Expanded eligibility and services under CMSP

As of May 1, 2016, the County Medical Services Program (CMSP) is changing some of its eligibility requirements and benefits.  CMSP provides limited-term health coverage for indigent residents in 35 mostly rural California counties.  These changes should be operational in C-IV counties by May 23, and in CalWIN counties by May 9.

Eligibility Changes

The CMSP Eligibility Manual has been revised with new provision taking effect after May 1, 2016.  Among the changes that have been made:

  • Increasing the cap on income eligibility from 200% FPL to 300% FPL
  • Eliminating the asset test and share of cost for those with incomes up to 138% FPL (in line with MAGI Medi-Cal)
  • Increasing the asset limit for those with incomes between 138% FPL and 300% FPL to $20,000 for individuals and $30,000 for couples
  • Reducing the share of cost for those with incomes between 138% FPL and 300% FPL by 75%
  • Establishing a one-month retroactive eligibility period that replaces the ten-day pre-enrollment eligibility period
  • Revising the term of enrollment to six months

Note that the CMSP application process is supplemental to the Medi-Cal application.  The time period for counties to complete all processing will be 75 days.  Undocumented recipients will still be primarily limited to restricted scope benefits.

CMSP ACL No. 16-02 (April 27, 2016).

Benefit Changes

As of May 1, 2016, CMSP members with a share of cost will qualify for a new CMSP Primary Care Benefit in addition to the CMSP Standard Benefit.  Under this new Primary Care Benefit, eligible members will receive:

  • Up to three medical office visits with a primary care doctor, specialist, or other selected services with no share of cost or copay
  • Preventive health screenings with no copay or share of cost
  • Specific diagnostic tests and minor office procedures with no copay or share of cost
  • Prescription drug coverage up to $1500 in prescription costs, with a $5 copay

Benefits must be provided during the Primary Care Benefit eligibility period (members will get a special card in addition to the standard CMSP card and BIC) by a contracted CMSP provider with a reservation.

The Primary Care Benefit will begin the first of the month following approval for CMSP eligibility with no retroactive coverage provided.

CMSP ACL No. 16-03 (April 27, 2016).

WTW requirements for Pregnant Woman Only Assistance Units

The California Department of Social Services has issued instructions about Welfare-to-Work (WTW) requirements for Pregnant Woman Only (PWO) Assistance Units. Pregnant women with no other eligible children in the home are now eligible for CalWORKs beginning in the second trimester of pregnancy.

Unless exempt from WTW, PWOs must participate for 20 hours per week to meet minimum participation requirements because they are considered a household with a child under age 6.  However, to meet federal participation requirements, PWOs must participate 30 hours per week, 20 hours of which much be in a federally approved activity.  If a PWO meets the 20 hours per week minimum but not the 30 hours per week federal requirement, the PWO’s 24 month clock ticks. ACL 16-21 (April 15, 2016).

CAPI eligibility for citizens of free associated states

The California Department of Social Services has issued a clarification that citizens of the free associated states of the Marshall Islands, Micronesia Palau are eligible for the Cash Assistance Program for Immigrants (CAPI).

Persons are eligible for CAPI if they are lawful immigrants who would have been eligible for Supplemental Security Income (SSI) benefits before August 22, 1996, the day the federal welfare reform law became effective.  Lawful immigrants who were eligible for SSI before August 22, 1996 include persons who qualify as Persons Residing Under Color Of Law (PRUCOL).

Citizens of the freely associated states are PRUCOL and are therefore eligible for CAPI.  ACL 16-33 (May 2, 2016).

Implementation of SB 75 Health for All Children

DHCS has issued a letter to inform counties about the expansion of Medi-Cal to individuals under age 19 without satisfactory immigration status but who are otherwise eligible for the program.  CalHEERS changes should be effective no sooner than May 15, 2016, with eligibility effective as of May 1, 2016 (assuming implementation of system changes occurs in May; effective eligibility will be pushed back according to when CalHEERS changes).

SB 75 does not implement new aid codes (the DHCS letter includes a crosswalk of aid codes as a reference), nor does it change any requirements to verify citizenship under federal regulations or state law.  Counties, however, must not request verification from children who do not claim satisfactory immigration status.  The SB 75 determination and transition does not reset a beneficiary’s annual redetermination date.

Individuals under 19 who do not have satisfactory immigration status are eligible for full-scope Medi-Cal under SB 75.  Individuals who turn 19 on or before May 1, 2016, will not be considered eligible for full-scope benefits through the transition of current restricted-scope beneficiaries.  The transition population is supposed to receive three notices: a general information notice, a notice of action, and a managed care plan enrollment notice.

New applicants will be able to submit an application through all current application pathways.  Prior to SB 75 implementation, new applicants will be determined eligible for restricted scope eligibility and can then be considered part of the transition population for full-scope eligibility.  Retroactive coverage is available for only those months when SB 75 is available; restricted scope retroactivity will be available in appropriate cases.  New enrollees will receive a notice of action and a Health Care Options enrollment packet (in non-COHS counties).

The transition period is expected to begin no sooner than May 15, 2016.  Once both CalHEERS and SAWS are ready, SAWS will identify eligible restricted scope individuals under age 19 and process the transition into full scope through CalHEERS and/or SAWS, then generate and send an appropriate NOA.  New enrollees and transition population beneficiaries will be enrolled in managed care depending on whether the beneficiary resides in a COHS or non-COHS county, whether the beneficiary will be aging out within six months, and whether the beneficiary has a share of cost or other health coverage.

When SB 75 eligible individuals age out of the program, Counties must redetermine eligibility.  A timely NOA is always required in these situations; if a beneficiary does not receive timely notice, counties will restore eligibility manually in SAWS until a proper and timely notice is issued.

DHCS ACWDL 16-12 (May 4, 2016).

Manual Workaround to Preserve Covered California Coverage for Pregnant Women

DHCS issued a letter to the counties about a workaround for women enrolled in a Covered California plan with premium tax credits to remain in their health plans and not transition to Medi-Cal when they report a pregnancy.

The State expanded full-scope Medi-Cal for pregnant women from 60% FPL to 138% FPL.  Pregnancy-related Medi-Cal, covering women between 138% and 213% FPL, has been considered minimum essential coverage (MEC), which would normally disqualify them from Covered California plans with APTCs.

There is an exception for women who are enrolled in APTCs and then become pregnant, making them eligible for MEC Medi-Cal.  This workaround allows these pregnant women to keep their Covered California plan rather than being transitioned to Medi-Cal, if they choose.  While a change request has been submitted to CalHEERS to fix this, it is tentatively scheduled to take effect in October 2016.

The M9 manual workaround involves informing affected women who have been impacted by the transition about their option to remain in Covered California.  Pregnant women can either contact a County eligibility worker or Covered California to exercise this option.  These women will be discontinued from Medi-Cal, and the pregnancy record will be removed from the CalHEERS account.

DHCS MEDIL I-16-03 (April 14, 2016).

Misconduct and unemployment insurance ALJ duty to develop the record

The California Unemployment Insurance Appeals Board (CUIAB) has issued P-B-510 which holds that due process requires the Administrative Law Judge (ALJ) to develop the record in an unemployment insurance hearing.  The case involves termination for tardiness based on an employer’s no fault attendance policy.  The decision first holds that an employer’s attendance policy has no bearing on eligibility for unemployment insurance, and whether an employee has committed misconduct is based on unemployment insurance law and the particular facts of the case and not on the employer’s attendance policy.

The decision continues that, in attendance cases, the final incident must be analyzed to determine if it is misconduct, and that is done by examining whether the incident breached an important duty to the employer and injured or tended to injure the employers interest.  If so, the employee must show good cause.  If there is not good cause, the employee will have committed misconduct if the final incident was substantially detrimental to the employer’s interest or the employee had at least one prior justified warning for a similar incident.

The CUIAB then found that the ALJ had to a duty to develop “a comprehensive evidentiary record” surrounding the final incident, including the reason for the tardiness, the reasons the employee did not provide notice of the tardiness, the impact on the employer and the facts surrounding prior attendance issues and reprimands.  The ALJ failed to develop the record, and that failure justified remand for a new hearing to fully develop the record.  P-B-510 (February 24, 2016).