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USER INFORMATION

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Medi-Cal Policy

MC 50801 Medi-Cal Special Treatment Programs – General MC 50803 Medi-Cal Special Treatment Programs – Beneficiary MC 50805 Real Property Medi-Cal Special Treatment Programs MC 50807 Personal Property Medi-Cal Special Treatment Programs MC 50809 Gross Income Medi-Cal Special Treatment Programs MC 50811 Annual Net Worth

MC 50813 Percentage Obligation

MC 50815 Application Process Medi-Cal Special Treatment Programs MC 50817 Eligibility Requirements Medi-Cal Special Treatment Programs MC 50819 Verification Requirements Medi-Cal Special Treatment Programs MC 50820 Eligibility Determination Medi-Cal Special Treatment Programs MC 50823 Beginning Date of Eligibility Medi-Cal Special Treatment Programs MC 50825 Determination of Annual Net Worth

Mc 50827 Determination and Application of Percentage Obligation Medi-Cal Special Treatment Program

MC 50831 Share of Cost Medi-Cal Special Treatment Programs Supplement Beneficiary

MC Article 18 – Fair Hearings

MC 50951 Right to State Hearing MC 50953 State Hearing

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MC Article 19 – Estate Recoveries, Waivers & Estate Hearings

MC 50960 Definitions MC 50961 Estate Claims MC 50962 Notification

MC 50963 Undue Hardship Criteria MC 50964 Estate Hearing

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MC Definitions, Abbreviations and Program Terms

MC 50000- MEANING OF WORDS - _{Words have their usual meaning unless the context or a}

definition clearly indicates a different meaning.

• SHALL means mandatory

• MAY means permissive

SHOULD means suggested or recommended. MC 50004-Medi-Cal Program

Administration What is the Department?

The Department is the State (California) agency that is approved by the Department of Health and Human Services to administer the Medi-Cal program.

The county welfare department is responsible for local (county level) administration of the Medi-Cal Program under the direction of the Department.

MC 50005-Medi-Cal Regulations _{What are Medi-Cal regulations?}

They are the rules, principals, and systems that are put into effect for the purposes of administering the Medi-Cal Program.

MC 50007-Fiscal Intermediary Any individual, partnership or association, corporation or institution contracted with the Department for the performance of fiscal services related to the program.

MC 50009-Medi-Cal Consultant _{A professional individual employed by the Department to}

provide advice in matters related to services provided under Medi-Cal.

MC 50009.1-Medi-Cal Review _{A periodic, but not less than annual, evaluation of the}

health needs of each beneficiary in each: • mental hospital,

• skilled nursing facility, and • intermediate care facility

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50009.2-Medi-Cal Review Team _{A team comprised of a physician and other appropriate}

health and social service personnel that conduct a medical review.

MC 50009.3- Health Care Services _{The medical services, social services, supplies, devices,}

drugs and any other medical that an eligible person is entitled to receive in accordance with Medi-Cal

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MC 50012-Abbreviations _{ABD -} _{Aged, Blind or Disabled}

ABD–MN - Aged, Blind or Disabled- - Medically Needy.

AFDC - Aid to Families with Dependant Children (obsolete) see CalWORKs

AFDC- - MN - Aid to Families with Dependant Children- - Medically Needy Identification

BIC Benefits Issuance Card BRU- Benefits Review Unit

CalWORKs- California Work Opportunity and Responsibility to Kids Program

CETA- Comprehensive Employment and Training Act

CHDP- Child Health and Disability Prevention Program

EAS- Eligibility and Assistance Standards Manual

ETS- Employment Training Service

HIC- Social Security Health Insurance Claim Number

INS- Immigration and Naturalization Service LTC- Long-Term Care

MBSAC- Minimum Basic Standard of Adequate Care

MEDS- Medi-Cal Eligibility Data System MBU- Mini Budget Unit

MFBU- Medi-Cal Family Budget Unit MI- Medically Indigent

MN- Medically Needy

OASDI- Old Age Survivors and Disability Insurance Other PA- Other Public Assistance

PA- Public Assistance PCCM- Primary Care Management POE- Proof of Eligibility

SDX- State Data Exchange SSN- Social Security Number

SSI/SSP- Supplemental Security Income/State Supplement Program

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MC 50013-Adequate Consideration _{The receipt of cash or property which is fair and}

reasonable under the circumstances considering the net market value of property that is sold, converted or

transferred.

MC 50014-Adult

1931(b) Program An adult is:

• For the 1931(b) Program:

A Person 18 years of age or older, if

he/she is not enrolled as a full-time student (as defined by the school) in high school or he/she has completed high school, and is not in a vocational or technical training program.

• For the Medically Needy Only Program:

A person who is 21 years of age or older. A person who is 21 years of age or older. A blind or disabled medically needy (MN)

person who is 18 to 21 years of age who is living in the home of a parent and not currently enrolled in school, college

university, or course of vocational/technical training to prepare for gainful employment. Any person who is 18 to 21 years of age

who is:

1. not living in the home of a parent or caretaker relative

2. not claimed as a tax dependant of his/her parent(s)

3. not receiving out-of-home care from a public agency.

A person 14 to 18 years of age who is not living in the home of a parent or caretaker relative and who does not have a parent, caretaker relative or legal guardian handling any of his/her financial affairs.

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MC 50019-Aid to Families with

Dependant Children The public assistance program that provided a cash grant _{and Medi-Cal to children deprived of parental support or}

care and their eligible relatives prior to CalWORKs.

MC 50021-Applicant _{The individual or family making an application, request}

for restoration of aid, or reapplication

C 50022-Application _{A written request for aid.}

MC 50023-Approval of Eligibility _{The determination made by the county department that a}

person or family is eligible for Medi-Cal.

MC 50024-Beneficiary _{A person who has been determined eligible for Medi-Cal.}

MC 50025-Board and Care _{Receipt of board, room, personal care and supplemental}

services related to individual needs in a non-medical protective living environment.

MC 50025.1 -Burial Insurance _{Insurance that can only be used to pay the burial}

expenses of the insured.

MC 50026-Cash Grant _{The money payment made to a person eligible for}

CalWORKs, SSI/SSP, General Relief, or CAPI.

MC 50027-Certification Date for

Claims Clearance The date of the most recent service listed on the MEDS _{SOC screen.}

MC 50028-Certification - Effective

Date The date the person is certified to receive Medi-Cal _benefits.

MC 50029-Certification for Medi-Cal _{The determination by the Department that a person is}

eligible for Medi-Cal and;

• has no share of cost

• has met the share of cost or is in long-term care and;

• has a share of cost that is less than the cost of long-term care at the Medi-Cal rate.

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MC 50029.5-Certified Long-Term Care

Insurance Policy or Certificate Any long-term care insurance policy/certificate certified _{and approved by the Department of Health Services.}

MC 50030-Child _{For 1931(b) a child is:}

• For the 1931(b) Program:

A person up to their eighteenth birthday. A person 18 years of age or older, if he/she

is enrolled as a full-time student (as defined by the school) in high school or has not completed high school, is in a vocational or technical training program which cannot result in a college degree, provided he/she can reasonably be expected to complete either program before reaching age 19.

• For the Medically Needy Only Program:

A person under the age of 21 except for persons who are specified as adults in MEM section MC 50014.

• For Medi-Cal Program purposes:

An unborn is considered a child .

MC 50031-Child Health and Disability

Prevention Program (CHDP)Gateway A community based program for early identification and _{referral for treatment of persons under 21 years of age.}

MC 50032-Competent _{Being able to act on one’s own behalf in business and}

personal matters.

MC 50033-Contiguous Property _{Adjacent or adjoining property that is not separated by a}

road, street, right of way or in any other manner.

MC 50034-Conversion of Property _{Changing property from one form to another without}

changing ownership.

MC 50035-County Agency _{An administrative division of a county government or a}

non-county organization that has a contract with the county to act on the County’s behalf.

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MC 50035.5-County Cash-Based

Medi-Cal Eligibility Eligibility for Medi-Cal benefits that is based on the _{Department’s determination of eligibility for a cash grant}

or IHSS.

MC 50036-County Department _{The department authorized by the county Board of}

Supervisors to administer aid programs, including Medi-Cal.

MC 50036.5-County Case Error Rate _{The number of quality control case reviews found in}

error.

MC 50037-Eligibility and Assistance

Standards Manual (EAS) Regulations pertaining to AFDC, APSB, SSP and EVH _programs.

MC 50037.5-Eligibility Quality Control _{The Federal and/or State mandated review of Medi-Cal}

cases to ensure proper determination of eligibility.

MC 50038-Eligibility Services _{Services provided relating to the initial and continuing}

determination of a person’s or family’s Medi-Cal eligibility.

MC 50038.5-Emergency Assistance _{Public assistance programs that provide assistance for}

30 days to:

• Families not meeting the qualifications for the federal CalWORKs program.

• Those children who are being, or in immediate danger of being abused, neglected or exploited and to families of such children.

MC 50039- Encumbrances of Record _{Obligations for which property is security. Evidenced by}

a written document

MC 50041-Family Member _{A family member is described as:}

• A child or sibling children.

• The parents married/unmarried of the sibling children.

• The stepparents of the sibling children.

• The separate children of either unmarried parent or of the stepparent.

• If no children, family member means a single person or a married couple.

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MC 50041.5-Federal Poverty Level _{The income level based on the official poverty line}

defined by the Federal Office of Management and Budget.

MC 50043-Heirloom _{Any item of personal property, other than cash and}

securities, which has substantially sentimental value, has been owned by a family for a least two generations and is intended to be retained by the family in succeeding

generations.

MC 50044-Home _{Real or personal property, fixed or mobile, located on}

land or water, in which a person or family lives.

MC 50045-Immigration and

Naturalization Services (INS) The branch of the United States Government that _{administers regulations regarding aliens in the United}

States.

NAME HAS BEEN CHANGED TO:

Bureau of Citizenship and Immigration Services

MC 50045.1-Impairment Related Work

Experience (IRWE) The expenses of a “working disabled” Qualified Medicare _{Beneficiary (QMB), or Specified Low-Income Medicare}

Beneficiary (SLMB) program applicant/beneficiary which are necessary to become or remain employed.

MC 50045.3-Income and Eligibility

Verification System (IEVS) The federally mandated system established to obtain, _{use, and verify information relevant to eligibility and share}

of cost.

MC 50045.5-In-Home Supportive

Services (IHSS) The program which provides necessary personal and _{domestic care so that aged, blind, and disabled persons}

may remain in their own homes.

MC 50046-Inmate _{A person living or being cared for in an institution.}

Exclusions:

• Persons residing at a facility for vocational training or educational purposes,

Person temporarily in an institution pending more suitable arrangements, i.e.: Children pending foster care placement.

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MC 50047-Institution _{An establishment which provides food and shelter, and}

some service or treatment to four or more persons unrelated to the proprietor.

MC 50048-Institution -- Medica _{Any of the following types of public or private}

hospitals/medical facilities licensed by an official State standard setting authority:

• Acute care hospital

• Acute Psychiatric hospital • Intermediate care facility Skilled nursing facility

MC 50049-Institution -- Mental

Diseases An institution primarily engaged in providing diagnosis, _{treatment or care for persons with mental illness.}

MC 500MC 50-Institution --

Non-medical Any institution providing non-medical residential care, _{custodial care, custody or restraint. This includes penal}

institutions.

MC 50051-Institution -- Private _{A privately owned or nonprofit facility managed and}

controlled by an individual, private association or corporation.

MC 50052-Institution -- Public _{An Institution that is the responsibility of a governmental}

unit or which a governmental unit exercises administrative control.

Exclusions:

Medical facilities and publicly operated community residences serving no more than 16 persons.

MC 50052.5-Institution - -

Tuberculosis An institution primarily engaged in providing diagnosis, _{treatment or care for persons with tuberculosis.}

MC 50053-Intraprogram Status

Change A change in a person’s or family’s eligibility from one aid _{category to another category, in which the first digit of}

the aid code remains the same.

MC 50054-Interprogram Transfer A transfer of eligibility from one aid category to another _{aid category in which the first digit of the aid code}

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MC 50054.5-Life Insurance _{A contract for which premiums are paid during the}

lifetime of the insured, and on which the insuring company pays the face amount of the policy to the beneficiary upon the death of the insured.

MC 50054.7-Limited Service Status _{The beneficiary has limited use of the Medi-Cal card}

because of:

1. improper utilization of service, 2. application as a child, or,

3. participation in a pilot project conducted by the Department.

MC 50055-Linked _{Meeting the following requirements:}

• SSI/SSP requirements of age, blindness or disability

• (1931(b) (former AFDC rules) requirements for deprivation of parental support or care

Reference: CalWORKs Deprivation Section

MC 50056-Long-Term Care (LTC) _{Inpatient medical care which lasts for more than the}

month of admission and is expected to last for at least 1 (one) full calendar month after the month of admission.

MC 50057-Marriage _{The state of being married. Includes a legal common-law}

marriage.

MC 50058-Medi-Cal _{California’s medical assistance program and the benefits}

available under the program.

MC 50059-Medi-Cal Card AKA

Benefits Identification Card (BIC) A computer identification card issued to a person certified _{to receive Medi-Cal in order to identify the cardholder and}

to authorize the receipt of Medi-Cal covered services.

MC 50059.5-State Dollar Error Rate _{The Medicaid dollar error rate reported to the Department}

by the United States Dept. of Health and Human Services, less any portion that is attributed to the State caused errors.

MC 50059.6-Federal Standard _{The Medicaid dollar error rate standard that the State is}

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MC 50059.7-State Caused Errors _{Errors in a county that the State assumes responsibility}

for.

MC 50060-Medi-Cal Family Budget

Unit (MFBU) The persons who are included in the Medi-Cal eligibility _{and share of cost determination.}

MC 50060.5-Medi-Cal Only Eligibility _{A person’s or family’s eligibility for Medi-Cal benefits that}

has been determined separately from any other aid or benefit program.

MC 50060.6-Medical Support _{Any liability or payment for the purpose of medical care}

under a court or administrative order.

MC 50061-Medically Indigent (MI)

Person or Family A person or family eligible under the Medically Indigent _program.

Reference: Article 5 - Medi-Cal Programs;

MEM Section MC 50251 MC 50062-Medically Needy (MN)

Person or Family A person or family eligible under the Medically Needy _program.

MC 50063-Minimum Basic Standard

of Adequate Care (MBSAC) The amount necessary to provide a CalWORKs family _{with the basic needs.}

MC 50063.5-Minor Consent Services _{Restricted services related to:}

• Sexual assault

• Drug or alcohol abuse for children 12 years of age or older

• Pregnancy • Family planning

• Venereal disease for children 12 years of age or older.

Mental health care for children 12 years of age or older.

MC 50064-Multiple Dwelling Unit _{Any dwelling with more than one separate living unit.}

NOTE: As a minimum a unit would include a bathroom and a kitchen.

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MC 50064.5-Nonrecurring Lump Sum

Payment A payment accrued over more than one calendar month _{and not expected to be received again in the future.}

MC 50065-Obligate _{To incur a cost for health care services.}

MC 50066-Other Public Assistance

(Other PA) Recipient A person eligible for Medi-Cal under one of the _{categories in the Other Public Assistance program, which}

consists of/includes:

• Four Month Continuing Eligibility (Section MC 50243)

• Nine Month Continuing Eligibility (Section MC 50244)

• In-Home Supportive Services (Section MC 50245) • Twenty Percent Social Security Increase (Section

MC 50247)

MC 50067-Overpayment _{The receipt of Medi-Cal benefits when there is no}

entitlement to all or a portion of the benefits received.

MC 50068-Parent _{The natural or adoptive parent of a child.}

MC 50068.5-Parent-Minor _{A person who meets the definition of a medically needy}

child and has his/her own child or children living in the home.

MC 50069-Parents – Unmarried _{Parent who are living together with their common child}

and the parents are not married to each other.

MC 50070-Patient _{A person receiving individual professional services by a}

licensed practitioner of the healing arts towards

maintenance, improvement, or protection of health, or the alleviation of disability or pain.

MC 50071-Persons Living in the

Home All of the following:

• Persons physically present in the home • Persons temporarily absent from the home

because of hospitalization, visiting, vacation, trips in connection with work, or because of similar reasons

Reference: MEM Section MC 50071.3

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MC 50073-Property – Personal _{Possessions or interest, exclusive of real property (see}

MC 50074), title that may easily transported or stored; including but not limited to:

• Cash on Hand • Bank accounts • Notes

• Mortgages, • Deeds of trust,

• Cash surrender value of life insurance • motor vehicles

• uncollected judgments, and

interest in a firm in receivership, a lawsuit, patents and copyrights.

MC 50074-Property – Real _{Land and improvements which generally includes any}

immovable property attached to the and any oil, minerals, timber or other rights related to the land.

MC 50075-Property - Separate _{Any item that is considered separate property under}

California Property Law. Property that is acquired by an individual by any method prior to marriage, after

obtaining an interlocutory or final judgment of dissolution, or while voluntarily separated; or at any time by gift or inheritance, or purchases made with funds that are separate property or with funds from the sale of separate property.

MC 50076-Property – Share of

Community Is to be treated as if each spouse owns one-half of the _{community property.}

MC 50077-Public Agency _{An administrative division of local, state or federal}

government, or an organization that has a contract to act in behalf of the local, state or federal government.

MC 50078-Public Assistance (PA)

Recipient A person or family receiving assistance under the _{CalWORKs, SSI/SSP, refugee program.}

MC 50079-Public Funds _{Monies provided by local, state or federal government.}

See Section MC 50256 for more information

MC 50079.5-Publicly Operated

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MC 50079.6-Qualified Disabled and

Working Individual An individual who meets the eligibility requirements for _{the Qualified Disabled and Working Individual program.}

MC 50079.7-Qualified Medicare

Beneficiary An individual who meets the eligibility requirements for _{the Qualified Medicare Beneficiary program.}

Reference: MEM MC 50258

MC 50081-Reapplication _{An application for Medi-Cal only eligibility made in the}

same county as a previous under the following circumstances:

• the previous application was denied or withdrawn, or

• Medi-Cal only eligibility based on the previous application has been discontinued for more than 12 months.

MC 50083-Redetermination _{The review of a person’s or family’s Medi-Cal eligibility.}

MC 50084-Relative _{Any of the following persons:}

Mother, father, grandfather, grandmother, son, daughter, brother, sister, stepfather, stepbrother, stepsister, uncle, aunt, first cousin, nephew, niece, half-brother, half-sister, or any such person of denoted by a prefix of gran, great or great-great; or the suffix in-law.

MC 50085-Relative Caretaker _{A relative who provides care and supervision to a child, if}

there is no natural or adoptive parent in the home.

MC 50086-Repayment _{The liquidation of an overpayment in response to}

issuance of demands and recovery by the Department of Benefit Payments.

MC 50087-Residence _{The place in which a person or family lives or is}

physically present.

MC 50088-Responsible relative _{A relative who is responsible to contribute to the cost of}

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MC 50089-Restoration _{The approval of Medi-Cal only eligibility for a person or}

family in the same county as that in which they were previously eligible for Medi-Cal only, if the effective date of the approval occurs within 12 months of the end of the previous period of eligibility.

MC 50090-Share of Cost _{A person’s or family’s net income in excess of their}

maintenance need that must be paid or obligated toward the cost of health care services before the person/family may be certified and receive medical services.

MC 50091-Share of Encumbrances _{That portion of the encumbrances (liens, charges, or}

claims) attributed to each portion of jointly owned property.

MC 50091.5-Specified Low-Income

Medicare Beneficiary (SLMB) An individual who meets the eligibility criteria for the _{SLMB program.}

Reference: MEM Section MC 50258.1 MC 50093-State Data Exchange (SDX) The data system by which the Federal Government

provides information to the State regarding the eligibility of SSI/SSP applicants and recipients.

MC 50094-Stepparent _{A person who is married to a parent of a child and is not}

the other parent of the child.

MC 50095-Supplemental Security Income/State Supplemental Program (SSI/SSP)

The federal and state payments that are paid to aged, blind, or disabled persons.

MC 50095.5-Theraputic Wages _{Wages that are earned by an individual who has been}

prescribed work as therapy by a physician who does not have a financial interest in the long-term care facility in which the individual resides.

MC 50095.7-Title II Disregard Person _{A person who meets all the conditions in section MC}

50564.

Reference: MEM Section MC 50564

MC 50096-Transfer of Property _{A change of ownership whereby a person no longer hold}

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MC 50097-Verification _{The process of obtaining acceptable evidence which}

substantiates statements made by an applicant/beneficiary.

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MC Article 2 – Administration

MC 50101 - County Department Responsibilities

What are the requirements for follow-up/control on anticipated changes?

Eligibility staff are responsible for ensuring Medi-Cal benefits are paid only on behalf of eligible

beneficiaries and to ensure that the share of cost (SOC) amounts are correct on a continuing basis. There are situations where an EW can reasonably anticipate changes in circumstances and thereby establish a Future Action Control (FAC)on LEADER to control for follow-up contact to see if the change has occurred and if so, to get updated information and take appropriate action.

NOTE: If client is in receipt of UIB. Control for 90 days to question the client about his employment status and possible increased income from employment.

See FUTURE ACTION CONTROLS - USER

INITIATED for LEADER procedures

What do I do if I take a new application and one of the family members meets the definition of LTC, or is in a medical facility and is expected to meet the LTC definition?

If the SAWS 1 application has not been completed and you know that a member of the family meets the LTC definition you must refer the applicant, or the person making the request to the LTC District. If the SAWS 1 is completed and it is discovered that a member of the family meets the definition of LTC , you must do the following: Inform the applicant or representative that eligibility will be determined and if approved, the case will be transferred to the LTC District and determine eligibility and share of cost as expeditiously as possible and if Medi-Cal is

approved, transfer case to the LTC District within 3 days per LEADER instructions with a miscellaneous transmittal.

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Responsibilities of district staff for processing Long-Term Care cases

What do I do if I have an approved case and there is a change in circumstance where one of the family members now meets the definition of LTC?

If the person that may now be eligible for LTC does not have an at-home spouse or dependent family member(s) then fully document the LEADER case comments to reflect all of the pertinent information received. You must inform the

beneficiary/representative that the change may result in an increase in the SOC and that the case will be transferred to the LTC district. You must also determine whether the LTC person will be allowed to retain income for upkeep of the home. (see MC

50605 - maintenance Need - Persons in LTC) If

there is an at-home spouse or dependent family member(s) you must follow the same procedures as mentioned before and immediately prepare the case for transfer to the LTC District within 3 working days. The transfer transmittal should indicate that this is an LTC case with an at-home spouse or dependent family member.

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MC Article 3 – County of Responsibility

MC 50120 - County of Responsibility General Policy

Can a Los Angeles County resident apply for Medi-Cal in another County? If so, which county is responsible for processing the case?

Yes. A California resident or his/her representative, spouse or responsible relative may apply for Medi-Cal in any County within the state. Normally, the County of Responsibility for determining the initial and continuing MC eligibility is the county

where the applicant resides.

Types of Applications Are there situations where applications can be taken and sometimes processed in a county other than the county of residence?

Yes.

Regular - If applicant applies for MC in a different county from

where he/she lives, the County of Responsibility is the county that takes the application, for the purposes of making the initial determination of eligibility, issuing benefits and filing the

application.

Courtesy - Rare situations and should be determined on a

case by case basis. Hardship must exist for the client and the action must be mutually agreed upon by the two counties.

If all the information required to determine eligibility is

available, the receiving county shall issue benefits before the case is transferred to the applicant’s County of Residence for processing.

If information is not available the receiving county shall forward the application to the County of Residence within 15 days from the date of application for follow up and completion.

Competent Applicant - LTC - Would be processed the same

as the Regular application.

Incompetent Applicant - LTC - Would be processed the same

as the Regular application with the exception being that the case is transferred to the County of Residence of the incompetent persons spouse, responsible relative, or other representative for ongoing maintenance

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See APPLICATION for LEADER procedures

MC 50136 - Inter-county Transfer Procedure Overview

What is a Medi-Cal Only (MAO) intercounty transfer?

By definition, a Medi-Cal Only (MAO) inter-county transfer (ICT) is the transfer of responsibility of Medi-Cal eligibility from one county to another, within the state of California, when a beneficiary changes his/her county of residence.

See ICT for LEADER procedures

Responsibility Who is responsible for processing a ICT case?

To facilitate the ICT process and the completion of required reports the district may have an ICT unit.

Intake Workers: If the applicant changes his county of residence while the case is pending, the application must be approved before the case is transferred to the ICT unit.

Approved Workers: Upon receipt of information that the applicant has changed his county of residence, on the same day you are to hand carry the case to the ICT

Eligibility Supervisor.

When do I initiate an inter-county transfer?

When a permanent change in county address or a change for an indefinite period is reported, the EW must assist the

beneficiary with the transition of Medi-Cal benefits to the Receiving County. Counties are responsible for transferring case record information from the beneficiary’s old county of residence (Sending County) to the new county of residence (Receiving County) so that Medi-Cal benefits can continue without interruption.

What do I do if the change of address is temporary?

If a beneficiary reports a temporary change in county address due to seasonal employment, medical care, or other personal reasons and the beneficiary continues to maintain a primary residence in Los Angeles County an ICT shall not be initiated. The EW must ensure that the Medi-Cal Eligibility Data System (MEDS) record for the beneficiary is updated to show the temporary residence county address and county code to facilitate continued access to medical care in the temporary

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residence county. Comments must be documented with the person’s temporary address, as well as, the reason for absence and the beneficiary reminded of his/her reporting responsibilities for changes that can affect Medi-Cal eligibility. The EW manually initiates an EW 12 MEDS transaction

through the district MEDS liaison.

See ADDRESS - CHANGE/CORRECTION for LEADER procedures

What are the sending EW’s responsibilities?

The Sending County EW’s responsibilities are:

• Initiate to the Receiving County within seven calendar days of the report that a beneficiary is living in another county

• Confirm the change of address by telephone if a telephone number is provided to the county • Send an ICT Informing Notice (MC 358-S) to the

beneficiary regarding the county address change and the initiation of the case transfer to the Receiving County;

• Complete a change of address to LEADER and ensure that MEDS has been properly updated either by

LEADER to MEDS interface or by an on-line MEDS transaction as necessary;

• Continue Medi-Cal “on-line” on MEDS during the ICT process pending changes in LEADER programming, until Receiving/Sending EW’s agree upon

discontinuance/approval dates;

• Initiate a change of residence address and residence county code on MEDS manually using an EW 12 MEDS transaction (questions regarding the EW 12 process should be directed to the district MEDS Liaisons); • Notify the Receiving County of the initiation of a case

transfer in writing with a MC 360;

• Send an ICT packet to the Receiving County with copies of available documents supporting the beneficiary’s eligibility through the ICT transfer period (30 day transfer period has been eliminated);

• Annotate the missing documentation or verification on the MC 360 for the Receiving County to follow-up with the beneficiary at the next redetermination if sending

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EW is unable to locate documents/verification.

What forms does the sending EW use to initiate an ICT?

The ICT forms/notices are the following:

• MC 358S (12/02) Medi-Cal Informing Notice Intercounty Transfer - Sending County

• MC 358S (SP) (12/02) Medi-Cal Information Notice Intercounty transfer - Sending County

• MC 359R (12/02) Medi-Cal Notice of Action Intercounty Transfer - Receiving County

• MC 359R (SP) (12/02) Medi-Cal Notice of Action Intercounty Transfer - Receiving County

• MC 360 (7/02) Notification of Medi-Cal Intercounty Transfer

These forms are not yet available through Materials

Management. Photocopies must be used until supplies are available.

What documents must the Sending County EW include in the ICT packet?

The Sending County must provide information necessary for the Receiving County to initiate an active Medi-Cal case for the beneficiary and must ensure any documentation supporting the beneficiary’s eligibility is promptly sent. The following is a list of photocopied documents the Sending County EW must include in the ICT packet:

• Current Medi-Cal application and appropriate

supplements including MC 210S-W for Primary Wage Earner or the last annual redetermination form (MC 210 RV Pilot)

• Identification and/or social security numbers • Computer generated case documents, budget

worksheets for Medi-Cal Family Budget Unit

(MFBU)/Mini Budget Units (MBU) or standard state forms

• Description of MFBU/MBU

• Last Notice(s) of Action for eligibility or share-of-cost • Case Narrative/Summary

• Copy of ICT information Notice (MC 358-S) sent to beneficiary

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If the case situation applies, the following documents may also be required:

• Income or property verification (MC 176P or case narrative on how income or property was verified for current eligibility.

• Pregnancy verification for full-scope benefits. • Medi-Cal Statement of Citizenship, Alienate, and

Immigration Status (MC 13)

• Other Health Coverage Information (DHS 6155) • Child, Spousal and Medical Support Information, CA

2.1s, including any court orders for child/spousal support.

• Veterans Referral, CA-5

• Copy of Disability and Adult Programs decision or verification of incapacity

• Authorized Representative form or letter,

What if the beneficiary reports changes in circumstances related with the move?

If the beneficiary reports changes, such as a change in employment or household composition, which would require the Receiving County to follow-up or complete an eligibility review once the transfer is completed, the Sending County must annotate the information on the MC 360, Notification of Medi-Cal Intercounty Transfer, and in the case documents provided to the Receiving County.

What are the Receiving EW responsibilities?

• Complete the ICT no later than the first of the month after the 30-day ICT notification from the Sending County;

• The beneficiary shall not be required to complete a new application;

• A full eligibility review shall not be conducted until the next annual redetermination unless there is a change in circumstances which might affect Medi-Cal eligibility; • Review the ICT packet for completeness upon receipt of

the ICT notification;

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Medi-Cal status on MEDS;

• Review case documents and initiate action to continue Medi-Cal benefits for the beneficiary;

• Contact the Sending County caseworker listed on the MC 360, Notification of Medi-Cal Intercounty Transfer, if there are questions regarding the ICT or if there are missing documents but do no delay while waiting for additional information;

• Puts the incoming ICT on LEADER as though it is a new intake;

• Verify that LEADER has submitted a successful MEDS EW05 transaction to assume responsibility for the case beginning the upcoming month;

• Reset the redetermination due date in LEADER to 12 months from the most recent redetermination month in the Sending County once the approval action functions ; • Notify the Sending County caseworker of the effective

date of Medi-Cal benefits for the beneficiary by telephone, electronic mail, fax transmittal, or written correspondence so that the Sending County can take action to terminate benefits and;

• Send a Notice of Action (MC 359-R) to the beneficiary notifying him/her of the effective date of Medi-Cal benefits in the Receiving County, as well as the new caseworker name, telephone number, and work hours.

See APPLICATION - SELECT FOR PROCESSING for LEADER procedures

What if a beneficiary contacts either the Sending or Receiving County requesting benefits after his/her Medi-Cal case has already been terminated less than 30 days due to “whereabouts unknown” or “loss of contact”?

If a beneficiary contacts the Sending County within 30 days of a termination, the Sending County EW shall restore the

beneficiary’s case without a break in aid. The EW shall then inform the beneficiary that an ICT will be initiated to the new county.

If the beneficiary contacts the Receiving County requesting Medi-Cal, after verifying that the beneficiary was on Medi-Cal in the Sending County within the last 30 days, the Receiving County worker shall contact the Sending County worker to

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request restoration of Medi-Cal benefits and an ICT for the beneficiary.

The EW should advise the beneficiary to contact the Sending County EW to report any other changes associated with the move, ensure that his/her case restoration is in effect, and that an ICT has been initiated to the Receiving County.

What if a beneficiary contacts either the Sending or Receiving County requesting benefits after his/her Medi-Cal case has already been terminated more than 30 days but less than 60 days due to “whereabouts unknown” or “loss of contact”?

When the beneficiary contacts either the Sending or Receiving County after Medi-Cal benefits have been terminated for more than 30 days but less than 60 days the workers in both

counties shall jointly evaluate the beneficiary’s current situation to determine which option, restoration in the county of record (Sending County) or reapplication in the new county (Receiving County) is best for the beneficiary.

What if the beneficiary contacts either the Sending or Receiving County requesting benefits after his/her Medi-Cal case was terminated due to failure to complete the annual redetermination?

If the beneficiary contacts the Sending County EW within 30 days of the effective date of termination and completes the annual redetermination, the Sending County EW shall restore the case and initiate an ICT to the Receiving County.

If the beneficiary contacts the Receiving County within 30 days of the effective date of termination due to failure to complete the annual redetermination, the Receiving County can assist the beneficiary with completing the annual redetermination in the Receiving County. Only ask the beneficiary to provide new or changed information and contact the Sending County for copies of other verification and documentation already in the Sending County’s case file so that the beneficiary can comply with the annual redetermination requirement and continue to receive Medi-Cal in the Receiving County with no interruption of benefits.

What if the beneficiary contacts either the Sending or Receiving County requesting benefits after his/her Medi-Cal case was terminated due to failure to complete the annual redetermination more than 30 days?

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If the beneficiary contacts the Sending or the Receiving County after the case has been terminated more than 30 days, a new application for Medi-Cal may be required unless the beneficiary provides evidence of good cause for not completing the annual redetermination.

What if a managed care plan beneficiary/member contacts the Sending County EW and indicates that he/she needs medical services/prescription refills in the Receiving County?

The Sending County EW shall advise the managed care beneficiary to contact Medi-Cal Managed Care, Office of the Ombudsman, at (888) 452-8609 for assistance or emergency disenrollment.

What if a managed care plan beneficiary/member contacts the Receiving County EW and indicates that he/she needs medical services/prescription refills before the effective date of disenrollment from his/her Sending County’s managed care plan?

The beneficiary may call the Office of the Ombudsman at (888) 452-8609 and request immediate disenrollment from the

Sending County’s managed care plan. If the Office of the Ombudsman can verify that the residence address has been reported/changed on MEDS, they will initiate a disenrollment from the plan on MEDS.

MC 50137 - Intercounty Transfer Effective Date of Discontinuance

What is the effective date of discontinuance?

Do not initiate action to terminate benefits until an effective date of benefits for the beneficiary is confirmed with the

Receiving County. Counties involved in an intercounty transfer establish the effective date of discontinuance based on the confirmation of the effective date benefits are confirmed with the Receiving County.

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MC Article 4 – Application Process

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)

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• 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

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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

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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.

USER INFORMATION DPSS DISCLAIMER STATEMENT