MEDI-CAL PROGRAM & POLICY · medi-cal program & policy webex presentation iv 06/02/2014 1 thank you for joining our webex presentation. please mute your phone, we will

MEDI-CAL PROGRAM

& POLICY

06/02/2014 WEBEX PRESENTATI ON I V 1

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MEDI-CAL PROGRAM & POLICY WEBEX PRESENTATION IV MAY 20, 2014

06 /02 /2014 WEBEX PRESENTATION IV 2

SCENARIO #1

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Answer: The correct Eligibility Results should display a MAGI aid code of M3.

Under the MAGI hierarchy, Parent/Caretaker Relative is above

pregnancy.

Question: What should the correct Eligibility Results be on LEADER? Aid code M3 for

Parent/Caretaker Relative or M9 for Pregnancy?

WEBEX PRESENTATION IV

Situation: The household consists of a pregnant mother and child. Mother is

applying for herself only. She is a U.S. citizen and her household

income is under 100% of the FPL.

Situation: Household consists of a pregnant participant and her undocumented

husband who is not applying for aid. Household income is 100% of the

FPL.


SCENARIO #2

Question: Should the participant be evaluated under aid code M1 or M9?

Answer: Due to her pregnancy, she is evaluated under the MAGI/Medi-Cal

category for pregnant women. Since her income is over 60% of the FPL,

she is then evaluated under aid code M9 (60%-213% of the FPL).

Since aid code M9 is restricted to pregnancy services only, the

participant has the option of purchasing additional unsubsidized

coverage through the Covered CA Exchange.

NOTE: If the participant is eligible under aid code M9, based on the

MAGI/Medi-Cal hierarchy she cannot be reevaluated under aid code

M1.

SCENARIO #3

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Question: When is it appropriate to evaluate a Parent/ Caretaker Relative applicant,

for APTC under aid code X2 (100%-150%) as opposed to when their

income is between 0% -109% (aid code M3) or 0% -138% (aid code M1)?

If income exceeds 109% but below 138% the applicant will be evaluated for aid code M1 before they are evaluated for X2.

When income falls between

139%-150% FPL, the applicant

would be evaluated for aid

code X2.

If applicant is a Parent/Caretaker Relative with income at or below 109% FPL, then he/she would be eligible to aid code M3.

Answer:

SCENARIO #4

06/02/2014 6

Answer 1: Aid codes M1 and 64 are equal in coverage. To determine which aid

code to choose, the eligibility worker must first determine if the client

already has Medicare coverage. The worker should then choose an

aid code based on the following:

If the applicant has Medicare coverage, and they are seeking dual

coverage (MEDI-MEDI), the applicant would need to be approved

under aid code 64 (An individual must have a Medi-Cal Aged, Blind

or Disabled (ABD) aid code to become MEDI-MEDI).

If the applicant does not have Medicare coverage, the worker should

follow the Medi-Cal hierarchy and select aid code M1 on LEADER.

Question 1: What aid code should eligibility staff choose on LEADER?


Situation: Applicant is single never married, disabled, under the age of 65, with

income below 138% of the Federal Poverty Level (FPL). Eligibility results

on LEADER show that the applicant is eligible to MAGI aid code M1, and

Non-MAGI aid code 64.

SCENARIO #4 (CONTINUED)


Question 2: Should the worker ask the consumer which coverage he/she prefers?

Answer 2: The only time a worker should ask the consumer which coverage they

prefer, is if the consumer is eligible for SOC Medi-Cal and APTC

through Covered CA. Since SOC Medi- Cal by itself is not considered

Minimum Essential Coverage, the consumer may incur tax penalties if

they choose not to accept APTC. Otherwise, the worker should

continue to follow the Medi-Cal hierarchy and evaluate for MAGI

eligibility first.

SCENARIO #5


Answer 1: Yes. The boyfriend would need to be added to the case as he is the

primary tax filer and is claiming all household members as his tax

dependents.

Question 1: Should the boyfriend be added to the case?

Situation: The household consists of a single mother applicant, her three children

and her boyfriend with no mutual children. The single mother’s parents

live at the same address but have a separate Medi-Cal case. The RFTHIs

provided by the applicant indicate that the boyfriend claims all members

as his tax dependents (the mother, her three children, and her parents)

in addition to a niece who lives in Mexico.

Answer 2: Yes. The tax filer’s income must be counted in the MAGI evaluation for all

tax dependents.

Question 2: Count his income towards all members?

NOTE: All tax household members must have a valid SSN, Individual Tax

Identification Number (ITIN), or Adoption Tax Identification Number (ATIN) in order for them to be claimed as tax dependents.


06/02/2014 9 WEBEX PRESENTATI ON I V

Answer 3: Yes. This can be treated as a single case. We can include the applicant’s

parents and the boyfriend’s niece. The boyfriend’s niece who lives in

Mexico, must be identified as “not in the household” and “not requesting

aid” in the LEADER Case Individual Information screen.

We need to split the tax filing household members into three different

Non-MAGI SFU Groups.

This feature is in the LEADER Household Relationship screen-Non-MAGI SFU Group

tab, and would be completed as follows:

Group #1- Applicant + her three children + her boyfriend.

Group #2- Applicant’s parents- They are aged and not eligible for

MAGI. LEADER will evaluate them for Non-MAGI.

Group #3 - Boyfriend’s niece who lives in Mexico.

Question 3: Will this scenario be treated as a single case?

NOTE: Applicant’s Parent’s separate Medi-Cal case would need to be linked with Applicant’s case.


06/02/2014 10 WEBEX PRESENTATI ON I V

The example below illustrates grouping for a mixed household, which can be

viewed from the “Non-MAGI SFUGrp” tab in the Household Relationship Screen.

When we have a mixed household (individuals eligible for Non-MAGI Medi-Cal and

others eligible under MAGI) we would separate them into groups to allow LEADER to

correctly evaluate those groups that are eligible under Non-MAGI programs.

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NOTE: This slide is for reference purposes only and does not reflect the case scenario

individuals described.

SCENARIO #6

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Answer: Husband continues to be eligible under 6H. Since he is receiving

Medicare, he should continue to evaluated under an ABD aid code.

Wife is eligible for MAGI under aid code M1 since the household income

is below 138% FPL. When incorrect eligibility results are returned from

CalHEERS, staff should ensure that all relevant screens are reviewed and

are displaying the correct tax filing information.

Question: What is the correct aid code that should be reflected in the Eligibility

Summary Screen on LEADER?


Situation: John has a Pre-ACA case approved under disability aid code 6H.

Participant is married and wife Mary, who is a U.S. Citizen, is requesting a

MAGI evaluation. John is receiving $1680.84 monthly. RFTHI information

has been obtained and SFU/EDBC run. MAGI fails and it indicates Mary

should be X7 (unsubsidized coverage). Based on the HH of 2, Mary

should be eligible for MAGI, monthly income is below the $1809.00 limit

for a HH of 2 adults.


Ensure the “Business, Income, Tax ” tab information is completed for the couple in

the “CalHEERS Assistance Information” Screen.

The couple reported not filing taxes, therefore, in the Case Individual Information,

the Primary Tax Flier field should be “N” for both. Failure to enter the correct tax

filing status will result in incorrect eligibility determination.

12



Primary Tax Filer field should be populated “N” in this particular scenario.

Y

JOHN

JOHN

Family Unit

Y

FOLLOW UP QUESTIONS…


Question: If we do deny the case, how can we fail a MC/MAGI case through

LEADER? Is there a screen in LEADER we can update in order to deny a

MC/MAGI case correctly?

Answer: Currently, the MAGI Medi-Cal cannot be “denied” because CalHEERS

is not programmed to accept denials. We will let staff know once both

systems (CalHEERS & LEADER) interface denial actions and they are

properly functioning for denials.


REMINDERS

Please ensure all required screens are complete and updated with the correct

information.

The following slides are the new LEADER CalHEERS screens:

There are three tabs in this screen that need to be completed:

The General tab will be the first to be enabled for the applicant on the case.

Note: In the field “Do you want to apply for financial assistance?” field, you must

enter “Y” for the applicant to be evaluated for MAGI, Medi-Cal and APTC / CSR.

16

CALHEERS ASSISTANCE SUMMARY

“GENERAL” TAB

Be sure to correctly update available fields.

Complete all fields in “Business, Income, Tax” tab.

Both drop downs must be completed manually. Failure to enter the correct tax

filing status will result in incorrect eligibility determination.

17


Miscellaneous tab must be completed for all members of the household.

Individual Address button is a mandatory field that must be completed for every

individual of the household.

The Request evaluation for MAGI, APTC/CSR must be “Y” for pre-ACA cases. This

field must be completed by a supervisor or higher.

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“MISCELLANEOUS” TAB

All mandatory fields must be completed;

Individual Address Sub-screen should be modified for individuals who are tax

dependents but not living at the same address.

Mailing address window allow selection of an Address box as shown below if

different from home address;

Note: Preferred Form of Communication Drop Down must be completed;

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INDIVIDUAL ADDRESS

The Immigration/Ctzn Docs tab must be completed if the individual is a

naturalized citizen or a legal permanent resident;

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IMMIGRATION/CTZN DOCS

Note: different fields will be available depending on verification type entered.

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This screen displays the selected program that was approved during the

authorization final disposition performed in the MAGI/APTC/CSR/Non-MAGI

Selection screen.

CALHEERS CASE COMPARISON

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The purpose of this screen is to alert staff of information received through e-

verification from CalHEERS.

Note: currently not available and is pending further guidance from ESD

CALLHEERS CASE QUEUE REQUEST

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This is a “view only” screen, and provides the user with a unified case view.

Aid codes for all programs are displayed for each household member

CALLHEERS CASE VIEW

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This screen has pre-populated income information reported

to CalHEERS that is electronically sent to LEADER. This screen includes:

Name of the individual

Begin date of reported earnings

Source of income

Frequency

Hire date, etc.

The income information needs to be reviewed and manually entered by

staff in the Employment Training Screen and Earned Income Screen in

LEADER.

When staff prints the screen, it will display the income information of the

individuals shown as having income.

CALHEERS INCOME

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CALHEERS INCOME


QUESTIONS?


HOW TO FIND MEDI-CAL CALL-OUTS

http://dpss.lacounty.gov/MyDPSS/default.cfm Go to:

Select: (1) My DPSS (2) My Applications tab (3)Document Library

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http://dpss.lacounty.gov/MyDPSS/default.cfm



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HOW TO FIND MEDI-CAL CALL-OUTS

Select: (4) Douments tab (5) Medi-Cal (6) Search

For questions please e-mail us at:

[email protected]

Visit our Health Care Reform webpage at:

http://www.ladpss.org/dpss/health/reform/default.cfm

To download WebEX presentations, please use this link:

http://dpss.lacounty.gov/dpss/health/reform/publications.cfm


ADDITIONAL RESOURCES

mailto:[email protected]

http://dpss.lacounty.gov/dpss/health/reform/default.cfm

http://dpss.lacounty.gov/dpss/health/reform/publications.cfm

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