MC 50141 - Application Process - General
What information is needed to determine eligibility?
The information given by the applicant/beneficiary on the following forms will serve as the primary basis for eligibility and share of cost determinations:
• MC 210, Medi-Cal Mail-In Application • MC 176 SA, Medi-Cal Status Report
NOTE: Most sections of the MC 210 and MC 176 consists of yes or no answers. If “no” is checked then no additional information is needed. If “yes” is checked, and the balance of the Section is incomplete or inconsistent, clarification should be obtained from the applicant.
See APPLICATION-SELECT FOR PROCESSING for LEADER procedures
MC 50141.1 -
Verification/Documentation Documentation
What does it mean to document case information?
To document is to record information or file
supporting evidence in the case record. Examples:
A. Photocopy of a pay stub may be filed in the case record as documentation of earnings B. An entry may be made by the EW in Case
Comments in LEADER which records information from the documents that were seen.
See CASE COMMENTS for LEADER procedures
MC 50141.3 - Client Representatives - Eligibility Process
Policy
Who can assist a client in the eligibility determination process?
The following:
• A Guardian or Conservator
• A Spouse or Parent/Caretaker Relative • An Authorized Representative (AR)
• A Designated Representative • An Acting Representative, or
• An Executor or Administrator of a client’s estate.
Guardian/Conservator A Guardian or Conservator-
The person appointed by a court to handle the affairs and/or estate of a minor or someone incapable of managing his/her own affairs.
NOTE: A guardian/conservator must act fully on
behalf of the client. Which includes providing all eligibility and share of cost information, reporting all changes, etc. on behalf of the client.
Guardianship/conservatorship must be verified and documented in the case record.
The Benefits Issuance Cards (BICs) and all
documents must be issued in the name of the client. However, the guardian=s/conservator=s address must be used as the mailing address.
A Spouse or Parent/Caretaker Relative-
A Spouse or Parent/Caretaker Relative-
The spouse of a client may act fully on the client=s behalf without a MC 306, APPOINTMENT OF REPRESENTATIVE on file. This means that the spouse may assist the client in:
• The application/redetermination, • Fair hearing process,
• bringing in/picking up documents, • discuss any case related information
pick up a Medi-Cal immediate need card if the client is too ill to personally pick it up, etc.
Parent/Caretaker Relative- A Parent/Caretaker Relative
The Parent/Caretaker Relative of a child must act on behalf of the child unless, the child:
• is not living with his/her parents and no person or agency accepts legal responsibility
for the child, or
• is applying for minor consent services.
See MC 50147.1 Child Applying for Minor
Consent Services for more information
NOTE: EWs are NEVER to ask the client to complete forms MC 306 or DHS 7068 when the person assisting or full representing them is a spouse or parent/caretaker.
An Authorized Representative - (Competent Clients only)-
An Authorized Representative - (Competent Clients only)-
The person/agency the client designated to assist him/her in the application/redetermination or fair hearing processes. An MC 306 or written statement may be used to designate an AR. The MC 306 authorizes the EW to work with the AR and details:
1. the actions that the AR is able to take on behalf of the client;
2. the client’s and AR’s responsibilities; and the rights of the client in regard to appointing and revoking the designation.
NOTE: AR is limited to assisting the client in
carrying out his/her responsibilities only during the application/ redetermination and fair hearing processes. THE
SIGNED MC 306 is VALID ONLY through the application/
redetermination process and the conclusion of the fair hearing.
The MC 306/written statement is not used:
• when a spouse, parent, caretaker relative or MFBU members provide assistance to the client in meeting his/her responsibilities, or • to designate representatives for an
incompetent person. An incompetent
person CANNOT designate an AR.
See AUTHORIZED REPRESENTATIVE for LEADER procedures
A Designated Representative A Designated Representative
Any person (other than a Spouse or
Parent/Caretaker Relative) the client designates outside of the application/redetermination/fair hearing process to:
• bring in/pick up documents
• share necessary information which includes verbal discussion of case information.
Written consent in the form of a handwritten note from the client is acceptable. The note must include:
1. case identification,
2. name of Designated Representative, 3. the specific activity that the client is
authorizing,
4. the date the activity is to take place; and 5. the client’s signature and date it was signed.
Verbal consent may be accepted only when written consent cannot be provided and eligibility staff is satisfied that it is the client who is making the verbal consent. THIS MUST BE DOCUMENTED IN THE CASE RECORD.
An Acting Representative An Acting Representative
Any person or agency may assist in the eligibility determination for an incompetent client if all the following conditions exist:
A. The client has no spouse, parent, caretaker relative, guardian, conservator, executor or administrator to act in his/her behalf.
B. The person/agency has sufficient knowledge of the client’s affairs to give specific and complete to vital questions about the client. The person/agency must be able to provide appropriate documentation
C. The person/agency is willing to sign all documents and accept responsibility for the statements made on behalf of the client.
the Acting Representative:
D. DHS 7068 - must be given/sent to the representative to inform him/her of his/her reporting responsibilities.
All necessary verification/documentation to
determine incompetency, eligibility and share of cost must be obtained from the acting representative. A copy of all NOAs must be provided to the acting representative. However, the BIC must be sent to an incompetent client at his/her residence
address.
See MPIH Section MC 50163 for more information
Executor or Administrator of a Client’s Estate.
Executor or Administrator of a Client’s Estate
The executor/administrator is responsible for
providing all eligibility and share of cost information and verification. In the case of a deceased client’s estate, the executor/administrator must act fully on behalf of the client.
The BICs and Novas must be issued in the client’s name and sent to the mailing address of the
executor/administrator.
MC 50141.4 - Address Where are Benefits Issuance Cards (BICs) mailed to?
BICs are to be mailed to the client’s residence unless it will result in a hardship to the client.
Mailing Address What are some of the reasons a client may request the use of a mailing address verses his/her residence address?
Some reasons may include:
• An Long Term Care client whose spouse at home acts on the client’s behalf,
• when the client states that the resident mail box is not secure (has been robbed),
• a residence at which the Post Office does not deliver mail,
etc.
See ADDRESS - CHANGE/CORRECTION for LEADER procedures
What types of mailing addresses may be used?
The mailing address may include:
• a Post Office Box,
• Commercial Mail Receiving Agent (CMRA), • the home of a friend or relative or,
• any address other than the address of a • medical provider or billing or collection agent
of the provider. (See Note)
NOTE: With the exception of an LTC home or other institution where the client is
residing, a medical provider or the
billing/collection agent of a provider
cannot be used as the case mailing address. This includes situations where
the medical provider may be acting as the clients Authorized Representative
See MPIH Section MC 50163 for more information
Residence Address What is a residence address?
The residence address must be the address where the client is living.
Exception: Special procedures must be applied to Homeless or Minor consent clients.
What should the Eligibility Worker do when it is discovered that the client is not living at the address reported as his/her address?
The worker should:
1. Contact the client by phone or in writing at the last known address to determine the current residence. This contact must be initiated within 3 days of discovery.
client within the 10 days.
3. If the client does not respond within 10 days of second contact, take Medi-Cal termination action, code WU
See TERMINATE CASE for LEADER procedures 4. If the client does report his/her residence
address, note the address in LEADER and proceed to do the following:
5. Submit the residence address as a change if this address is different from the mailing address.
See ADDRESS CHANGE/CORRECTION for LEADER procedures
6. Initiates district or Inter-County transfer as appropriate if the residence is outside of district or county boundaries.
See CASE TRANSFER for LEADER procedures
Homeless Clients- Special Procedures What address is used for Homeless clients?
A homeless client may use an address of a friend, relative, Post Office box, Commercial Mail
Receiving Agent, etc., as a mailing address.
If the homeless client has no mailing or residence address, the district address shall be used on LEADER as both the mailing and residence address.
See ADDRESS CHANGE/CORRECTION for LEADER procedures
• The client shall complete a PA 853 Affidavit stating that he/she has no residence address and agrees to having his/her cards and other documents held at the district office. The completed PA 853 is to be filed in the documentation folder.
• Prior to approval action, the case shall be administratively reviewed at the level of Deputy District Director or higher.
• The District address shall be used on CDMS as both the mailing residence address.
Minor Consent Clients - Special Procedures
What address is used for a child who is eligible for Minor Consent services?
The district address shall be used as both the mailing and residence address unless the minor states that his/her application is not of a
confidential nature.
If the minor wants a mailing address different from the residence address follow the general mailing address procedures.
See ADDRESS CHANGE/CORRECTION for LEADER procedures
MC 50143 - Persons Who May File An Application For Medi-Cal
Who can apply for Medi-Cal?
Any person who wants to receive Medi-Cal may file an APPLICATION FOR PUBLIC ASSISTANCE (SAWS-1), and complete the application process, even if it appears that the person is ineligible. In addition, if the applicant is unable to apply on his own behalf or is deceased, any of the following persons may file the application on his/her behalf:
A. The person’s spouse, legal guardian, conservator or executor;
B. A person who knows about an individual’s need may apply for Medi-Cal benefits, such as a relative, friend, neighbor, private hospital, or nursing home administrator; or C. A public agency representative, such as a
probation officer.
NOTE: When an individual is acting on behalf of
a Long-Term Care applicant is non- cooperative and another individual is not available to help, the EW must DENY the application and notify the non-
cooperative person. The EW must then file a second SAWS-1 on behalf of the applicant, as well an application for retroactive coverage if the second
SAWS-1 is filed after the month in which the initial SAWS-1 was submitted.
MC 50147 - Child Applying For Minor Consent Medi-Cal Services
What are Minor Consent Services?
Minor consent services are those health care services which a child my legally obtain without parental consent. the categories are:
• Pregnancy & pregnancy related care • Family planning services
• Sexual assault services
• Sexually transmitted diseases treatment • Drug & alcohol abuse treatment/counseling • Mental Health outpatient care *
NOTE: *Mental health treatment/counseling for a child 12 years of age or older who is mature enough to participate intelligently. The child must be either:
• In danger of causing serious harm to him/herself or other if the treatment is not
received, or
• The alleged victim of incest or child abuse.
Mental health treatment or counseling is covered under Medi-Cal only on an outpatient basis.
What are the age requirements for children requesting Minor Consent services?
There is parental responsibility for :
• All children under age 21 living at home with their parents.
• children 12 to 18 living away from home - Parents handling their financial affairs. • Any children 18-21 years of age - whether
living at home or away - if claimed by their parent(s) for income tax purposes.
However, if such a child requests services covered by the Minor Consent Program, the parents are not financially responsible and the child may sign an
application and have a case opened in his/her own name.
Exceptions: Persons under 21 years of age who are defined as adults are not eligible for Minor Consent
Services and must be processes for full-scope or restricted Medi- Cal benefits. They are
categorized as:
A. a blind or disabled MN person between 18-21 years of age, living with a parent and not currently enrolled in school;
B. any person who is now or has been married,
regardless of age, unless the marriage was annulled; or
C. any person 14-18 years of age who is not living with a parent or caretaker and who does not have a parent, caretaker relative or legal guardian handling his/her financial affairs.
What forms are needed for a child applying only for Minor Consent Services?
The following forms are to be completed:
• MC 210 STATEMENT OF FACTS
• MC 210A SUPPLEMENT TO STATEMENT OF FACTS FOR RETROACTIVE
COVERAGE/RESTORATION (if retroactive coverage is requested
• MC 219 IMPORTANT INFORMATION FOR PERSONS REQUESTING MEDI-CAL and;
• MC 4026 REQUEST FOR ELIGIBILITY FOR LIMITED SERVICES*
service(s). Completion of this form is required for the initial month for all types of services (including mental health) and for each following month in which he/she is requesting Medical coverage other
than mental health care. The completed
form must be obtained prior to approving eligibility for that month.
See APPLICATION-SELECT FOR PROCESSING for LEADER procedures
What documentation is needed if the child is applying only for Mental Health Services under the Minor Consent Program?
The child needs to submit a statement which states that the child need mental health treatment or counseling. The statement must come from one of the following mental health professionals:
• licensed marriage, family and child counselor • licensed educational psychologist
• credential school psychologist; • clinical psychologist,
• psychiatrist
• licensed clinical social worker • or a licensed psychologist.
In lieu of submitting the monthly MC 4026s, the statement is good for the length indicated in the original statement therefore, the minor is not
required to submit a statement nor MC 4026 each month. However, the child must come into
the district office and be seen by his/her EW each month.
What if the child applying for Minor Consent Services is also a child in an ongoing
CalWORKs or MAO case?
In this situation, the child continues to be included as a CalWORKs or MAO family member. No change whatsoever is to be made on the CalWORKs or MAO case. The EW shall not
any aspect of the child=s separate case. State law provides that the case is be confidential and that the parents shall not be asked or be
required to contribute to the cost of minor consent services received by their child.
NOTE: New Minor Consent applicants must always be assigned a new 14-digit County ID number.
What are the appropriate Minor Consent aid codes?
The aid codes are based on two (2) factors: 1) type of service requested, and 2) age of minor. Aid codes are as follows:
7M Restricted to minors who are at least 12 years of age, limited to sexually
transmitted diseases, drug and alcohol abuse, family planning and sexual assault services with or without a SOC. This aid
code does not cover any mental health services.
7N Restricted to pregnant minors, limited
to pregnancy and pregnancy related and family planning services, without a SOC. No age restriction.
7P Restricted to minors who are least 12 years of age, limited to the same services provided under 7M, with or without a SOC and also covers outpatient mental health services
7R Restricted to minors under age 12, limited to family planning and sexual assault services, with or without a SOC.
This aid code cannot be used for mental health services, services for drug and alcohol abuse or sexually transmitted diseases.
51049. - Application Form What form is needed to make an application for Medi-Cal services?
a case must be formally opened and approval/denial action taken.
See APPLICATION DATE for LEADER procedures
MC 50151 - Date of Application What date should be used for “Date of Application”?
The date of application is the date the completed application form is received by DPSS, whether it be by mail, in person, or by telephone.
See APPLICATION DATE-CORRECTION for LEADER procedures
MC 50153 - Medi-Cal Application Process For All Programs
What should be done if a client appears to be eligible for other programs?
When taking an application, the EW should
determine the program under which the person or family may be eligible and process the application under the appropriate program. Applications for persons who appear to be eligible for :
• SSI/SSP - are to be referred to the Social Security Administration for a determination of SSI/SSP eligibility.
• CalWORKs- are to be advised of the potential eligibility and the application shall be processed under the CalWORKs cash grant program.
See CalWORKs ADD PROGRAM TO CASE for LEADER procedures
MC 50155 - Withdrawal of Application - Request For Discontinuance
What happens if the applicant or a beneficiary states that he/she wishes to withdraw the application?
The EW shall obtain written documentation such as a letter or a completed MC 215 Request for
Withdrawal of Application or Discontinuance of Eligibility.
See APPLICATION- CANCEL/DENY
What should be done if the applicant fails to sign the MC 215 or provide a written request?
If the applicant fails to sign the MC 215 or provide a written request, denial action is to be taken.
If a beneficiary fails to sign the MC 215 or provide a written request, discontinuance action is to be taken.
If the beneficiary contacts DPSS prior to the effective date of discontinuance to request that Medi-Cal be continued, rescission action is to be taken.
See APPLICATION- CANCEL/DENY
/WITHDRAWAL for LEADER procedures MC 50157 - Face-To-Face Interview
Requirements
Is a face-to-face interview required?
A face-to-face interview with the applicant, or the person completing the MC 210 is not required.
MC 50159 - Statement of Facts What is the Statement of Facts for?
The Statement of Facts (MC210) is used in the determining of the applicant’s:
• Eligibility. • Share of Cost.
• Other health care coverage.
MC 50163 - Persons Who May
Complete and Sign The Statement Of Facts
Who should complete and sign the MC 210