amount of child care paid by the parent/caretaker relative and not reimbursed.

Important

Do not allow child care which will be reimbursed by another source.

• Divide the quarterly total by three.



• After calculating the adjusted monthly income, round it to the nearest dollar before comparing to the FPL income standard. (Use the usual Medi-Cal rounding rules; if the decimal number is 0.49 or less, round down, and if the decimal number is 0.50 or larger, round up).

• If the family's average net-nonexempt earned income is less than or equal to 185% of the federal poverty level for the MFBU, establish or continue Additional TMC (Aid Code 59/5T).

Note:Due to federal requirements, eligibility for Additional TMC is based on the average earnings that the family received in the first 3 months of Initial TMC even though there is a time lag and the income may fluctuate.

• If the average net-nonexempt income of the MFBU is over 185% of the federal poverty level:

• Discontinue Initial TMC (39/3T) at the end of the 6th month, or

• Discontinue Additional TMC (59/5T) as soon as a timely and adequate NOA can be issued.

• Evaluate eligibility under another Medi-Cal program.

37.5 Termination of Initial/Additional TMC

Initial TMC (Aid Code 39/3T) can only be terminated prior to the end of the initial six months if any of the reasons below exists. Additional TMC can be terminated at anytime if any of the following reasons exist, or as soon as a ten-day NOA can be issued if a status report (MC 176 TMC) is not received.

• Lack of California residency

• Whereabouts unknown (e.g., mail returned with no forwarding address)

• Client requests discontinuance

• There is no longer an eligible child in the home. The family must be discontinued at the end of the month in which the last child resides in the home. A ten-day NOA is required.



37.6 Redetermination Due to Loss of TMC Eligibility

As soon as ineligibility for TMC is known, EWs must follow the SB 87 ex parte process and send a redetermination packet immediately.

When the Statement of Facts on file is over 12 months, send the following to the client:

• A “Medi-Cal Annual Redetermination” (MC 210 RV) form• The “Important Information for Persons Requesting Medi-Cal” (MC 219).

Additional forms must be sent as appropriate such as:

• “Statement of Citizenship, Alienage, and Immigration Status” (MC 13)

Reminder:Completion of an MC 13 is not required for U.S. citizens/nationals. An MC 13 must be sent only if there is a change in citizenship/immigration status.

• “Health Insurance Questionnaire” (DHS 6155). Send this form only if the client reports new or a change in OHC information.

Note:Other health coverage may be available through the employer and the client may qualify for the Employer Group Health Plan Program (EGHP) or the Health Insurance Premium Payment Program (HIPP). [Refer to “Health Insurance Premium Payment (HIPP) Program,” page 12-15.]

Processing the Redetermination Packet

The chart below identifies different situations that may occur and provides corresponding actions that an EW must take to redetermine a client’s continued eligibility for Medi-Cal.

If the... Then...

Client does not return the redetermination forms within 20 calendar days,

Discontinue the case at the end of the Initial TMC six-month period with a ten-day NOA or as soon as a ten-day NOA can be issued to discontinue the Additional TMC eligibility.



Redetermination packet is returned incomplete within the 20-day time frame,

• Attempt to contact the client by phone or by sending the Request for Information” (MC 355) form.

• Allow an additional 20 calendar days for the client to provide the requested information/ verification.

• Discontinue the case at the end of the Initial TMC six-month period with a ten-day NOA, or as soon as a ten-day can be issued to discontinue the Additional TMC eligibility.

Requested information is received AFTER the case is discontinued, but within 30 days from the discontinuance date,

The EW must evaluate continued Medi-Cal eligibility using the information received and rescind the discontinuance action if eligibility exists.

Client returns the packet and is determined to be ineligible for another Medi-Cal program,

• Send the client an MC 355 explaining the potential basis for Medi-Cal eligibility, if not previously sent.

• Allow 10 calendar days for the client to provide any new information or verification.

• Discontinue the case at the end of the Initial TMC six-month period with a ten-day NOA, or as soon as a ten-day can be issued to discontinue the Additional TMC eligibility.

Client returns the packet and is determined to be eligible for ongoing zero share-of-cost (SOC) Medi-Cal benefits under Section 1931(b) or MN/MI,

Transfer the individuals to the appropriate Aid Code(s), and send the appropriate NOA to inform the client of the new Medi-Cal program.

Client returns the packet and is determined to be eligible for Medi-Cal with a share of cost,

• A ten-day NOA is required.

• Allow Aid Code 38 for one month and then transfer to SOC Medi-Cal if there is no time for a ten-day notice. Note: Aid Code 38 for one month is not appropriate if the client returned the packet early enough to send a ten-day share-of-cost notice.

• All eligible children must be evaluated for CEC or referred to the/Healthy Kids program as appropriate.

If the... Then...



37.7 Initial and Additional TMC Discontinuance NOA

When discontinuing Initial or Additional TMC, the TMC discontinuance NOA lists reasons for ineligibility including:

a. No longer an eligible child in the home

b. Failure to meet reporting requirements

c. The caretaker relative has no earnings in one or more of the last three months

d. Family income exceeds 185% of the federal poverty level.

Note:Establish eligibility under another Medi-Cal Program if enough information is known.

37.8 Conversion After TMC Discontinuance

Individuals being terminated from TMC will automatically convert to Aid Code 38 at MEDS Renewal in the last month of TMC unless:

• Medi-Cal has been approved under another program prior to MEDS Renewal, or

• Ineligibility for Medi-Cal has been determined. (The discontinuance must be received by MEDS prior to Renewal in order to prevent automatic conversion to Aid Code 38 by MEDS.)

Note:Persons who were eligible for restricted TMC (i.e., undocumented) are not eligible for Aid Code 38 because they are not entitled to full scope benefits.



37.9 Questions and Answers

1. Q: Is the family eligible for TMC if they lose CalWORKs or Section 1931(b) due to increased amount of State Disability Insurance (SDI) or Temporary Worker’s Compensation? A: No. Only an increase in earnings from actual employment can make the family eligible for TMC.

2. Q: If a family received CalWORKs for two months before termination and Section 1931(b) for one month before being ineligible due to increased earnings from employment, can they have TMC for meeting the three of the last six months requirement? A: Yes.

3. Q: In the Additional TMC (59/5T), do we include family members who are not receiving TMC but are receiving Medi-Cal in another program in the family size for the 185% FPL test? A: Yes. The family size includes everyone who is a family member in the household if they are receiving TMC or other Medi-Cal except persons who are PA/Other PA. Their earned income is counted and they are included in the family size for the 185%.

4. Q: If the TMC flyer is returned months after the CalWORKs or Section 1931(b) case has been discontinued and it is determined that the family was discontinued for increased earnings from employment, should the case be processed for TMC? A: Yes, If the family still meets the TMC eligibility criteria, they may be eligible for TMC if they are not eligible for Section 1931(b). Aid Code 39 must be reported retroactively to MEDS immediately following the CalWORKs, Edwards, or Section 1931(b) Aid Code when they were discontinued and the family may only receive the remainder of the initial TMC period. If eligible for the additional six months, they may continue.

5. Q: May an employed parent return home and be added during the TMC period? A: Yes. He/she may be added if his/her income/resources would have been



included in the CalWORKS or Section 1931(b) case. If he/she chooses to be added, his/her income will be counted. Once added, he/she may not be excluded until TMC eligibility ends.

6. Q: May an 18-year-old child who is not enrolled in school return home and be added to the TMC unit? A: No, unless he/she would have met the definition of a child if he/she had been in the home at the time the TMC began.

7. Q: If the family has excess property at the time or during the TMC period, is the family still eligible for TMC? A: Yes. There is no property limit/requirements for the TMC program.

8. Q: Is there a limit to the amount of child care expenses which are necessary for the employment of the parents or spouse of a parent? A: No.

9. Q: If the stepparent with no children of his/her own is not the PWE and his/her earnings from employment cause the family to lose Section 1931(b), is the family eligible for TMC: A: Yes, if the stepparent meets the definition of a caretaker relative because he/she shares in the care and control of his/her spouse’s children. This does not need to be verified for TMC purposes.

10. Q: If the parent was terminated from Section 1931(b) and is eligible for TMC, but the child was only eligible for the MN program with a share of cost or the Percent Programs due to Sneede, is the child eligible for TMC? A: Yes. The child may be added to the TMC case with the parent.



37.10Four-Month Continuing

37.10.1 Background

The Four-Month Continuing Medi-Cal program was effective August 1, 1984. This program was created to allow families who lost AFDC eligibility due to the collection of or increased collection of child/spousal support to retain no-cost Medi-Cal for four months.

In January 1998, the AFDC program was replaced by the California Work Opportunity and Responsibility to Kids (CalWORKs) cash program and Section 1931(b) Medi-Cal. With the elimination of AFDC, eligibility for the Four-Month Continuing program became linked to prior receipt of CalWORKs (cash-based) or Section 1931(b) Medi-Cal only.

The Four-Month Continuing program has been expanded to include restricted benefits (emergency and pregnancy-related services only) for those individuals who do not have Satisfactory Immigration Status (SIS).

37.10.2 Policy

The Four-Month Continuing program provides four months of extended Medi-Cal for individuals who are discontinued from either cash-based (CalWORKs) Section 1931(b) or Section 1931(b)-Only Medi-Cal due to the collection or increased collection of child/spousal support.

Persons discontinued from CalWORKs or Section 1931(b)-Only Medi-Cal are eligible for four consecutive months of zero share of cost Medi-Cal benefits if both:

• The discontinuance is due in whole, or in part, to the receipt/collection of the increased receipt/collection of child/spousal support, AND

• The client received CalWORKs (cash-based Section 1931(b) or Section 1931(b)-Only Medi-Cal), or was eligible to receive CalWORKs/Section 1931(b) in at least three of the six months immediately prior to the month they became ineligible for CalWORKs/Section 1931(b) Medi-Cal.



37.10.3 Four Month Continuing Requirements

Individuals are established on Aid Type 54/5W and are:

• Eligible for zero share of cost Medi-Cal for four consecutive months regardless of whether other eligibility requirements are met.

• Not required to submit status reports, or complete redeterminations.

• Any months of zero share-of-cost Medi-Cal, including Aid Code 38, received by the family after ineligibility for cash-based Section 1931(b) or Section 1931(b)-Only has occurred, must be deducted from the four months of extended coverage.

Once determined eligible, there are no other program requirements except that the family must continue to have an eligible child and reside in California.

• Families who leave California, but then return prior to the expiration of their four months, may receive the remainder of the months.

• Families who were terminated from a cash program similar to CalWORKs in another state are not entitled to Four-Month Continuing benefits in California.

Eligibility for continuing Medi-Cal must be evaluated before the end of the fourth month.

Eligibility may exist when the increase in child/spousal support alone is not enough to terminate the family from Section 1931(b), but the increase, when combined with another circumstance, would be sufficient to cause ineligibility.

Note:Persons receiving Four-Month Continuing Medi-Cal are ineligible members of the MFBU when determining Medi-Cal eligibility for other family members and may use their uncovered medical expenses to reduce other family member’s share of cost.

37.10.4 Ineligibility for Four Month Continuing

Individuals who do not meet the Section 1931(b) eligibility requirements (age, deprivation) are not eligible for Four Month Continuing Medi-Cal.

• If there is no longer a child in the home under the eligible age, the parent(s) is also ineligible.



• Eligibility for regular Medi-Cal must be determined for family members ineligible for Four Month Continuing.

• Persons receiving Aid Codes 01 and 08 are NOT eligible for Four Month Continuing.

37.10.5 Period of Eligibility

• The beginning date of four-month eligibility is the month immediately following the month in which the family became ineligible for CalWORKs/Section 1931(b)regardless of the actual date of discontinuance.

• After discontinuing CalWORKs/Section 1931(b), establish Medi-Cal benefits under Aid Code 54/5W depending on how many months of Four-Month Continuing eligibility are remaining. (Refer to example which follows.) The appropriate termination date must be sent to MEDS.

• A redetermination (RV) due date must coincide with the third month of Aid Code 54 eligibility. Prior to the end of the four-month period, the continuing EW must redetermine ongoing Medi-Cal eligibility following SB 87 process.

Example:Mrs. Lyons and her two children have been receiving CalWORKs for the last two years. The District Attorney’s Office has finally had Mr. Lyon’s paycheck garnished, and the amount they will collect, plus Mrs. Lyon’s other income, will make the family ineligible for CalWORKs. She reports this timely and her CalWORKs is discontinued 1/31. The family will be on Four-Month Continuing Medi-Cal, Aid Code 54 from 2/1 through 5/31. An RV packet must be sent in April.

If the Statement of Facts on file is over 12 months, then the EW must send the following to the client:

• MC 210 RV• MC 219.

[Refer to “Redetermination Due to Loss of TMC Eligibility,” page 37-21] for required ex parte time frames and needed actions.

37.10.6 EW Responsibility

When a client is discontinued from cash-based Section 1931(b) (CalWORKs) or Section 1931(b)-Only Medi-Cal due to the collection of, or an increase in, child/spousal support, follow these procedures:



• Eligibility for Section 1931(b) Medi-Cal must be evaluated first, and if not eligible, then:

• Determine if the collection or increased collection of child/spousal support is at least one of the reasons for CalWORKs discontinuance.

• Review the case information to determine if the customer received CalWORKs/Section 1931(b) in three of the last six months.

Note:If both of the above apply, then establish Four-Month Continuing Medi-Cal, Aid Type 54/5W, for the appropriate period. No new SAWS 2 or MC 210 is required, even if the annual redetermination becomes due for the previously discontinued CalWORKs. Otherwise, follow normal discontinuance procedures. Edwards (Aid Code 38) will be automatically established by MEDS Renewal.

• Send the client the MC 323 Approval Notice of Action, which states the specific time period of eligibility for Four-Month Continuing entitlement.

37.11Edwards v. Kizer

37.11.1 Background

Effective 4/30/82, a preliminary injunction was issued which requires that Medi-Cal benefits be continued for persons who are being discontinued from CalWORKs until the family’s eligibility or ineligibility for “Medi-Cal Only” has been determined and a timely and adequate notice of action is issued.

After several years of negotiations, the Department of Health Services reached a formal settlement agreement with the plaintiff’s attorneys. The terms of the judgement include:

• The modification of MEDS to allow the automatic issuance of Aid Code 38 based on the CalWORKs discontinuance code; and,

• The use of a mandated, shorter “Statement of Facts”, when there is insufficient information on file to determine ongoing eligibility.



Aid Code 38 continues to be a “transitional” Aid Code for certain persons discontinued from cash assistance. County error will be cited if Edwards extends beyond two months; however, Aid Code 38 must be continued if Medi-Cal eligibility has not been determined timely.

37.11.2 Persons Affected

Persons being discontinued from cash assistance under the following aid codes must be reviewed for ongoing Medi-Cal eligibility as required by Edwards:

• CalWORKs (30, 33, 35, 3E, 3G, 3H, 3L, 3M, 3P, 3R, 3U)• CalWORKs-FC (40, 42, 4C, 4G)• RCA/ECA (01,08)• Transitional Medi-Cal (39, 59) and Four Month Continuing (54), if ongoing

Medi-Cal eligibility has not been approved/denied by the end of the Transitional Medi-Cal eligibility period.

RCA/ECA and Edwards

Effective April 2, 1998, individuals terminated from Refugee Cash Assistance (RCA) or Entrant Cash Assistance (ECA), Aid Codes “01” and “08” are eligible for Edwards transitional Medi-Cal benefits until the Medi-Cal redetermination for ongoing Medi-Cal eligibility is completed.

37.11.3 Auto CalWIN/MEDS Conversion

The State automatically issues Aid Code 38 benefits for the future month to individuals at MEDS Renewal when they have been active on MEDS in the current calendar month in one of the following Aid Codes:

01, 08, 30, 33, 35, 38, 39, 3E, 3G, 3H, 3L, 3M, 3P, 3R, 3U, 40, 42, 4C, 4G, 54, or 59 AND

A negative action was taken for a reason other than the following:

• Death• CalWORKs and Medi-Cal discontinued at the recipient’s request• Failure to cooperate with Medi-Cal requirements• Children on CalWORKs who are transferred into another county administered

program (i.e., Foster Care)• Determined ineligible for Medi-Cal• Resident of a non-medical public institution• Loss of California residency.



When an entire MFBU is being discontinued for a reason other than those listed above:

• MEDS will automatically convert the case to Aid Code 38 at MEDS Renewal, and

• CalWIN will automatically convert the case to Aid Code 38 on the 5th working day of the month following the cash discontinuance. A Notice of Action is automatically generated in this process.

NOTE: EWs must manually convert any case (and send a NOA) when Edwards is required and/or already established on MEDS if the case was not automatically converted in CalWIN. [Refer to “Discontinuing INDIVIDUALS from CalWORKs/RCA/ECA,” page 37-31]

Reminder:Edwards cases may not be transferred out of the District Office until Medi-Cal eligibility has been determined.

37.11.4 General Requirements

Aid Code 38 Medi-Cal benefits are to be issued only until:

• A redetermination of ongoing eligibility can be made following SB 87 process, and

• A timely and adequate NOA is sent.

Effective July 1, 2001, the completion of an Edwards packet is NO LONGER REQUIRED for continuation of Medi-Cal after placement in Aid Code 38. The SB 87 process replaced the Edwards process. Aid Code 38 continues to be a “transitional” Aid Code for certain persons discontinued from cash assistance while determining their continued Medi-Cal eligibility under SB 87 regulations. [Refer to Senate Bill (SB) 87 Process, Chapter 8.]

Note:An MC 210 RV is required only when the SAWS 2 on file is over 12 months old.

37.11.5 Discontinuing INDIVIDUALS from CalWORKs/RCA/ECA

Individuals will automatically be converted to Aid Code 38 on CalWIN and MEDS the month following cash discontinuance UNLESS:



• The discontinuance is for one of the “non-Edwards” reasons, AND

• The action is taken prior to MEDS cutoff.

Parent(s) ages 21-64 are not eligible for Medi-Cal when their children have no deprivation, except:

• A pregnant woman

• A medically indigent adult (MIA) in long term care.



37.11.6 Discontinuing CalWORKs/RCA/ECA Case, Information on File

If... Then...

The EW is certain that CalWORKs /RCA/ECA recipients are ineligible for ongoing Medi-Cal,

Discontinue the case.

CalWORKs/RCA/ECA was discontinued due to increased hours/earnings,

Evaluate eligibility for Transitional Medi-Cal (TMC), or Refugee Medi-Cal Assistance (RMA).

CalWORKs only (not RCA/ECA) was discontinued due to increased child/spousal support,

Evaluate eligibility for 4-Month Continuing, Aid Code 54. [Refer to “Four-Month Continuing,” page 37-26.]

CalWORKs/RCA/ECA was discontinued for another reason and there IS enough information on file to establish ongoing Medi-Cal,

Establish eligibility for Section 1931(b) and set the RV due date 12 months from the date the SAWS 2 on file was signed.

• A 10-day NOA is needed if there will be a share of cost.

Note: Include an MC 219 in the next annual Medi-Cal RD. An MC 13 is only required for noncitizens if one is not already on file.

Additional time/information is needed to determine ongoing Medi-Cal eligibility,

• Establish Aid Code 38. Exception: Clients alleging disability must be set up using the appropriate aid codes.

• Follow SB 87 “ex parte” review process.

• If information is not provided within the allowable SB 87 time frame or eligibility no longer exists, discontinue Aid Code 38.

37.11.7 MFBU Considerations

Edwards (Aid Code 38) recipients must be included in the MFBU of other family members who are applying for Medi-Cal; for example, the absent parent who has returned home. Aid Code 38 recipients are included as “ineligible persons” when determining the share of cost for other family members. Edwards persons can use their medical expenses which are not covered by Medi-Cal to reduce the share of cost for other family members.



37.12Bridging Program (7X)

Effective 3/1/99, Assembly Bill 2780 created the Bridging Program which provides one additional month of no-cost, full scope health coverage to Medi-Cal eligible children between the ages of one and nineteen who would otherwise have a share-of-cost (SOC) and who appear to be eligible for the Healthy Families Program (HFP). The Bridging Program is for one month only, immediately following a period of full-scope, zero SOC Medi-Cal. There is no property limit. The family’s case information is referred to the HFP for enrollment if consent has been given.

Effective January 1, 2013, the enactment of Assembly Bill (AB) 1494 required that the HFP stop enrolling new children by December 31, 2012 and transition all HFP enrolled children into the Medi-Cal program effective January 1, 2013. As a result, the Bridging Program was eliminated along with Bridging Performance Standards.

37.13Healthy Families to Medi-Cal PE Program

37.13.1 Background

Effective July 1, 2002, state law provided for a two-month Healthy Families to Medi-Cal (HF to MC) Bridging Program, when all or some of the family members are no longer eligible for the HFP and appear eligible for zero share-of-cost (SOC) Medi-Cal based on income screening.

When a child appeared to be Medi-Cal eligible, the HF Annual Eligibility Review (AER) form was sent to the residence county for a Medi-Cal determination and two months of extended eligibility was issued under Aid Code 7Y. This eligibility ended without EW action.

Due to state budget cuts, the HF to MC Bridging Program was discontinued effective July 1, 2007 and was replaced by the HF to MC Presumptive Eligibility (PE) program. This change was implemented through an expansion of the Accelerated Enrollment (AE) process. The case information used for the HF to MC Bridge serves as the Medi-Cal application.

Due to the transition of HFP enrolled children to Medi-Cal starting January 1, 2013, the Healthy Families to Medi-Cal PE program ended effective April 1, 2013.



37.14Kaiser Dues Subsidy Program

37.14.1 Definition

The Kaiser Dues Subsidy Program provides Kaiser health care coverage for a sliding-scale fee to former CalWORKs/Employment Services (CWES) participants who are now employed. Employment Services participants must have been terminated from CalWORKs due to unsubsidized employment and either do not qualify for Transitional Medi-Cal (TMC) or other Medi-Cal programs with no share of cost (SOC), or are being terminated from TMC.

This program is not to be confused with the Kaiser coverage that may be available to Medi-Cal recipients under managed care as part of the Santa Clara Family Health Plan. [Refer to “Overview of the Managed Care Two-Plan Model,” page 15-2]

37.14.2 Eligibility Criteria

Two years of reduced cost health care coverage may be available to qualified individuals who are employed and meet the following conditions:

• Have been actual Employment Services (CWES) participants.

Note:Those who have only registered at Employment Services are not eligible.

• Have been terminated from CalWORKs due to unsubsidized employment (increased wages, etc.).

• Have been terminated from TMC, or who are not otherwise eligible for full-scope Medi-Cal with no SOC.

• Are within Kaiser's income and asset guidelines.

Note:Persons with a SOC or restricted Medi-Cal are potentially eligible.

• Work for an employer who does not contribute to the cost of a medical care plan.



• Reside within Kaiser's service area.

Certain dependents of qualified individuals may also be covered.

37.14.3 How To Apply

Potentially eligible persons must contact Kaiser Permanente directly at (800) 255-5053. Kaiser will send an enrollment package and determine eligibility (that is, income and assets limit). No medical review is required.

Kaiser will require the client's termination or denial notice of TMC as verification of eligibility to the program.

37.15Kaiser Permanente Steps Plan

Kaiser Permanente has created a program called “Steps Plan” which is designed to give current and former Kaiser members the opportunity to have an affordable health plan. The Steps Plan allows members to have Kaiser Permanente coverage by paying only 20% to 80% of the total monthly premium. There are four levels to the Steps Plan: 20%, 40%, 60%, and 80%. Qualified members stay at one level for 12 consecutive months. Each year thereafter, the health plan member will move up gradually to the next higher premium level. The monthly premium is determined by member’s family size and income.

37.15.1 Eligibility Criteria

To be eligible for the Kaiser Permanente Steps Plan, the person must meet all of the following conditions:

• Be a current or former Kaiser Permanente member for at least six out of the last twelve months, prior to experiencing any qualifying event which causes him/her to lose health coverage. Application for the Steps Plan must be made within 12 months of the following qualifying events:

• Loss of employment/layoff• Reduction in employment to part-time hours• Death of spouse, subscriber, or domestic partner• Loss of no-cost Medi-Cal• End of COBRA benefits• Reached the age limit on a subscriber’s account



• Employer no longer offers group health coverage.

• Reside within the Kaiser Permanente California service area

• Be ineligible for Medicare or no cost Medi-Cal

• Be ineligible for subsidized coverage through spouse or employer

• Is age 19 or older

• Have a family size and income are within Kaiser’s Steps Plan level chart.

37.15.2 Income Limit

The family size and income must be within the following ranges:

If a family has this many members...

Then annual income must be between...

1 $8,590 and $25,770

2 $11,610 and $34,830

3 $14,630 and $43,890

4 $17,650 and $52,950

5 $20,670 and $62,010

6 $23,690 and $71,070

7 $26,710 and $80,130

8 $29,730 and $89,190

37.15.3 How to Apply

Potentially eligible persons must contact Kaiser Permanente directly at (800) 255-5053 or visit their website at www.kaiserpermanente.org. Kaiser will send an enrollment package and determine eligibility.


Medi-Cal Handbook Transitional Medi-Cal (TMC) 37 ... · the family proves that the discontinuance...

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